Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study

BackgroundTo estimate excess mortality for care home residents during the COVID-19 pandemic in England, exploring associations with care home characteristics. MethodsDaily number of deaths in all residential and nursing homes in England notified to the Care Quality Commission (CQC) from 1st January 2017 to 7th August 2020. Care home level data linked with CQC care home register to identify homes characteristics: client type (over 65s/children and adults), ownership status (for-profit/not-for-profit; branded/independent), and size (small/medium/large). Excess deaths computed as the difference between observed and predicted deaths using local authority fixed-effect Poisson regressions on pre-pandemic data. Fixed-effect logistic regressions were used to model odds of experiencing COVID-19 suspected/confirmed deaths. FindingsUp to 7th August 2020 there were 29,542 (95%CI: 25,176 to 33,908) excess deaths in all care homes. Excess deaths represented 6.5% (95%CI: 5.5% to 7.4%) of all care home beds, higher in nursing (8.4%) than residential (4.6%) homes. 64.7% (95%CI: 56.4% to 76.0%) of the excess deaths were confirmed/suspected COVID-19. Almost all excess deaths were recorded in the quarter (27.4%) of homes with any COVID-19 fatalities. The odds of experiencing COVID-19 attributable deaths were higher in homes providing nursing services (OR: 1.8, 95%CI: 1.6 to 2.0); to older people and/or with dementia (OR: 5.5, 95%CI: 4.4 to 6.8); among larger (vs. small) homes (OR: 13.3, 95%CI: 11.5 to 15.4); belonging to a large provider/brand (OR: 1.2, 95%CI: 1.1 to 1.3). There was no significant association with for-profit status of providers. InterpretationTo limit excess mortality, policy should be targeted at care homes to minimise the risk of ingress of disease and limit subsequent transmission. Our findings provide specific characteristic targets for further research on mechanisms and policy priority. FundingNIHR. Summary boxO_ST_ABSEvidence before this studyC_ST_ABSGlobally, residents in care homes have experienced disproportionately high morbidity and mortality from COVID-19. Excess mortality incorporates all direct and indirect mortality effects of the pandemic. We searched MEDLINE for published literature, pre-publication databases (medRxiv and Lancet pre-print) and grey literature (ONS and Google) for care homes AND COVID-19 AND mortality, to 31st October 2020. We screened for evidence on excess deaths in care homes in England, and international evidence of the association of COVID-19 deaths and outbreaks with care home characteristics. Official estimates from England and Wales have reported aggregated excess deaths by place of occurrence, but we identified no peer-reviewed excess deaths study in this setting. These aggregates, however, do not account for care home residents dying in other settings (e.g. hospital), nor provide sufficient information to reflect on the impacts of enacted policies over the period, or to inform new policies for future virus waves. Previous peer-reviewed and pre-publication studies have also shown the heterogeneous effects of COVID-19 by care home characteristics in other countries. Particularly important from the current literature appears to be care home size, with larger care homes tending to be associated with more negative outcomes in studies with smaller sample sizes. A study from the Lothian region of Scotland additionally found excess deaths concentrated in a minority of homes that experienced an outbreak. However, a national breakdown of excess deaths by care home characteristics is largely lacking from the current literature in England, with a specific market structure and policy context. Added value of this studyWe use nationally representative administrative data from all care homes in England to estimate overall excess deaths and by care home characteristics: setting type (nursing or residential home), client types (offering services for people aged 65+ and/or people with dementia or offering services to children and adults), ownership status (whether not-for-profit - charity/NHS/LA-run homes - or for-profit), whether known to be affiliated to a large provider/brand or independent, and classification according to their registered maximum bed capacity (small, medium and large). We then used multivariable logistic regression to estimate the adjusted odds of a care home experiencing a suspected or confirmed COVID-19 death across these characteristics. We found that only 65% of excess deaths were flagged as officially confirmed/suspected COVID-19 attributed. However, almost all excess deaths occurred in the roughly quarter of care homes that reported at least one suspected/confirmed COVID-19 death. After adjusting for other care home characteristics, larger care homes (vs. small) had the highest odds of experiencing at least one suspected/confirmed COVID-19 death. These findings confirm those from the previous literature, in a unique policy context and with national data. Implications of all the available evidenceThe fact that nearly all excess deaths occurred in care homes with at least one COVID-19 attributed death suggests that directly-attributed deaths are very likely to be under-recorded. It also suggests that any indirect mortality effect, of COVID-19 and any enacted policies, were predominantly constrained to those homes experiencing an outbreak. Larger homes are likely to experience higher footfall in general, and so higher probability of contact with an infected individual, which is likely a contributing factor to the association. Furthermore, it might be easier to ensure person-centred protocols in small care homes due to the scale. There is an urgent need for further research to explore the mechanisms in relation to care home characteristics. Also, to empirically test effective interventions, in consideration of additional impacts on quality of life and psychological wellbeing. However, until this is possible, prioritising existing resources, such as testing and PPE equipment, for care homes to prevent ingress of disease is key to preventing large excess mortality.