Reconcilable Differences?

Questions about NYC "Wave 1" death data

You’ve probably heard about the New York nursing home scandal.

Short version: Governor Andrew Cuomo killed a whole bunch of people by sending covid-positive patients into nursing homes. He then tried to cover up the total number of residents who died from covid by excluding from public announcement the number that died in hospitals.

More-detailed version: Two weeks after cutting off visitors to nursing homes and telling New Yorkers to stay home, Andrew Cuomo issued an advisory on March 25th, saying hospitalized covid patients couldn’t be denied readmission or new admission to a nursing home/long-term care facility based solely on a confirmed or suspected covid-19 diagnosis.

Under this policy, there were more than 9,000 admissions from hospitals to such facilities. Roughly 2,800 were readmissions of patients who were sent back from a hospital to the care facility where they’d been living, while 6,300 were patients sent from hospitals to such facilities for the first time.¹ Facing pressure from lawmakers and families, Cuomo rescinded the directive on May 10, 2020. The Governor’s efforts to underreport the number of resident deaths were later exposed.

Andrew Cuomo is undoubtedly one the pandemic’s worst politicians. As much as I loathe everything about his response to covid-19, I can’t let my disdain get in the way of making sure the data actually tells the story now being told.²

In particular, my eyes are on how the prevailing narrative stacks up against the New York City numbers. Do data support the “Covid-Ran-Rampant-In-NYC-Nursing-Homes-Because-of-Cuomo’s-Directive” claim? More importantly, do they substantially help explain New York City’s lockdown-triggered spring 2020 mortality event?

I don’t know yet, but here are some differences between data sources that are hard for me to reconcile. I’m hoping readers can help.

Big Picture

I'll start with some “Wave 1” totals from CDC WONDER, the U.S.’s central public mortality database.³ By July 18, 2020, there were 19,860 NYC⁴ resident deaths that cite covid-19 as underlying cause.

A “Place of Death” query shows where these people died. Most were inside hospitals or outpatient facilities; relatively few were inside nursing homes/LTCFs.

WONDER v. NYDOH

If 9% of deaths that attributed covid as underlying cause being in NYC nursing homes sounds low, remember this number doesn’t include residents who died in hospitals. (But 9% was less than I expected too.)

Unfortunately, we can’t discern that total from WONDER, because the database doesn’t track how many medical-facility deaths were transfers from nursing homes.

Fortunately, NYDOH’s “Statewide COVID-19 Nursing Home and Adult Care Facility Fatalities” dataset lists resident covid deaths by county & by week,⁵ in three categories:

• lab-confirmed covid-19 disease that occurred at the facility

• lab-confirmed covid-19 disease that occurred outside of the facility,

• covid-19 presumed disease that occurred at the facility⁶.

Here’s the Wave 1 summary⁷:

To my eye, these data don’t jibe well with the WONDER figures — even after considering a) the two sources show slightly different things, b) the WONDER data covers a few more days, and c) NYDOH says its data is self-reported by facilities & hasn’t been verified for accuracy.

The issues I see follow:

• NYDOH shows 1,411 lab-confirmed covid deaths in facilities. Both the dictionary for the dataset & my correspondence with the NYDOH affirm that a “lab-confirmed” covid death was a patient who tested positive for covid before or at their death. Laying aside the problems such a definition created, I’m curious whether these deaths were deaths for where covid was determined to be an underlying cause? We don’t know. Regardless, the NYDOE “confirmed” number is 400+ covid deaths fewer than the WONDER number…and fewer than I anticipated.)

• The confirmed + presumed in-facility total is more than double the confirmed in-facility total, and nearly double the of covid-underlying cause deaths in WONDER. More specifically, WONDER says there were 7,687 deaths from all causes inside of nursing homes/LTCFs, 5,852 of which did not attribute covid as underlying cause. Is NYDOH data saying 2,017 of those deaths are presumed covid deaths?

• If we include an additional 538 facility deaths that WONDER says listed covid as a contributing cause, that’s 2,373 - more than 1,300 deaths fewer than NYDOH is reporting for confirmed + presumed together. Again, are NYC nursing homes reporting presumed covid deaths of people for whom covid appears nowhere on the death certificate?

• WONDER shows 16,440 covid-as-underlying-cause deaths in inpatient, outpatient, + emergency room deaths. Assuming NYDOH’s “out of facility” number is almost entirely hospital deaths, that means nursing home residents comprise a relatively low percent of that total (2,195/16,440 = 13.3%). Who were the other thousands that (purportedly) died from covid in NYC hospitals?

• If we take NYDOH’s total number of NYC nursing home resident deaths (confirmed + presumed) at face value, and subtract it from the total number of Wave 1 deaths WONDER shows (n=19,860), that means 72% of Wave 1 covid deaths in NYC were not nursing home residents⁸. Who were they, and where are they supposed to have contracted the virus? (In the hospital?)

Enter 2019

Pretend the NYDOE data doesn’t exist, is too error-laden to take seriously, or that I’ve made mistakes in calculation or assumption that others will catch. Comparing WONDER’s Wave 1 place of death data for NYC 2020 to the same weeks in 2019 still should raise your eyebrows.

Here’s 2019 vs. 2020, with raw-number & percent change for deaths from all causes. (Remember, the bulk of these deaths were between mid-March 2020 and mid-May 2020.)

Massive increases everywhere except hospice facilities. I suspect the decrease there is for one of two reasons: 1) people who would’ve been sent to hospice facility were instead kept in the hospital, and/or 2) hospice facility patients chose to die at home.

The proportion of deaths at each type of place also shifted, with a greater percent occurring in hospitals and nursing homes.

Note: This is 100% stacked bar chart.

At every place of death except hospitals, non-covid deaths exceeded covid-attributed deaths. There were almost twice as many covid deaths among hospital inpatients as non-covid. Indeed, it appears being in a hospital greatly increased the chance that a death would be attributed to covid.

How much of the mortality increase for each place of death was attributed to covid? Take a look:

Incredibly, we’re supposed to believe that over 100% of the increase in hospital inpatient deaths was from a virus that, for most people, isn’t much more deadly than flu. So, in effect, there were no additional deaths in among NYC inpatient during these months that weren’t attributed to covid? Does that make sense? (No, it does not.)

As skeptical as I am of the at-home covid death number, it’s notable that 75% of the home mortality rise were non-covid deaths. And for all the talk of covid rampaging nursing homes, over 60% of the rise in death at those facilities wasn’t deaths credited to the virus. Huh.

If you look at above table and wonder whether a generous definition of “covid death” - aided & abetted by PCR testing - led to an inordinate number of hospital deaths being attributed to the virus, and is helping “cover” the non-covid death toll, I am with you.

Back to the Beginning

Now go back to the NYDOH data.

To reiterate:

• The state’s “confirmed out of facility” number for NYC nursing homes suggests most covid-attributed deaths in hospitals were not nursing home residents. Who were those people, and did most of them come to the hospital because they were experiencing respiratory-illness symptoms?

• The state’s total number of confirmed NYC nursing home resident covid deaths (3,606) is a lower % of the total number of NYC covid deaths than I expected (18%). Even confirmed + presumed covid is less than a third. Is it me, or is that low?

• It’s unclear whether “presumed in-facility” deaths for NYC nursing homes are deaths the state is counting as covid deaths without covid being anywhere on the death certificate. Without those 2,000 deaths - and knowing some portion of the *confirmed* in-facility deaths are a function of testing vs. actual illness/cause - am I crazy to say that factors other than covid may be much more responsible for the 164% increase in deaths occurring inside NYC nursing homes?

Please, don’t misunderstand me. I’m not saying covid-19 isn’t a real disease that is deadly for some people, or that covid-19 didn’t kill nursing home residents (in NYC and elsewhere).

I am saying the data I’ve presented in both this post and a previous one raise serious questions about who all died in the NYC spring 2020 mortality wave, how, and from what.

In my opinion, the answers are more complex than “Andrew Cuomo.”

Additional graphs posted on 9/24/22 for reference

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Subsequent posts:

The NYC Nursing Home Narrative, Part 1: How Many New York City Nursing Home Residents Died in Spring 2020?

New York City Spring 2020: Emergency Department/Outpatient Deaths & Cuomo's Nursing Home Policy, Part 1.5

FDNY Suddenly Closes My FOIL Request for Ambulance Transfer Data

1. https://apnews.com/article/new-york-andrew-cuomo-us-news-coronavirus-pandemic-nursing-homes-512cae0abb55a55f375b3192f2cdd6b5/

2. That includes the information in the New York attorney general’s office’s Jan 2021 report, and the March 2022 audit from the state comptroller.

3. I defined the Wave 1 timeframe as through mid-July 2020 to be consistent with the New York State comptroller’s audit.

4. Bronx, Kings, New York, Queens, and Richmond Counties

5. Per a health department response to me: “The data source is the daily COVID-19 survey through the New York State Department of Health’s Health Electronic Response Data System (HERDS). Hospitals, nursing homes, and adult care facilities are required to complete this survey daily. Please further note, the data is reported by each facility and had not been verified for accuracy. The information from the survey is used for statewide surveillance, planning, resource allocation, and emergency response activities. Hospitals began reporting for the HERDS COVID-19 survey in March 2020, while Nursing Homes and Adult Care Facilities began reporting in April 2020. It is important to note that fatalities related to COVID-19 disease that occurred prior to the first publication dates are also included."

6. The CDC issued new guidance on April 14, 2020, redefining what constituted a covid death, stating that death counts include both confirmed and probable deaths.

7. The time period is four days shorter than the WONDER database allows (7/14/20 vs 7/18/20). This makes little difference, as the overwhelming majority of deaths were in March, April, and May.

8. If we subtract the 5,623 confirmed + presumed total from the total number of NYC Wave 1 deaths that WONDER says listed covid anywhere on the death certificate (n=21,336), we’re left with an even higher percentage of covid deaths that were not nursing home residents (74%).