Estimating COVID-19 Hospitalizations in the United States With Surveillance Data Using a Bayesian Hierarchical Model: Modeling Study

BackgroundIn the United States, COVID-19 is a nationally notifiable disease, meaning cases and hospitalizations are reported by states to the Centers for Disease Control and Prevention (CDC). Identifying and reporting every case from every facility in the United States may not be feasible in the long term. Creating sustainable methods for estimating the burden of COVID-19 from established sentinel surveillance systems is becoming more important.ObjectiveWe aimed to provide a method leveraging surveillance data to create a long-term solution to estimate monthly rates of hospitalizations for COVID-19.MethodsWe estimated monthly hospitalization rates for COVID-19 from May 2020 through April 2021 for the 50 states using surveillance data from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) and a Bayesian hierarchical model for extrapolation. Hospitalization rates were calculated from patients hospitalized with a lab-confirmed SARS-CoV-2 test during or within 14 days before admission. We created a model for 6 age groups (0-17, 18-49, 50-64, 65-74, 75-84, and ≥85 years) separately. We identified covariates from multiple data sources that varied by age, state, and month and performed covariate selection for each age group based on 2 methods, Least Absolute Shrinkage and Selection Operator (LASSO) and spike and slab selection methods. We validated our method by checking the sensitivity of model estimates to covariate selection and model extrapolation as well as comparing our results to external data.ResultsWe estimated 3,583,100 (90% credible interval [CrI] 3,250,500-3,945,400) hospitalizations for a cumulative incidence of 1093.9 (992.4-1204.6) hospitalizations per 100,000 population with COVID-19 in the United States from May 2020 through April 2021. Cumulative incidence varied from 359 to 1856 per 100,000 between states. The age group with the highest cumulative incidence was those aged ≥85 years (5575.6; 90% CrI 5066.4-6133.7). The monthly hospitalization rate was highest in December (183.7; 90% CrI 154.3-217.4). Our monthly estimates by state showed variations in magnitudes of peak rates, number of peaks, and timing of peaks between states.ConclusionsOur novel approach to estimate hospitalizations for COVID-19 has potential to provide sustainable estimates for monitoring COVID-19 burden as well as a flexible framework leveraging surveillance data.     

Trends in COVID-19–Related Medication Use in US Nursing Homes, 2018-2022

ObjectivesLittle is known about how COVID-19 treatment patterns have evolved over time in nursing homes (NHs) despite the devastating effects of COVID-19 in this setting. The aim was to describe changes in COVID-19–related medication use over time among NH residents in the United States.DesignRetrospective cohort study.Setting and ParticipantsThis study used electronic health records (EHR) from 11 different US NH corporations between January 1, 2018, and March 31, 2022.MethodsThe use of medications approved for COVID-19–related conditions or known to be used off-label for COVID-19 during the study period is identified. We described trends in the use of each drug and combined use per 1000 NH residents over calendar time [quarters (Q)].ResultsA total of 59,022 unique residents with the use of an eligible medication were identified. Hydroxychloroquine use sharply increased from 9.8 in 2020Q1 to 30.2 orders per 1000 individuals in 2020Q2. Dexamethasone use increased sharply from 14.8 in 2020Q2 to a peak of 121.9 orders per 1000 individuals in 2020Q4. Azithromycin use increased from 44.1 in 2019Q3 to a peak of 99.9 orders per 1000 individuals in 2020Q4, with a drop in 2020Q3 of 51.3 per 1000 individuals in 2020Q3. Concurrent use of azithromycin and hydroxychloroquine increased sharply from 0.3 in 2020Q1 to 10.6 orders per 1000 residents in 2020Q2 and then drastically decreased to 0.6 per 1000 residents in 2020Q3. Concurrent use of dexamethasone and azithromycin rose considerably from 0.7 in 2020Q2 to 28.2 orders per 1000 residents in 2020Q4.Conclusions and ImplicationsAs in other settings, COVID-19–related medication use in NHs appears to have changed in response to the shifting evidence base and availability of medications during the pandemic. Providers should continue to diligently modify their prescribing as new evidence accrues.     

Staffing and Protective Equipment Access Mitigated COVID-19 Penetration and Spread in US Nursing Homes During the Third Surge

ObjectivesDuring the last quarter of 2020—despite improved distribution of personal protective equipment (PPE) and knowledge of COVID-19 management—nursing homes experienced the greatest increases in cases and deaths since the pandemic's beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic.DesignCross-sectional analysis.Setting and ParticipantsFacility-level data from 13,156 US nursing home facilities.MethodsTwo series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020.ResultsNursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%; n = 10,592) of facilities reported at least 1 COVID-19 case, 49.44% (n = 6504) reported at least 1 hospitalization, and 49.76% (n = 6546) reported at least 1 death during this third surge. N95 mask shortages were associated with increased odds of at least 1 COVID-19 case [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.05-1.40] and hospitalization (1.26, 95% CI 1.13-1.40), as well as larger numbers of hospitalizations (1.11, 95% CI 1.02-1.20). Nursing aide shortages were associated with lower odds of at least 1 COVID-19 death (1.23, 95% CI 1.12-1.34) and higher hospitalizations (1.09, 95% CI 1.01-1.17). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50-bed) and midsized (50- to 150-bed) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates >75% increased odds of experiencing a COVID-19 case (1.48, 95% CI 1.35-1.62) or death (1.25, 95% CI 1.17-1.34).Conclusions and ImplicationsAdequate staffing and PPE—along with reduced occupancy and smaller facilities—mitigate incidence and magnitude of COVID-19 cases and sequelae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.     

Background rates of adverse events of special interest for COVID-19 vaccine safety monitoring in the United States, 2019–2020

BackgroundThe U.S. Food and Drug Administration (FDA) Biologics Effectiveness and Safety (BEST) Initiative conducts active surveillance of adverse events of special interest (AESI) after COVID-19 vaccination. Historical incidence rates (IRs) of AESI are comparators to evaluate safety.MethodsWe estimated IRs of 17 AESI in six administrative claims databases from January 1, 2019, to December 11, 2020: Medicare claims for adults ≥ 65 years and commercial claims (Blue Health Intelligence®, CVS Health, HealthCore Integrated Research Database, IBM® MarketScan® Commercial Database, Optum pre-adjudicated claims) for adults < 65 years. IRs were estimated by sex, age, race/ethnicity (Medicare), and nursing home residency (Medicare) in 2019 and for specific periods in 2020.ResultsThe study included >100 million enrollees annually. In 2019, rates of most AESI increased with age. However, compared with commercially insured adults, Medicare enrollees had lower IRs of anaphylaxis (11 vs 12–19 per 100,000 person-years), appendicitis (80 vs 117–155), and narcolepsy (38 vs 41–53). Rates were higher in males than females for most AESI across databases and varied by race/ethnicity and nursing home status (Medicare). Acute myocardial infarction (Medicare) and anaphylaxis (all databases) IRs varied by season. IRs of most AESI were lower during March–May 2020 compared with March–May 2019 but returned to pre-pandemic levels after May 2020. However, rates of Bell’s palsy, Guillain-Barré syndrome, narcolepsy, and hemorrhagic/non-hemorrhagic stroke remained lower in multiple databases after May 2020, whereas some AESI (e.g., disseminated intravascular coagulation) exhibited higher rates after May 2020 compared with 2019.ConclusionAESI background rates varied by database and demographics and fluctuated in March–December 2020, but most returned to pre-pandemic levels after May 2020. It is critical to standardize demographics and consider seasonal and other trends when comparing historical rates with post-vaccination AESI rates in the same database to evaluate COVID-19 vaccine safety.     

Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic

ObjectiveTo evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD.DesignRetrospective cohort study.Setting and ParticipantsTwo cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020.MethodBy linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects.ResultsOf the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL.Conclusions and ImplicationsAL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.     

The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department

BackgroundIt is known that there has been an increase over the years in attacks by patients admitted to the emergency department (ED) on healthcare workers; it is unclear what effect the COVID-19 pandemic has on these attacks.Aimto verify through a long-term time analysis the effect of COVID-19 on ED attacks on healthcare workers.Mothodsa quasi-experimental interrupted time-series analysis on attacks on healthcare workers was performed from January 2017 to August 2021. The main outcome was the monthly rate of attacks on healthcare workers per 1000 general accesses. The pandemic outbreak was used as an intervention point.Results1002 attacks on healthcare workers in the ED were recorded. The rate of monthly attacks on total accesses increased from an average of 13.5 (SD 6.6) in the pre-COVID-19 era to 27.2 (SD 9.8) in the pandemic months, p < 0.001. The pandemic outbreak led to a significant increase in attacks on healthcare workers from 0.05/1000 attacks per month (p = 0.018), to 4.3/1000 attacks per month (p = 0.005).ConclusionsThe COVID-19 pandemic has led to a significant increase in attacks on healthcare workers in the ED. Trends compared to pre-pandemic months do not seem to indicate a return to normality. Health institutions and policymakers should develop strategies to improve the safety of the working environment in hospitals and EDs.     

Impact of the COVID-19 pandemic on pediatric and adolescent vaccinations and well child visits in the United States: A database analysis

BackgroundThe COVID-19 pandemic has disrupted healthcare, including immunization practice and well child visit attendance. Maintaining vaccination coverage is important to prevent disease outbreaks and morbidity. We assessed the impact of the COVID-19 pandemic on pediatric and adolescent vaccination administration and well child visit attendance in the United States.MethodsThis cross-sectional study used IBM MarketScan Commercial Database (IMC) with Early View (healthcare claims database) and TriNetX Dataworks Global Network (electronic medical records database) from January 2018–March 2021. Individuals ≤ 18 years of age who were enrolled during the analysis month of interest (IMC with Early View) or had ≥ 1 health encounter at a participating institution (TriNetX Dataworks) were included. We calculated the monthly percent difference between well child visit attendance and vaccine administration rates for 10 recommended pediatric/adolescent vaccines in 2020 and 2021 compared with 2018–2019. Data were stratified by the age groups 0–2 years, 4–6 years, and 9–16 years.ResultsIn IMC with Early View, the average monthly enrollment for children 0–18 years of age was 5.2 million. In TriNetX Dataworks, 12.2 million eligible individuals were included. Well child visits and vaccinations reached the lowest point in April 2020 compared with 2018–2019. Well child visit attendance and vaccine administration rates were inversely related to age, with initial reductions highest for adolescents and lowest for ages 0–2 years. Rates rebounded in June and September 2020 and stabilized to pre-pandemic levels in Fall 2020. Rates dropped below baseline in early 2021 for groups 0–2 years and 4–6 years.ConclusionsWe found substantial disruptions in well child visit attendance and vaccination administration for children and adolescents during the COVID-19 pandemic in 2020 and early 2021. Continued efforts are needed to monitor recovery and catch up to avoid outbreaks and morbidity associated with vaccine-preventable diseases.     

Effectiveness of COVID-19 vaccines at preventing emergency department or urgent care encounters and hospitalizations among immunocompromised adults: An observational study of real-world data across 10 US states from August-December 2021

BackgroundImmunocompromised (IC) persons are at increased risk for severe COVID-19 outcomes and are less protected by 1–2 COVID-19 vaccine doses than are immunocompetent (non-IC) persons. We compared vaccine effectiveness (VE) against medically attended COVID-19 of 2–3 mRNA and 1–2 viral-vector vaccine doses between IC and non-IC adults.MethodsUsing a test-negative design among eight VISION Network sites, VE against laboratory-confirmed COVID-19–associated emergency department (ED) or urgent care (UC) events and hospitalizations from 26 August-25 December 2021 was estimated separately among IC and non-IC adults and among specific IC condition subgroups. Vaccination status was defined using number and timing of doses. VE for each status (versus unvaccinated) was adjusted for age, geography, time, prior positive test result, and local SARS-CoV-2 circulation.ResultsWe analyzed 8,848 ED/UC events and 18,843 hospitalizations among IC patients and 200,071 ED/UC events and 70,882 hospitalizations among non-IC patients. Among IC patients, 3-dose mRNA VE against ED/UC (73% [95% CI: 64–80]) and hospitalization (81% [95% CI: 76–86]) was lower than that among non-IC patients (ED/UC: 94% [95% CI: 93–94]; hospitalization: 96% [95% CI: 95–97]). Similar patterns were observed for viral-vector vaccines. Transplant recipients had lower VE than other IC subgroups.ConclusionsDuring B.1.617.2 (Delta) variant predominance, IC adults received moderate protection against COVID-19–associated medical events from three mRNA doses, or one viral-vector dose plus a second dose of any product. However, protection was lower in IC versus non-IC patients, especially among transplant recipients, underscoring the need for additional protection among IC adults.     

Shifting US Patterns of COVID-19 Mortality by Race and Ethnicity From June–December 2020

ObjectivesThe COVID-19 pandemic has disproportionately affected racial and ethnic minorities in the United States and has been devastating for residents of nursing homes (NHs). However, evidence on racial and ethnic disparities in COVID-19–related mortality rates within NHs and how that has changed over time has been limited. This study examines the impact of a high proportion of minority residents in NHs on COVID-19–related mortality rates over a 30-week period.DesignLongitudinal study.Setting and ParticipantsCenters for Medicare & Medicaid Services Nursing Home COVID-19 Public Use File data from 50 states from June 1, 2020, to December 27, 2020.MethodsWe linked data from 11,718 NHs to (1) Nursing Home Compare data, (2) the Long-Term Care: Facts on Care in the U.S., and (3) US county-level data on COVID cases and deaths. Our primary independent variable was proportion of minority residents (blacks and Hispanics) in NHs and its association with mortality rate over time.ResultsDuring the first 6 weeks from June 1, 2020, NHs with a higher proportion of black residents reported more COVID-19 deaths per 1000 followed by NHs with a higher proportion of Hispanic residents. Between 7 and 12 weeks, NHs with a higher proportion of Hispanic residents reported more deaths per 1000, followed by NHs with a higher proportion of black residents. However, after 23 weeks (mid-November 2020), NHs serving a higher proportion of white residents reported more deaths per 1000 than NHs serving a high proportion of black and Hispanic residents.Conclusions and ImplicationsThe disparities in COVID-19–related mortality for nursing homes serving minority residents is evident for the first 12 weeks of our study period. Policy interventions and the equitable distribution of vaccine are required to mitigate the impact of systemic racial injustice on health outcomes of people of color residing in NHs.     

COVID-19 positivity rates,hospitalizations and mortality of adults with and without intellectual and developmental disabilities in Ontario,Canada

BackgroundAcross and within countries there is a need to understand how the COVID-19 pandemic has impacted populations of individuals with intellectual and developmental disabilities (IDD).ObjectiveRates of COVID-19 positivity for adults with IDD, including Down syndrome, relative to adults without IDD in Ontario, Canada were compared. Health profiles and case-based rates of hospitalizations, intensive care unit admissions, and mortality within 30 days of testing positively were compared for those with IDD, including Down syndrome, versus those without IDD.MethodsThis retrospective cohort study linked health administrative databases using unique encoded identifiers to describe population-level COVID-19 positivity, related hospital use and mortality from January 15, 2020 to January 10, 2021. Incidence rate ratios (RR) and 95% confidence intervals were calculated.ResultsRelative to adults without IDD, COVID-19 positivity rates were 1.28 times higher for adults with IDD and 1.42 times higher for adults with Down syndrome.Compared to adults without IDD, adults with IDD were more than twice as likely to be hospitalized following COVID-19 (RR:2.21 (95%CI: 1.93,2.54)) and to die (RR:2.23 (95%CI: 1.86,2.67). These RRs were greater for adults under 65. For adults with Down syndrome, mortality rates were 6.59 (95%CI: 4.51,9.62) times higher than those without IDD.DiscussionIn Ontario, Canada, hospitalization and mortality rates associated with COVID-19 are higher for adults with IDD than other adults. These findings should inform vaccination strategies that often prioritize older adults in the general population resulting in people with IDD, who are often in younger age groups, being overlooked.     

COVID-19 cases,hospitalizations and deaths after vaccination: a cohort event monitoring study,Islamic Republic of Iran

ObjectiveTo investigate the incidence of coronavirus disease 2019 (COVID-19) cases, hospitalizations and deaths in Iranians vaccinated with either AZD1222 Vaxzevria, CovIran® vaccine, SARS-CoV-2 Vaccine (Vero Cell), Inactivated (lnCoV) or Sputnik V.MethodsWe enrolled individuals 18 years or older receiving their first COVID-19 vaccine dose between April 2021 and January 2022 in seven Iranian cities. Participants completed weekly follow-up surveys for 17 weeks (25 weeks for AZD1222) to report their COVID-19 status and hospitalization. We used Cox regression models to assess risk factors for contracting COVID-19, hospitalization and death.FindingsOf 89 783 participants enrolled, incidence rates per 1 000 000 person-days were: 528.2 (95% confidence interval, CI: 514.0–542.7) for contracting COVID-19; 55.8 (95% CI: 51.4–60.5) for hospitalization; and 4.1 (95% CI: 3.0–5.5) for death. Compared with SARS-CoV-2 Vaccine (Vero Cell), hazard ratios (HR) for contracting COVID-19 were: 0.70 (95% CI: 0.61−0.80) with AZD1222; 0.73 (95% CI: 0.62–0.86) with Sputnik V; and 0.73 (95% CI: 0.63–0.86) with CovIran®. For hospitalization and death, all vaccines provided similar protection 14 days after the second dose. History of COVID-19 protected against contracting COVID-19 again (HR: 0.76; 95% CI: 0.69–0.84). Diabetes and respiratory, cardiac and renal disease were associated with higher risks of contracting COVID-19 after vaccination.ConclusionThe rates of contracting COVID-19 after vaccination were relatively high. SARS-CoV-2 Vaccine (Vero Cell) provided lower protection against COVID-19 than other vaccines. People with comorbidities had higher risks of contracting COVID-19 and hospitalization and should be prioritized for preventive interventions.     

Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020

ObjectiveTo measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff.DesignRetrospective cross-sectional study.Setting and ParticipantsCenters for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts).MethodsWe estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics.ResultsOf the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant.Conclusions and ImplicationsThese findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.     

U.S. Nursing Home Quality Ratings Associated with COVID-19 Cases and Deaths

ObjectivesTo inform future policies and disaster preparedness plans in the vulnerable nursing home setting, we need greater insight into the relationship between nursing homes’ (NHs’) quality and the spread and severity of COVID-19 in NH facilities. We therefore extend current evidence on the relationships between NH quality and resident COVID-19 infection rates and deaths, taking into account NH structural characteristics and community characteristics.DesignCross-sectional study.Setting and Participants15,390 Medicaid- and Medicare-certified NHs.MethodsWe obtained and merged the following data sets: (1) COVID-19 weekly data reported by each nursing home to the Centers for Disease Control and Prevention’s National Healthcare Safety Network, (2) Centers for Medicare & Medicaid Services Five Star Quality Rating System, (3) county-level COVID-19 case counts, (4) county-level population data, and (5) county-level sociodemographic data.ResultsAmong 1-star NHs, there were an average of 13.19 cases and 2.42 deaths per 1000 residents per week between May 25 and December 20, 2020. Among 5-star NHs, there were an average of 9.99 cases and 1.83 deaths per 1000 residents per week. The rate of confirmed cases of COVID-19 was 31% higher among 1-star NHs compared with 5-star NHs [model 1: incidence rate ratio (IRR) 1.31, 95% confidence interval (CI) 1.23-1.39], and the rate of COVID-19 deaths was 30% higher (IRR 1.30, 95% CI 1.20, 1.41). These associations were only partially explained by differences in community spread of COVID-19, case mix, and the for-profit status and size of NHs.Conclusions and ImplicationsWe found that COVID-19 case and death rates were substantially higher among NHs with lower star ratings, suggesting that NHs with quality much below average are more susceptible to the spread of COVID-19. This relationship, particularly with regard to case rates, can be partially attributed to external factors: lower-rated NHs are often located in areas with greater COVID-19 community spread and serve more socioeconomically vulnerable residents than higher-rated NHs.     

Factors Associated With COVID-19 Hospitalizations and Deaths in French Nursing Homes

ObjectivesTo describe the clinical characteristics and management of residents in French nursing homes with suspected or confirmed coronavirus disease 2019 (COVID-19) and to determine the risk factors for COVID-19–related hospitalization and death in this population.DesignA retrospective multicenter cohort study.Setting and ParticipantsFour hundred eighty nursing home residents with suspected or confirmed COVID-19 between March 1 and May 20, 2020, were enrolled and followed until June 2, 2020, in 15 nursing homes in Marseille’s greater metropolitan area.MethodsDemographic, clinical, laboratory, treatment type, and clinical outcome data were collected from patients’ medical records. Multivariable analysis was used to determine factors associated with COVID-19–related hospitalization and death. For the former, the competing risk analysis—based on Fine and Gray’s model—took death into account.ResultsA total of 480 residents were included. Median age was 88 years (IQR 80-93), and 330 residents were women. A total of 371 residents were symptomatic (77.3%), the most common symptoms being asthenia (47.9%), fever or hypothermia (48.1%), and dyspnea (35.6%). One hundred twenty-three patients (25.6%) were hospitalized and 96 (20%) died. Male gender [specific hazard ratio (sHR) 1.63, 95% confidence interval (CI) 1.12-2.35], diabetes (sHR 1.69, 95% CI 1.15-2.50), an altered level of consciousness (sHR 2.36, 95% CI 1.40-3.98), and dyspnea (sHR 1.69, 95% CI 1.09-2.62) were all associated with a greater risk of COVID-19–related hospitalization. Male gender [odds ratio (OR) 6.63, 95% CI 1.04-42.39], thermal dysregulation (OR 2.64, 95% CI 1.60-4.38), falls (2.21 95% CI 1.02-4.75), and being aged >85 years (OR 2.36, 95% CI 1.32-4.24) were all associated with increased COVID-19–related mortality risk, whereas polymedication (OR 0.46, 95% CI 0.27-0.77) and preventive anticoagulation (OR 0.46, 95% CI 0.27-0.79) were protective prognostic factors.Conclusions and ImplicationsMale gender, being aged >85 years old, diabetes, dyspnea, thermal dysregulation, an altered level of consciousness, and falls must all be considered when identifying and protecting nursing home residents who are at greatest risk of COVID-19–related hospitalization and death.     

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.DesignRetrospective cohort study.Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.     

Risk of Death in Nursing Home Residents After COVID-19 Vaccination

ObjectivesIn the first months of 2021, the Dutch COVID-19 vaccination campaign was disturbed by reports of death in Norwegian nursing homes (NHs) after vaccination. Reports predominantly concerned persons >65 years of age with 1 or more comorbidities. Also, in the Netherlands adverse events were reported after COVID-19 vaccination in this vulnerable group. Yet, it was unclear whether a causal link between vaccination and death existed. Therefore, we investigated the risk of death after COVID-19 vaccination in Dutch NH residents compared with the risk of death in NH residents prior to the COVID-19 pandemic.DesignPopulation-based longitudinal cohort study with electronic health record data.Setting and ParticipantsWe studied Dutch NH residents from 73 NHs who received 1 or 2 COVID-19 vaccination(s) between January 13 and April 16, 2021 (n = 21,762). As a historical comparison group, we included Dutch NH residents who were registered in the same period in 2019 (n = 27,591).MethodsData on vaccination status, age, gender, type of care, comorbidities, and date of NH entry and (if applicable) discharge or date of death were extracted from electronic health records. Risk of death after 30 days was evaluated and compared between vaccinated residents and historical comparison residents with Kaplan-Meier and Cox regression analyses. Regression analyses were adjusted for age, gender, comorbidities, and length of stay.ResultsRisk of death in NH residents after one COVID-19 vaccination (regardless of whether a second vaccination was given) was decreased compared with historical comparison residents from 2019 (adjusted HR 0.77, 95% CI 0.69-0.86). The risk of death further decreased after 2 vaccinations compared with the historical comparison group (adjusted HR 0.57, 95% CI 0.50-0.64).Conclusions and ImplicationsWe found no indication that risk of death in NH residents is increased after COVID-19 vaccination. These results indicate that COVID-19 vaccination in NH residents is safe and could reduce fear and resistance toward vaccination.     

Mortality of Care Home Residents and Community-Dwelling Controls During the COVID-19 Pandemic in 2020: Matched Cohort Study

ObjectiveThis study aimed to estimate and compare mortality of care home residents, and matched community-dwelling controls, during the COVID-19 pandemic from primary care electronic health records in England.DesignMatched cohort study.Setting and ParticipantsFamily practices in England in the Clinical Practice Research Datalink Aurum database. There were 83,627 care home residents in 2020, with 26,923 deaths; 80,730 (97%) were matched on age, sex, and family practice with 300,445 community-dwelling adults.MethodsAll-cause mortality was evaluated and adjusted rate ratios by negative binomial regression were adjusted for age, sex, number of long-term conditions, frailty category, region, calendar month or week, and clustering by family practice.ResultsUnderlying mortality of care home residents was higher than community controls (adjusted rate ratio 5.59, 95% confidence interval 5.23?5.99, P < .001). During April 2020, there was a net increase in mortality of care home residents over that of controls. The mortality rate of care home residents was 27.2 deaths per 1000 patients per week, compared with 2.31 per 1000 for controls. Excess deaths for care home residents, above that predicted from pre-pandemic years, peaked between April 13 and 19 (men, 27.7, 95% confidence interval 25.1?30.3; women, 17.4, 15.9?18.8 per 1000 per week). Compared with care home residents, long-term conditions and frailty were differentially associated with greater mortality in community-dwelling controls.Conclusions and ImplicationsIndividual-patient data from primary care electronic health records may be used to estimate mortality in care home residents. Mortality is substantially higher than for community-dwelling comparators and showed a disproportionate increase in the first wave of the COVID-19 pandemic. Care home residents require particular protection during periods of high infectious disease transmission.