Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities

Abstract

Objective: To compare 30-day mortality in long-term care facility (LTCF) residents with and without COVID-19 and to investigate the impact of 31 potential risk factors for mortality in COVID-19 cases. Design: Retrospective cohort study. Setting and Participants: All residents of LTCFs registered in Senior Alert, a Swedish national database of health examinations in older adults, during 2019-2020. Methods: We selected residents with confirmed COVID-19 until September 15, 2020, along with timedependent propensity scoreematched controls without COVID-19. Exposures were COVID-19, age, sex, comorbidities, medications, and other patient characteristics. The outcome was all-cause 30-day mortality.Results: A total of 3731 residents (median age 87 years, 64.5% female) with COVID-19 were matched to 3731 controls without COVID-19. Thirty-day mortality was 39.9% in COVID-19 cases and 5.7% in controls [relative risk 7.05, 95% confidence interval (CI) 6.10-8.14]. In COVID-19 cases, the odds ratio (OR) for 30day mortality was 2.44 (95% CI 1.57-3.81) in cases aged 80-84 years, 2.99 (95% CI 1.93-4.65) in cases aged 85-89 years, and 3.28 (95% CI 2.11-5.10) in cases aged 90 years, as compared with cases aged <70 years. Other risk factors for mortality among COVID-19 cases included male sex (OR, 2.60, 95% CI 2.22-3.05), neuropsychological conditions (OR, 2.18; 95% CI 1.76-2.71), impaired walking ability (OR, 1.45, 95% CI 1.17-1.78), urinary and bowel incontinence (OR 1.51, 95% CI 1.22-1.85), diabetes (OR 1.36, 95% CI 1.14-1.62), chronic kidney disease (OR 1.37, 95% CI 1.11-1.68) and previous pneumonia (OR 1.57, 95% CI 1.32-1.85). Nutritional factors, cardiovascular diseases, and antihypertensive medications were not significantly associated with mortality. Conclusions and Implications: In Swedish LTCFs, COVID-19 was associated with a large excess in mortality after controlling for an extensive number of risk factors. Beyond older age and male sex, several prevalent clinical risk factors independently contributed to higher mortality. These findings suggest that reducing transmission of COVID-19 in LTCFs will likely prevent a considerable number of deaths.

Effectiveness of a fourth dose of mRNA COVID-19 vaccine against all-cause mortality in long-term care facility residents and in the oldest old: A nationwide, retrospective cohort study in Sweden

“…The covariates selected for the present study were based on results from previous studies based on similar populations. 9 , 18 Information on sex, year and month of birth, and country of birth were obtained from Statistics Sweden. From Senior Alert, we obtained data on risk of malnutrition and risk of pressure ulcer assessed using validated instruments that was used in the description and analyses of the LTCF cohort.…”

COVID-19 excess mortality among long-term care residents in Ontario, Canada

“…Globally, countries have reported a significant number of COVID-related deaths in LTC settings. In Sweden, more than 50% of all deaths occurred in LTC homes, the highest among the Scandinavian countries [ 2 ]. In Italy, municipalities with care homes had higher rates of excess deaths related to COVID compared to those without a care home [ 3 ].…”

COVID-19 prevalence and mortality in longer-term care facilities

“…[ 59 ] In a study of Swedish LTCF residents (median age 87), the 30-day mortality during the first wave of the pandemic was about 40% for COVID-19 cases compared to about 6% for the control group. [ 16 ] In a comparable study of Ontario, Canada, the 30-day mortality for COVID-positive LTCF residents (median age 86) was 24% higher than that of the control group and moderately above the metaregression IFR prediction of 17% (CI: 14–22%) for that age cohort. [ 60 , 61 ].…”

“…Large-scale studies of LTCF residents with COVID-19 did not observe any significant association between 30-day mortality risk and certain chronic conditions (i.e., chronic obstructive pulmonary disease, hypertension, coronary artery disease, heart failure) but did identify moderately elevated odds ratios for diabetes (OR 1·2; CI: 1·1–1·4) and chronic kidney disease (OR 1·3; CI: 1·1–1·6). [ 16 , 70 ] Mortality risk was linked more strongly to physical and cognitive impairments, although those links might at least partially reflect increased risk of exposure for the reasons noted above. [ 71 ].…”