Risk Factors Associated With Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in Ontario, Canada | Geriatrics | JAMA Network Open | JAMA Network
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    Original Investigation
    Infectious Diseases
    July 22, 2020

    Risk Factors Associated With Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in Ontario, Canada

    Author Affiliations
    • 1Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
    • 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada
    • 3Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, Ontario, Canada
    • 4Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
    • 5Department of Medicine and Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
    JAMA Netw Open. 2020;3(7):e2015957. doi:10.1001/jamanetworkopen.2020.15957
    Key Points español 中文 (chinese)

    Question  How does the risk of death from coronavirus disease 2019 (COVID-19) among residents of long-term care (LTC) homes compare with that among the general population?

    Findings  In this cohort study of 627 LTC facilities, the incidence rate ratio for COVID-19–related death among LTC residents was 13 times higher than that among community-living adults older than 69 years.

    Meaning  In this study, the risk of COVID-19–related death was elevated among LTC residents, highlighting the need for improved infection control, widespread testing, access to personal protective equipment, and other supports to protect this vulnerable population.


    Importance  The coronavirus disease 2019 (COVID-19) pandemic has been particularly severe among individuals residing in long-term care (LTC) facilities. As of April 10, 2020, half of Canada’s COVID-19 deaths had occurred in LTC facilities.

    Objective  To better understand trends and risk factors associated with COVID-19 death in LTC facilities in Ontario, Canada.

    Design, Setting, and Participants  This cohort study of 627 LTC facilities included 269 total individuals who died of COVID-19 in Ontario to April 11, 2020, and 83 individuals who died of COVID-19 in Ontario LTC facilities to April 7, 2020. Because population denominators were not available for LTC residents, they were approximated as the total number of LTC facility beds in Ontario (79 498), assuming complete occupancy.

    Exposures  Confirmed or suspected COVID-19 outbreaks; confirmed COVID-19 infection among residents and staff, diagnosed by real-time polymerase chain reaction testing.

    Main Outcomes and Measures  COVID-19–specific mortality incidence rate ratios (IRRs) for LTC residents were calculated with community-living Ontarians older than 69 years as the comparator group. Count-based regression methods were used to model temporal trends and to identify associations of infection risk among staff and residents with subsequent LTC resident death. Model-derived IRRs for COVID-19–specific mortality were generated through bootstrap resampling (1000 replicates) to generate median and 95% credible intervals for IRR over time.

    Results  Of 627 LTC facilities, 272 (43.4%) reported COVID-19 infection in residents or staff. Of 1 731 315 total individuals older than 69 years living in Ontario during the study period, 229 (<0.1%) died; of 79 498 potential residents in LTC facilities, 83 (0.1%) died. The IRR for COVID-19–related death in LTC residents was 13.1 (95% CI, 9.9-17.3) compared with community-living adults older than 69 years. The IRR increased sharply over time and was 87.3 (95% credible interval, 6.4-769.8) by April 11, 2020. Infection among LTC staff was associated with death among residents with a 6-day lag (eg, adjusted IRR for death per infected staff member, 1.17; 95% CI, 1.11-1.26).

    Conclusions and Relevance  In this cohort study of COVID-19–related deaths during the pandemic in Ontario, Canada, mortality risk was concentrated in LTC residents and increased during a short period. Early identification of risk requires a focus on testing, providing personal protective equipment to staff, and restructuring the LTC workforce to prevent the movement of COVID-19 between facilities.