Nursing home COVID-19 cases, deaths underreported in first wave of pandemic

An analysis of more than 15,000 U.S. nursing homes revealed that an estimated 43.7% of COVID-19 cases and 40% of COVID-19-related deaths prior to May 24, 2020, were not reported to the CDC’s tracking system.

The findings were published in JAMA Network Open.

“We did not find differences in nonreporting by facility characteristics (i.e., region, ownership, chain affiliation or star rating) as of May 24. This implies that facilities of all types omitted previous cases and deaths in the first [National Healthcare Safety Network] submission,” Karen Shen, PhD, of the department of economics at Harvard University, and colleagues wrote. “This may demonstrate a widespread inability of nursing homes to reliably collect data early in the pandemic or that pressures to report fewer cases and deaths were common to all facilities.”

In a cross-sectional study, Shen and colleagues compared COVID-19 cases and deaths reported to the CDC’s National Healthcare Safety Network (NHSN) with those reported to state health departments at the end of May 2020. The analysis included 15,415 nursing homes in 20 states. Among those facilities, 7,401 centers in 19 states were required to report deaths and 4,598 centers in 12 states were required to report infections. The researchers assessed for nonreporting using adjusted linear regression estimates.

The estimated 43.7% of cases and 40% of deaths in nursing homes that were not reported to the NHSN suggest that 68,613 cases and 16,623 deaths were not reported nationally, according to the researchers. This represents 11.6% of COVID-19 cases and 14% of related deaths among nursing home residents in 2020.

By Dec. 27, 2020, the estimated rate of unreported cases decreased to 13.9% and the estimated rate of unreported deaths decreased to 18.7%. Northeastern states had the greatest end-of-year nonreporting rates, according to the findings.

“To date, both academic and policymakers’ analyses of facility-level determinants of infections and mortality have likely been limited owing to the reliance on federal estimates,” Shen and colleagues wrote.

In a related commentary, Elizabeth M. White, PhD, APRN, an investigator in the department of health services, policy and practice at Brown University School of Public Health, discussed key takeaways from the study, the first being that future research using NHSN data must take into account this “data limitation.” Due to underreporting, data on COVID-19 prevalence and mortality are “likely flawed” and “may particularly bias estimates for nursing homes that had their most severe outbreaks during the initial U.S. wave of the pandemic,” White wrote.

The second key takeaway is that the “true toll of COVID-19 on nursing home residents may never be known” due to underreporting.

“Although current measures of COVID-19 prevalence and mortality reflect a devastating public health crisis for the nursing home population, it is likely that even more lives were impacted that will never be fully captured in existing data,” she wrote.

References:

Shen K, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.22885.

White EM. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.22885.