# A new framework for disentangling different components of excess mortality applied to Dutch care home residents during Covid-19

## TL;DR

This paper introduces a new method to analyze how much more care home residents died during the pandemic compared to what would be expected based on their usual high mortality and general population trends.

## Contribution

The paper introduces a novel framework called 'excess excess mortality' to disentangle mortality components in vulnerable groups during crises.

## Key findings

- Care home residents in the Netherlands experienced significant excess excess mortality during the pandemic.
- Older age and male gender were associated with higher excess excess mortality.
- The framework provides a methodological foundation for analyzing excess mortality in vulnerable groups.

## Abstract

Vulnerable subgroups of the population, such as care home residents, often face elevated mortality risks during crises like pandemics or wars. To correctly model and interpret the excess mortality of vulnerable groups during crises, a distinction must be made between the pre-existing heightened mortality of the vulnerable group, the general population’s excess mortality during the crisis, and the crisis-specific excess mortality unique to the vulnerable group.

We introduce the concept of “excess excess” mortality, which captures the extra excess mortality experienced by vulnerable groups during crises, beyond what can be explained by their excess mortality due to being vulnerable and general population excess mortality. Using individual-level data from Statistics Netherlands, we model the excess excess mortality of Dutch care home residents aged 70 and older during the Covid-19 pandemic. We extend standard relative survival methods by incorporating multiple excess mortality components and use an additive hazards model to accommodate periods of negative excess hazard.

The findings confirm the severe impact of the Covid-19 pandemic on care home residents. In general, men and older age groups experienced higher excess excess mortality, both in absolute and relative terms.

Our approach offers a new perspective on how to model and interpret excess mortality in vulnerable groups during a crisis and provides a methodological foundation for investigating excess excess mortality in other contexts.

The online version contains supplementary material available at 10.1186/s12874-025-02579-1.