Nursing Home Characteristics Associated With Resident COVID-19 Morbidity in Communities With High Infection Rates

Researchers examined nursing homes in communities with the highest COVID-19 prevalence to identify characteristics associated with resident infection rates.

As Chen, et al. (2021) note, "Nursing home (NH) residents have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. Transmission rates in an NH’s surrounding community have been identified as a key risk factor associated with NH COVID-19 outbreaks. It is not known whether some NHs within communities are more successful at mitigating outbreaks among residents than others. We examined NHs in communities with the highest COVID-19 prevalence to identify characteristics associated with resident infection rates."

This cross-sectional analysis used data on COVID-19 cases in US NHs reported through October 11, 2020, in the Centers for Medicare and Medicaid Services Nursing Home COVID-19 Public File. The first week of COVID-19 data reporting from the Centers for Medicare and Medicaid ended May 24, 2020. However, NHs could opt to report data retrospectively back to Jan. 1, 2020. The researchers merged these data with the 2017 Long-term Care: Facts on Care in the US (LTCFocus) database to obtain NH characteristics. They also used the USAFacts website to obtain county-level infection rates and the 2017 American Community Survey to obtain community characteristics. The Weill Cornell Medical College Institutional Review Board determined this study to be exempt from review because it did not involve human participants. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

The researchers say their analysis was restricted to counties in the top quartile of COVID-19 prevalence (mean, 36.0; range, 28.3-164.9 per 1000 population) nationwide. Within these counties, they compared facility characteristics by quartile of COVID-19 prevalence (cases per 1000 NH residents), including resident demographic characteristics (age, sex, and race), and activities of daily living score. The analysis also includes the number of NH beds, occupancy rate, for-profit status, chain membership, direct care staff hours, presence of an advanced practitioner (nurse practitioner or physician’s assistant), Alzheimer disease specialty unit presence, and the shares of residents covered by Medicare and Medicaid. County characteristics included median household income, percentage of individuals 75 years or older, and rural location. The researchers used 1-way analysis of variance for continuous variables and χ2 tests for categorical variables to test for statistical significance (2-sided P < .05) of differences in NH characteristics. Multivariable linear regression was used to examine characteristics associated with NH COVID-19 prevalence. They included hospital referral region fixed effects to account for unobserved regional factors that may affect COVID-19 spread. Standard errors were adjusted for clustering at the state level. Stata/IC version 16.0 (StataCorp LLC) was used for analysis.

The sample included 3008 NHs (255 923 occupied beds). The full cohort had a mean (SD) age of 78.4 (7.3) years, 165 582 residents (64.7%) were female, 90 341 residents (35.3%) were male, and 158 160 residents (61.8%) were insured by Medicaid. The NHs had a mean (SD) of 6.7 (9.5) COVID-19 cases per 1000 residents in the lowest quartile (755 NHs) and a mean (SD) of 677.1 (146.2) cases per 1000 residents in the highest quartile (752 NHs).

Adjusted estimates indicate that residents in NHs with more COVID-19 cases were older (regression coefficient, 2.2; 95% CI, 0.4-4.0; P = .02), the NHs had a lower proportion of White residents (−1.0; 95% CI, −1.7 to −0.2; P = .02), and residents had higher activities of daily living scores (7.1; 95% CI, 1.9-12.3; P = .009) (Table). In addition, a higher proportion of residents were insured by Medicaid (0.9; 95% CI, 0.1-1.7; P = .03), and the NHs had lower occupancy rates (−4.1; 95% CI, −5.1 to −3.0; P < .001) and fewer direct care hours per patient per day (−21.9; 95% CI, −32.7 to −11.0; P < .001). Nursing homes with more COVID-19 cases were more likely to have an advanced practitioner (33.7; 95% CI, 9.8-57.6; P = .007) compared with NHs with fewer COVID-19 cases among residents.

Reference: Chen AT, et al. Nursing Home Characteristics Associated With Resident COVID-19 Morbidity in Communities With High Infection Rates. JAMA Netw Open. 2021;4(3):e211555. doi:10.1001/jamanetworkopen.2021.1555

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