On Jan. 11, Oconee County’s St. Gabriel of Athens personal care home off Virgil Langford Road reported to the Department of Community Health its first two deaths from COVID-19 among its residents.
On Jan. 20, St. Gabriel’s reported three more deaths from COVID-19, and on Jan. 26 it reported one more death.
The next day, Jan. 27, it reported two more, bringing its total to eight.
On Jan. 22, Oconee County’s St. Mary’s Highland Hills Village personal care home, 1660 Jennings Mill Road, reported to the Department of Community Health the death of one of its residents from COVID-19.
These nine deaths all appeared in the Georgia Department of Community Health’s Long-Term Care Facility Report, released online each weekday by the Georgia Department of Public Health, which keeps the official state record of “confirmed” deaths from COVID-19.
That discrepancy between the death counts of the Department of Community Health and the death counts of the Department of Public Health--in evidence in Oconee County since the first of the year--has been present in the Northeast Health District since the outbreak of the pandemic a year ago.
It also is mirrored in current questions about the number of nursing home deaths in New York and elsewhere around the country.
Since Jan. 11, when the Department of Community Health listed the first of the nine COVID-19 deaths at St. Gabriel and St. Mary’s, the Department of Public Health has recorded 14 confirmed COVID-19 deaths in the county.
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Included in the confirmed deaths, were a 43-year-old, a 56-year-old, and five persons in their 70s. None of these was likely to be a long-term care facility resident.
An examination of actual date of death of those 14 confirmed deaths shows that only nine of them even occurred since Jan. 11, when St. Gabriel reported its first two deaths. Those nine include the 56-year-old and three of those in their 70s.
And only five of the 14 confirmed deaths occurred on dates when the long-term care facilities reported deaths. Those five on corresponding dates include the 56-year-old, a 73-year-old, and a 75-year-old.
Given the available evidence, it is possible to conclude that some of the deaths reported by St. Gabriel and St. Mary’s ultimately were included in the list of “confirmed” COVID-19 deaths for the state.
It also is nearly certain that many–and probably most–were not.
The situation in Oconee County does not appear to be unique, suggesting that the figures for the Northeast Health District and the state as a whole show this same pattern of officially undercounting deaths that the long-term care facility operators attribute to COVID-19.
Two Different Reports
The Department of Community Health and the Department of Public Health are two of Georgia’s four “Health Care Agencies,” with the Department of Behavioral Health and Disabilities and the Department of Human Services being the other two.
The Department of Community Health produces the Long-Term Care Facility Report on COVID-19 in the state’s long-term care facilities.
The Department of Public Health produces the Daily Status Report on COVID-19 overall.
The problem of an undercount of nursing homes deaths had been identified in Clarke County in early April of last year when PruittHealth Grandview announced 10 deaths at the nursing home when the Daily Status Report listed only nine deaths for Clarke County.
Later that month, when the Long-Term Care Facility Report was first produced, differences between the information being provided by the two agencies across several dimensions, including deaths, was striking.
The discrepancies between the reports of these two agencies have been obvious in Oconee County as well going back to May of last year.
While the Department of Public Health listed Oconee County as having no deaths attributed to COVID-19 at that time, the Department of Community Health listed two deaths at the High Shoals Health and Rehabilitation nursing home, 3450 New High Shoals Road in the west of the county.
The Department of Public Health first reported two “confirmed” deaths in the county a day later.
And while one of the deaths was of an 86-year-old man with a known chronic condition and the other was a woman more than 90 years old without a known chronic condition, the date of death of the man did not match with what relatives said was correct.
Discrepancies between the two reports have been in evidence elsewhere in the Northeast Health District, with Elbert County at one point having more deaths in the Department of Community Health Report than in the Department of Public Health Report.
Despite the discrepancies, media and other reports have indicated that nursing home deaths were included in the confirmed death lists of the Daily Status Report.
A widely circulated media report in April said that a third of the deaths in the state were at long-term care facilities, based on the counts at the facilities and the total death tally for the state.
On May 28, Gov. Brian Kemp said that “Right now, 48 percent of all COVID-19 deaths in Georgia are connected to long-term care facilities.”
The computation also was based on dividing the number of reported long-term care facility deaths by the total reported by the Department of Public Health.
It seemed to make sense that the two state health agencies counting deaths would count a COVID-19 death the same way and share the results of the counts.
Different Ways Of Counting
But the two agencies have different ways of gathering data and determining the cause of death.
The data in the Department of Community Health Long-Term Care Facility Report are provided to the Department of Community Health by the long-term facility operator. The operator lists the death as caused by COVID-19.
The data are not verified by the Department of Community Health before being passed to the Department of Public Health for distribution. Personal care homes also are not required to have medical workers on site.
For the Department of Public Health to treat a death as a confirmed COVID-19 death, it has to pass two standards.
First, there must be confirmation that the individual who died had COVID-19 based on a positive molecular test “reported through multiple sources including electronic lab reporting (ELR), State Electronic Notifiable Disease Surveillance System (SendSS), faxed case reports and calls from providers to DPH.”
Second, the “conformed “case then has to be reported to the Department of Public Health “as deceased by healthcare providers, medical examiners/coroners, or identified by death certificates with COVID-19 indicated as the cause of death.”
New Death Type Added
In early November, the Department of Public Health began reporting another COVID-19 death statistic called “probable” deaths in addition to “confirmed” deaths.
Probable deaths are “individuals who are antigen positive or individuals with compatible illness and known close contact to a case (and) that were either reported to DPH as deceased by healthcare providers or medical examiners/coroners, identified by death certificates with COVID-19 indicated as the cause of death, or there is evidence that COVID contributed to the individual’s death.”
Also included as “probable” deaths were “individuals with a death certificate that has COVID-19 indicated as the cause of death” and there is no laboratory evidence of COVID-19.
Funeral directors, according to Georgia code, file the death certificates.
“The funeral director or person acting as such who first assumes custody of the dead body shall file the certificate of death,” code states.
“Such director or person shall obtain the personal data from the next of kin or the best qualified person or source available and shall obtain the medical certification from the person responsible therefor,” the law states.
So it is quite easy to see why deaths reported by long-term care facility operators to the Department of Community Health are not immediately–and maybe not ever–reported as confirmed deaths by the Department of Public Health.
Questions To Answer
The real question, then, is how many of the deaths reported in the Long-Term Care Facility Report make it to the Department of Public Health list of confirmed deaths?
The governor’s statement and media reports suggested that all of them do.
And following from that, how many of the deaths in the Department of Public Health classification of confirmed deaths actually are long-term care facility resident deaths?
Finally, what would be the death count if all of the estimates of deaths were included, eliminating redundancies where possible?
For my reporting for this blog, I examine each issuance of the Department of Community Health Long-Term Care Facility Report, converting the file to a spread sheet, sorting cases by county, and selecting out data for facilities in the 10 counties of the Northeast Health District.
I then compare each day’s report with the previous day’s report to see what changes have taken place in each facility's report.
The Long-Term Care Facility Report is usually issued Monday through Friday.
The reports of the deaths at St. Gabriel and St. Mary’s in the Department of Community Health Reports in January brought into focus once again the issues of classification of deaths.
St. Gabriel told the Department of Community Health, in its Jan. 11 Long-Term Care Facility Report listing its first death, that it had 42 residents, 20 of whom had tested positive for COVID-19, and 10 staff members who had be positive for COVID-19.
St. Mary’s, in its report of its death on Jan. 22, said the facility had 49 residents, six of whom had tested positive for the disease (with one of those recovered), and 11 staff members who had been positive for COVID-19.
New Data Source
My starting point was the dates on which St. Gabriel and St. Mary’s listed deaths in their reports to the Department of Community Health. The Report contains no information about the characteristics of the deceased.
The Department of Public Health Daily Status Report lists deaths by county each day. By subtracting from the number on a given day the number of the previous day, it is possible to see how many new deaths are being reported in a given county. I do this analysis every day.
The Department of Public Health also lists basic characteristics of the deaths, such as age and sex. By comparing the reports day-to-day, it is possible to identify the characteristics of the person who died and whose death was added on a given day.
In addition, the Department of Public Health has begun releasing more archival data about the reports of deaths.
It now releases each day two separate files that contain confirmed deaths. One of the files has the deaths listed by when they were reported.
The other has the deaths listed by when the actual death took place.
The data are sorted by county.
By comparing changes in the two files day-to-day, that is, seeing what happens to the file listing deaths by date when a death also has been listed by date of report, it is possible to identify the date of death of most of the cases added. (Ambiguity occurs when more than one death is reported on a single day.)
These deaths also can be identified by age and by a few other characteristics.
I’ve listed all 14 deaths from Jan. 11, when St. Gabriel reported its first two deaths, through Feb. 17, in the chart at the right.
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I’ve also listed the dates of the reported deaths at the two personal care homes in Oconee County and the dates the 14 deaths were reported in the Department of Public Health Daily Status Report. I also listed the characteristics of the deceased.
Finally, I have listed the date those deaths actually occurred. In the cases where more than one death occurred, I have had to list the dates for both of those deaths, since it is not possible to distinguish between them.
What is clear is that five of the 14 confirmed deaths in the Department of Public Health Report occurred before Jan. 11, when the first of St. Gabriel’s deaths were reported, so none of these five could have been a death at the two Oconee County facilities.
Of the remaining nine confirmed deaths listed by the Department of Public Health, one occurred on Jan. 22, when St. Mary’s reported its death. The individual was 86-year-old.
One occurred on Jan. 20, when St. Gabriel reported three deaths. That person was 73-years-old.
One occurred on Jan. 26, when St. Gabriel reported a death. That person was 56-years-old.
Two occurred on Jan. 26 or Jan. 27, when St. Gabriel reported deaths. Those individuals were 75-years-old and 90-plus-years-old.
So, at a maximum, only five of the nine deaths reported at the long-term care facilities were recorded as confirmed deaths, and only five of the 14 deaths confirmed deaths could have been at a long-term care facility.
It seems more likely that the 56-year-old, the 73-year-old, and the 75-year-old , all of whom did not have a chronic condition, were not matches.
In that case, only two of the nine long-term care facility deaths were recorded as confirmed deaths, and only two of the 14 deaths reported in the county in the period were at long-term care facilities.
On Jan. 10, Oconee County had two “probable” deaths listed, and the county has picked up three since then. The Daily Status Report contains no information on “probable” deaths. It is possible some of the deaths at the two personal care homes were recorded as “probable” rather than “confirmed.”
It also is possible, of course, that more of the deaths from St. Gabriel and St. Mary’s will be recorded over time as "confirmed," but there certainly is no guarantee, given the methodology used, that this will be the case.
Extrapolation Of Findings
Oconee County has had deaths reported at both of the county’s other long-term care facilities covered by the Department of Community Health Long-Term Care Facility Report.
Magnolia Estates Of Oconee personal care home, 1641 Virgil Langford Road, has reported four deaths, and High Shoals Health and Rehabilitation has reported eight.
So out of Oconee County’s 55 deaths from COVID-19, a maximum of 21 would have occurred among long-term care facilities in the county if all of them had been counted.
If only half had been counted, that ratio would be more like 11 out of 55. And it also would mean that the death toll in the county–including the deaths in the long-term care facilities--would be about 10 deaths higher, or 65.
Add to that the five probable deaths, and the figure is 70.
If the undercount is more like two of the nine long-term care facility deaths being counted, the undercount is even greater.
That would suggest that the death figure would be more like 15 higher, or 70, and the figure with the “probable” deaths would be more like 75.
Extension To District
The Northeast Health District has 40 long-term care facilities covered by the Department of Community Health Long-Term Care Facility Report, with a total of 230 deaths reported since the beginning of the pandemic.
The District has 724 “confirmed” deaths and 64 “probable” deaths listed in the Department of Public Health Daily Status Report.
If half of the 230 deaths have been accepted as “confirmed” by the Department of Public Health–a generous estimate–that would mean the District should add another 115 deaths to its toll for a complete accounting.
So the District death count grows to somewhere in the neighborhood of 900, including the “probable” deaths.
If only about a fifth of the deaths from the long-term care homes have been included, an estimate of total District deaths, including those deaths in senior homes and the “probable” deaths, climbs to about 975.
Extension To State
For the entire state of Georgia, the Department of Public Health on Thursday listed 14,358 “confirmed” deaths in it Daily Status Report and 2,045 “probable” deaths.
The Long-Term Care Facility Report for Wednesday–the most recent one issued–listed 4,158 deaths at the state’s long-term care facilities.
So rough estimates would put the total number of deaths in the state, including “confirmed” deaths, “probable” deaths, and some portion of the long-term care facility deaths at between 18,500 and 19,750.
The lower figure is based on the assumption that half of the long-term care facility deaths already have been counted, and the high figure assumes only a fifth already have been counted.
These are only very rough estimates, of course, made more difficult because the state only began reporting “probable” deaths on Nov. 3.
For that reason, there is no way from the public data of knowing what the total number of “probable” deaths going back to the beginning of February of 2020 is.
There certainly were some deaths attributed to COVID-19 by long-term care facility operators that should not have been assigned to the disease, and there likely were some that should have been that were not.
In fact, the operators have an incentive not to list a death as caused by COVID-19 so as not to call attention to COVID-19 at the facility.
What seems certain is that the “confirmed” death figures for Oconee County, the Northeast Health District, and the state are very conservative ones that almost certainly underestimate the total number of deaths from COVID-19.
And it also is clear that no one really knows–or is saying–what percentage of the county, Northeast Health District’s, or state’s COVID-19 deaths have been at long-term care facilities.