Estimates of COVID-19 Cases and Deaths Among NH Residents Not Reported in Federal Data

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

JAMA Network Open posted the results of this original Public Health investigation on September 9, 2021.  [NOTE: you will see 2 Download PDF icons on this landing page that will allow you to download the PDF version of this report.]  Additionally, Invited Commentary on this investigation by Elizabeth M. White, PhD, APRN is found here

You read the findings correctly – approximately 44% of COVID-19 cases and 40% of COVID-19 deaths that occurred before the start of required NHSN report, suggesting that nationally more than 68,000 cases and 16,000 deaths went unreported.

The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021.

Main Outcomes and Measures … The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN.

Conclusions and Relevance …These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.

Dr. White offers these takeaways from the investigation:

  • The first key takeaway from these findings is that future research using the NHSN data must account for this significant data limitation. Cumulative measures of COVID-19 prevalence or mortality are likely to be flawed without correcting for underreporting and may particularly bias estimates for nursing homes that had their most severe outbreaks during the initial US wave of the pandemic. 
  • The second, more humbling conclusion from these findings is that the true toll of COVID-19 on nursing home residents may never be known. Given the delay in federal data collection, the most accurate data sources for nursing home cases and deaths during the initial US wave of the pandemic are state health departments. Yet only approximately half of US states collected and publicly released nursing home COVID-19 data during Spring 2020, and these states varied widely in the amount and quality of information reported.  As such, although current measures of COVID-19 prevalence and mortality reflect a devastating public health crisis for the nursing home population, it is likely that even more lives were impacted that will never be fully captured in existing data.

I encourage you to review and share this report with your colleagues.