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

Educational Objective
To understand the risks associated with mortality among residents with COVID-19 in long-term care facilities
1 Credit CME
Key Points

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.

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Article Information

Accepted for Publication: June 14, 2020.

Published: July 22, 2020. doi:10.1001/jamanetworkopen.2020.15957

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Fisman DN et al. JAMA Network Open.

Corresponding Author: David N. Fisman, MD, MPH, Dalla Lana School of Public Health, University of Toronto, 155 College St, Room 686, Toronto, ON M5T 3M7, Canada (david.fisman@utoronto.ca).

Author Contributions: Dr Fisman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fisman, Tuite.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Fisman, Bogoch.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Fisman.

Obtained funding: Fisman.

Administrative, technical, or material support: Bogoch, McCready.

Supervision: McCready.

Conflict of Interest Disclosures: Dr Bogoch reported serving as a consultant for BlueDot. No other disclosures were reported.

Funding/Support: The study was supported by grant OV4-170360 to Dr Fisman from the Canadian Institutes for Health Research.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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