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A Wake-Up Call about Infections in Long-Term Care Facilities

Summary:
Those live in long-term care facilities are by definition more likely to be older and facing multiple health risks. Thus, it's not unexpected that a high proportion of those dying from the coronavirus live in long-term care facilities. But the problem of infections and deaths in long-term care facilities predates the coronavirus pandemic, and will likely outlast it, too. Here's some text from the Centers for Disease Control website: Nursing homes, skilled nursing facilities, and assisted living facilities, (collectively known as long-term care facilities, LTCFs) provide a variety of services, both medical and personal care, to people who are unable to manage independently in the community. Over 4 million Americans are admitted to or reside in nursing homes and skilled nursing facilities

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Those live in long-term care facilities are by definition more likely to be older and facing multiple health risks. Thus, it's not unexpected that a high proportion of those dying from the coronavirus live in long-term care facilities. But the problem of infections and deaths in long-term care facilities predates the coronavirus pandemic, and will likely outlast it, too. Here's some text from the Centers for Disease Control website:
Nursing homes, skilled nursing facilities, and assisted living facilities, (collectively known as long-term care facilities, LTCFs) provide a variety of services, both medical and personal care, to people who are unable to manage independently in the community. Over 4 million Americans are admitted to or reside in nursing homes and skilled nursing facilities each year and nearly one million persons reside in assisted living facilities. Data about infections in LTCFs are limited, but it has been estimated in the medical literature that:
  • 1 to 3 million serious infections occur every year in these facilities.
  • Infections include urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others.
  • Infections are a major cause of hospitalization and death; as many as 380,000 people die of the infections in LTCFs every year.
If you're a number-curious person like me, you immediately think, "Where does that estimate of 380,000 deaths come from? A bit of searching unearths that the 380,000 is from the National Action Plan to Prevent Health Care-Associated Infections, a title which has the nice ring of a program that is already well-underway. But then you look at Phase Three: Long-Term Care Facilities, and it takes you to a report called "Chapter 8: Long-Term Care Facilities," which dated April 2013.  The 2013 report reads:
More recent estimates of the rates of HAIs [health-care associated infections] occurring in NH/SNF [nursing home/skilled nursing facility] residents range widely from 1.4 to 5.2 infections per 1,000 resident-care days.2,3 Extrapolations of these rates to the approximately 1.5 million U.S. adults living in NHs/SNFs suggest a range from 765,000 to 2.8 million infections occurring in U.S. NHs/SNFs every year.4 Given the rising number of individuals receiving more complex medical care in NHs/SNFs, these numbers might underestimate the true magnitude of HAIs in this setting. Additionally, morbidity and mortality due to HAIs in LTCFs [long-term care facilities] are substantial. Infections are among the most frequent causes of transfer from LTCFs to acute care hospitals and 30-day hospital readmissions.5,6 Data from older studies conservatively estimate that infections in the NH/SNF population could account for more than 150,000 hospitalizations each year and a resultant $673 million in additional health care costs.5 Infections also have been associated with increased mortality in this population.4,7,8 Extrapolation based on estimates from older publications suggests that infections could result in as many as 380,000 deaths among NH/SNF residents every year.5
Because I am on a hunt for the source of the estimate of 380,000 deaths, I take a look at note 5, which refers to a 1991 study: Teresi JA, Holmes D, Bloom HG, Monaco C & Rosen S. Factors differentiating hospital transfers from long-term care facilities with high and low transfer rates. Gerontologist. Dec 1991; 31(6):795-806.  

So to summarize the bidding. Here in 2020, in the midst of a pandemic where the infections are  causing particular harm in nursing homes, the CDC website in 2020 is quoting estimates of deaths from a study published in 2013, and the methodology for estimating those deaths relies on an extrapolation from a study published three decades ago in 1991. 

I'm sure there are many good people making substantial efforts to reduce infections in long-term care facilities, often at meaningful risk to their own health. But ultimately, the degree of success in reducing infections isn't measured by good intentions or efforts: it's measured by actual counts of infections and deaths. And when the CDC describes estimates of "serious infections" that vary by a factor of three, and estimates of deaths based on extrapolations from a 1991 study, it seems pretty clear that the statistics about infections in long-term care facilities are not well-measured or consistent over time.

This problem of infections in long-term care facilities will matter well beyond the pandemic. Populations are aging everywhere: in the United States, 3.8% of the population is currently over 80, but by 2050 it will likely rise to 8.2%. The demand for long-term care is likely to rise accordingly,  which in turn will raise difficult questions about where the workers for such facilities and the financial support will come from. Here, I would emphasize that it will take redoubled efforts if the future rise in number of people in long-term care is not to be matched by a similar rise in the number of people subject to infections, including when (not if) future pandemics arrive.

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