Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

Abstract

Importance: Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.

Objective: To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.

Design, setting, and participants: This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.

Exposures: The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.

Main outcomes and measures: The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.

Results: Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).

Conclusions and relevance: In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

Figure 1.. Crowding Index of Nursing Homes in Ontario, Canada

Distribution of the nursing home crowding index across 618 homes in Ontario, Canada. The nursing home crowding index was measured as the mean number of occupants per room and bathroom across an entire nursing home according to the following equation: N_residents ÷ (½N_bedrooms + ½N_bathrooms).

Figure 2.. Ranked COVID-19 Outbreak Size in Nursing Homes in Ontario, Canada

All 618 homes have been plotted according to the outbreak size and percentile rank of outbreak size (0 to 100) for homes with low (orange) and high (green) crowding index. Cases and deaths were identified between March 29 and May 20, 2020.

Figure 3.. Association Between Nursing Home Crowding Index and the Incidence of COVID-19 Cases and Deaths in Ontario, Canada

Points represent the mean crowding index and the incidence of COVID-19 cases (gray; cases per 100 residents) and deaths (orange; deaths per 100 residents) for 20 equally sized groups of homes based on the crowding index. Specifically, each group of homes included 5% of homes in each group (30-31). Groups were based on homes and represented a vigintile of the crowding index. Solid lines represent quasi-Poisson regression estimates and shaded regions represent 95% CIs.