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

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.

Hospitalizations and Mortality From Non-SARS-CoV-2 Causes Among Medicare Beneficiaries at US Hospitals During the SARS-CoV-2 Pandemic.

Importance: The increased hospital mortality rates from non-SARS-CoV-2 causes during the SARS-CoV-2 pandemic are incompletely characterized. Objective: To describe changes in mortality rates after hospitalization for non-SARS-CoV-2 conditions during the COVID-19 pandemic and how mortality varies by characteristics of the admission and hospital. Design, Setting, and Participants: Retrospective cohort study from January 2019 through September 2021 using 100% of national Medicare claims, including 4626 US hospitals. Participants included 8 448 758 individuals with non-COVID-19 medical admissions with fee-for-service Medicare insurance. Main Outcomes and Measures: Outcome was mortality in the 30 days after admission with adjusted odds generated from a 3-level (admission, hospital, and county) logistic regression model that included diagnosis, demographic variables, comorbidities, hospital characteristics, and hospital prevalence of SARS-CoV-2. Results: There were 8 448 758 non-SARS-CoV-2 medical admissions in 2019 and from April 2020 to September 2021 (mean [SD] age, 73.66 [12.88] years; 52.82% women; 821 569 [11.87%] Black, 438 453 [6.34%] Hispanic, 5 351 956 [77.35%] White, and 307 218 [4.44%] categorized as other). Mortality in the 30 days after admission increased from 9.43% in 2019 to 11.48% from April 1, 2020, to March 31, 2021 (odds ratio [OR], 1.20; 95% CI, 1.19-1.21) in multilevel logistic regression analyses including admission and hospital characteristics. The increase in mortality was maintained throughout the first 18 months of the pandemic and varied by race and ethnicity (OR, 1.27; 95% CI, 1.23-1.30 for Black enrollees; OR, 1.25; 95% CI, 1.23-1.27 for Hispanic enrollees; and OR, 1.18; 95% CI, 1.17-1.19 for White enrollees); Medicaid eligibility (OR, 1.25; 95% CI, 1.24-1.27 for Medicaid eligible vs OR, 1.18; 95% CI, 1.16-1.18 for noneligible); and hospital quality score, measured on a scale of 1 to 5 stars with 1 being the worst and 5 being the best (OR, 1.27; 95% CI, 1.22-1.31 for 1 star vs OR, 1.11; 95% CI, 1.08-1.15 for 5 stars). Greater hospital prevalence of SARS-CoV-2 was associated with greater increases in odds of death from the prepandemic period to the pandemic period; for example, comparing mortality in October through December 2020 with October through December 2019, the OR was 1.44 (95% CI, 1.39-1.49) for hospitals in the top quartile of SARS-CoV-2 admissions vs an OR of 1.19 (95% CI, 1.16-1.22) for admissions to hospitals in the lowest quartile. This association was mostly limited to admissions with high-severity diagnoses. Conclusions and Relevance: The prolonged elevation in mortality rates after hospital admission in 2020 and 2021 for non-SARS-CoV-2 diagnoses contrasts with reports of improvement in hospital mortality during 2020 for SARS-CoV-2. The results of this cohort study suggest that, with the continued impact of SARS-CoV-2, it is important to implement interventions to improve access to high-quality hospital care for those with non-SARS-CoV-2 diseases.