Excess deaths from COVID-19 among Medicare beneficiaries with psychiatric diagnoses: Community versus nursing home

Abstract

Background: Psychiatric illness may pose an additional risk of death for older adults during the COVID-19 pandemic. Older adults in the community versus institutions might be influenced by the pandemic differently. This study examines excess deaths during the COVID-19 pandemic among Medicare beneficiaries with and without psychiatric diagnoses (depression, anxiety, bipolar disorder, and schizophrenia) in the community versus nursing homes.

Methods: This is a retrospective cohort study of a 20% random sample of 15,229,713 fee-for-service Medicare beneficiaries, from January 2019 through December 2021. Unadjusted monthly mortality risks, COVID-19 infection rates, and case-fatality rates after COVID-19 diagnosis were calculated. Excess deaths in 2020, compared to 2019 were estimated from multivariable logistic regressions.

Results: Of all included Medicare beneficiaries in 2020 (N = 5,140,619), 28.9% had a psychiatric diagnosis; 1.7% lived in nursing homes. In 2020, there were 246,422 observed deaths, compared to 215,264 expected, representing a 14.5% increase over expected. Patients with psychiatric diagnoses had more excess deaths than those without psychiatric diagnoses (1,107 vs. 403 excess deaths per 100,000 beneficiaries, p < 0.01). The largest increases in mortality risks were observed among patients with schizophrenia (32.4% increase) and bipolar disorder (25.4% increase). The pandemic-associated increase in deaths with psychiatric diagnoses was only found in the community, not in nursing homes. The increased mortality for patients with psychiatric diagnoses was limited to those with medical comorbidities. The increase in mortality for psychiatric diagnoses was associated with higher COVID-19 infection rates (1-year infection rate = 7.9% vs. 4.2% in 2020), rather than excess case fatality.

Conclusions: Excess deaths during the COVID-19 pandemic were disproportionally greater in beneficiaries with psychiatric diagnoses, at least in part due to higher infection rates. Policy interventions should focus on preventing COVID-19 infections and deaths among community-dwelling patients with major psychiatric disorders in addition to those living the nursing homes.

Keywords: COVID-19; epidemiology; excess deaths; nursing home; psychiatric diagnoses.

FIGURE 1

Time trends in monthly mortality risks among Medicare fee‐for‐service beneficiaries from January 2019 to December 2021. Separate plots are shown for all beneficiaries, those without a psychiatric diagnosis, and those with specific psychiatric diagnoses; the denominator is the beneficiaries who were still alive on the first day of each month; the numerator is the beneficiaries who died within each month; The 1‐year mortality risk for all beneficiaries was 4.18% in 2019, and 4.79% in 2020 (14.6% increase).

FIGURE 2

Time trends in monthly mortality risks among community‐dwelling Medicare fee‐for‐service beneficiaries from January 2019 to December 2021. The denominator is the beneficiaries who were still alive on the first day of each month; the numerator is the beneficiaries who died within each month.

FIGURE 3

Time trends in monthly mortality risks among Medicare fee‐for‐service residents in nursing homes from January 2019 to December 2021. The denominator is the beneficiaries who were still alive on the first day of each month; the numerator is the beneficiaries who died within each month.