States had to decide how to count nursing home deaths. In N.Y., Cuomo used an 'outlier' method, experts say.
When Gov. Andrew Cuomo in New York was first accused of undercounting Covid-19 nursing deaths, his office gave a clear explanation:
The state did not include in its officially released tally of coronavirus deaths related to long-term care centers nursing home patients who died in the hospital, officials said, because they wanted to prevent "double counts" of the number of such deaths.
However, New York is characterized from its approach to counting nursing home deaths — a decision taken by New York's tale of nursing homes is smaller than it was and is under federal inquiry.
"It is difficult to compare state data, but New York is the only State that has explicitly stated that hospital-based deaths are excluded," said Priya Chidambaram, senior policy analyst at the Kaiser Family Founds.
Operators in other states, including Minnesota, Connecticut, Massachusetts and Vermont have instead claimed in recent interviews that, by referring information from nursing homes to other data providers, they find ways of totalizing all nursing homes, including people who died in hospitals without counting them twice.
Analysis analysts, including Chidambaram, said they knew no other state that counted nursing homeless deaths such as New York.
This left politicians as well as analysts questioning why New York did not find a comparable way to eliminate thousands of home-reported deaths from its number.
"New York is a sort of outlier when it comes to this matter," said David Grabowski, Harvard Medical School's long term specialist in treatment and professor of politics.
Per state has created its own system to count Covid-19 deaths in nursing homes and in general.
And New York specifically claimed from the early months of the pandemic that only those in the grounds, as opposed to a hospital or somewhere else, contained the public counts of treatment homicides.
The state pursued this route to prevent including these deaths two times in all New York residents who were killed by Dr. Howard Zucker, a state health official, told state legislators about the care of nursing homes after the pandemic during a hearing in August.
"We don't want to duplicate — this person died here and there, too," said Zucker, defining "incredibly transparent on information" as an administration of Cuomo.
New York officials have said it is necessary to check accounts of patients who died before they were made public, as the information given by nursing homes was not necessarily reliable, especially during the turbulent early days of the pandemic.
"It's natural to suppose that they don't have as much information as they could have on their walls," said Gary Holmes, a state medical department spokesperson.
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However, this strategy caused New York to omit a significant number of deaths from its officially reported overall care homes until recently.
The state said that nearly 8,500 nursing homes died of Covid-19.
But when New York finally included residents who died in hospitals, the cumulative shot was around 15,000 – more than any other state by the end of January, the long-term deaths count collected by the Kaiser Family Founds recorded on a state-by-state basis.
And the state reported the latest number just last month after its own attorney general published a report accusing Cuomo of under-counting deaths.
The health department of New York said a time-consuming verification procedure culminated in the delay in reporting the number of hospital-based deaths.
The Covid-19 states that day-to-day nursing homes and hospitals only include initials and age of tenants who died "to protect patient privacy."
Although more detail on hospital mortality is possible, information is entered in a different scheme, which sometimes lags behind and does not contain a patient's home name, he said.
"Great lengths have been taken to ensure accuracy in multiple source data reporting."
Holmes has reported the recently released death toll in New York has not increased as all child home deaths have been counted across the state wherever they occurred.
Officials in other Northeast and abroad told NBC News that a particular method has been taken to collect an exhaustive count of resident deaths – independent of the hospital or services – to prevent the double-counting dilemma of New York officials.
For example, in Minnesota, "deaths are categorized by location," said Scott Smith, spokesperson of the Ministry of Public Health.
The state depends on self-reported statistics from nursing homes to provide demographic details, death dates and other information.
Minnesota also gathers data from hospitals, clinics, medical examiners and death records for matching and excluding double-checking entries, Smith said.
Similarly, Connecticut uses self-reported reports from nursing homes, mandated to record any patient deaths "whether they occur in their premises or after transferring to a hospital," said David Dearborn, a state health care spokesperson.
The state also depends on information from the state veterinarian to avoid repetition of deaths in the cumulative number, Dearborn said.
"This process guarantees a precise total statewide."
Massachusetts is taking a similar method to cross-referencing death certificate nursing homes to eliminate repetition of inscriptions to capture complete Covid-19 deaths, a State health spokesperson said.
While the pandemic was unique in many aspects, the data issues are not fresh, said Grabowski, professor of Harvard Medical School.
"Historically, officials of public health often had to distinguish between death and residence immediately prior to death," he added.
"I see no reason why other states could classify their pre-residence and New York could not."
Bill Hammond, senior health policy fellow at the Empire Center, the right-hand think tank which has sued the state for failure to disclose the report on home-care deaths, said New York officials should have readily accessed the simple data.
According to New York's data collection form collected in the litigation, "the total number of residents of Covid 19 died outside your facility" and the total number of people who died outside your facility is specifically demanded for the nursing homes.
"This isn't a complicated thing to do," Hammond said, believing that New York authorities should have promptly issued death counts, both hospital and non-hospital, then re-checked the specifics later, if they found it appropriate.
"They use as a reason for postponement the need for maximum accuracy and the difficulty of reconciling both data sets," he said.
There are other discrepancies and wider contradictions in the data between states.
For eg, New York and Minnesota include possibly Covid-19 cases in death counts, but only some count laboratory-confirmed cases.
In certain nations, workers were counted in the overall number of deaths associated with long-term care, while in others they were not included or isolated.
Some states took months until comprehensive statistics on homeless deaths was published.
And facilities can not disclose correct details on their own.
The long-term care sector itself is doubtful that more evidence will have made a huge difference in the overall pandemic response.
"This is just another piece of data that could or could not show anything," said James Clyne, CEO and chairman of LeadingAge New York, which serves long term non-profit treatment facilities.
"Has anybody looked at it and found any findings?
It's not that everyone had this epiphany, because it was given."
However, experts say that detailed state knowledge is essential for the full effect of the pandemic on nursing homes.
Such data could help public health officials determine in the worst months of the pandemic, according to advocates.
Researchers may also classify the causes made the facilities more vulnerable to Covid-19 cases and deaths, and which management actions appear to lead to shielding residents and employees.
In the early months of the pandemic, for example, the Cuomo administration was on fire to insist that nursing homes allow patients released from hospitals to heal from Covid-19 — a move meant to clear much-needed space in hospitals.
By Can, the guidance was effectively overturned and federal authorities issued an analysis that claimed that it was not a leader of nursing homes.
However, more detailed research on deaths may help offer more reliable responses, according to analysts and advocates.
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"Families and residents have suffered during the Covid pandemic not to know what's going on in facilities," the bill said.
Just in the first week of May, the federal government began gathering nationwide statistics on Covid 19 incidents and deaths in nursing homes and hospitals were not necessary to provide prior information.