Staffing Levels and COVID-19 Cases and Outbreaks in U.S. Nursing Homes.

BACKGROUND/OBJECTIVES: Nursing homes have experienced a disproportionate share of COVID-19 cases and deaths. Early analyses indicated that baseline quality was not predictive of nursing home cases, but a more nuanced study of the role of nurse staffing is needed to target resources and better respond to future outbreaks. We sought to understand whether baseline nurse staffing is associated with the presence of COVID-19 in nursing homes and whether staffing impacts outbreak severity. DESIGN: We analyzed Centers for Medicare & Medicaid Services (CMS) facility-level data on COVID-19 cases and deaths merged with nursing home and county characteristics. We used logistic regressions to examine the associations of staffing levels from Nursing Home Compare with the outcomes of any COVID-19 cases and, conditional on at least one case, an outbreak. Among facilities with at least one case, we modeled count of deaths using hurdle negative binomial-2 regressions. SETTING: All nursing homes in the CMS COVID-19 Nursing Home Dataset with reports that passed the CMS Quality Assurance Check as of June 25, 2020. PARTICIPANTS: Residents of nursing homes that met COVID-19 reporting requirements. MEASUREMENTS: A nursing home is defined as having at least one case is if one or more confirmed or suspected COVID-19 case among residents or staff is reported. Conditional on at least one case, we examine two outcomes: an outbreak, defined as confirmed cases/certified beds >10% or total confirmed and suspected cases/beds >20% or >10 deaths, and the total number of deaths attributed to COVID-19 among residents and staff. RESULTS: A total of 71% of the 13,167 nursing homes that reported COVID-19 data as of June 14 had at least one case among residents and/or staff. Of those, 27% experienced an outbreak. Higher registered nurse-hours are associated with a higher probability of experiencing any cases. However, among facilities with at least one case, higher nurse aide (NA) hours and total nursing hours are associated with a lower probability of experiencing an outbreak and with fewer deaths. The strongest predictor of cases and outbreaks in nursing homes is per capita cases in the county. CONCLUSION: The prevalence of COVID-19 in the community remains the strongest predictor of COVID-19 cases and deaths in nursing homes, but higher NA hours and total nursing hours may help contain the number of cases and deaths.

The Metrics Matter: Improving Comparisons of COVID-19 Outbreaks in Nursing Homes.

OBJECTIVES: In the United States, nursing facility residents comprise fewer than 1% of the population but more than 40% of deaths due to Coronavirus Disease 2019 (COVID-19). Mitigating the enormous risk of COVID-19 to nursing home residents requires adequate data. The widely used Centers for Medicare & Medicaid Services (CMS) COVID-19 Nursing Home Dataset contains 2 derived statistics: Total Resident Confirmed COVID-19 Cases per 1000 Residents and Total Resident COVID-19 Deaths per 1000 Residents. These metrics provide a misleading picture, as facilities report cumulative counts of cases and deaths over different time periods but use a point-in-time measure as proxy for number of residents (number of occupied beds in a week), resulting in inflated statistics. We propose an alternative statistic to better illustrate the burden of COVID-19 cases and deaths across nursing facilities. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Using the CMS Nursing Home Compare and COVID-19 Nursing Home Datasets, we examined facilities with star ratings and COVID-19 data passing quality assurance checks for each reporting period from May 31 to August 16, 2020 (n = 11,115). METHODS: We derived an alternative measure of the number of COVID-19 cases per 1000 residents using the net change in weekly census. For each measure, we compared predicted number of cases/deaths by overall star rating using negative binomial regression with constant dispersion, controlling for county-level cases per capita and nursing home characteristics. RESULTS: The average number of cases per 1000 estimated residents using our method is lower compared with the metric using occupied beds as proxy for number of residents (44.8 compared with 66.6). We find similar results when examining number of COVID-19 deaths per 1000 residents. CONCLUSIONS AND IMPLICATIONS: Future research should estimate the number of residents served in nursing facilities when comparing COVID-19 cases/deaths in nursing facilities. Identifying appropriate metrics for facility-level comparisons is critical to protecting nursing home residents as the pandemic continues.

Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US.

Importance: It is important to understand differences in coronavirus disease 2019 (COVID-19) deaths by nursing home racial composition and the potential reasons for these differences so that limited resources can be distributed equitably. Objective: To describe differences in the number of COVID-19 deaths by nursing home racial composition and examine the factors associated with these differences. Design, Setting, and Participants: This cross-sectional study of 13 312 nursing homes in the US used the Nursing Home COVID-19 Public File from the Centers for Medicare and Medicaid Services, which contains COVID-19 cases and deaths among nursing home residents as self-reported by nursing homes beginning between January 1, 2020, and May 24, 2020, and ending on September 13, 2020. Data were analyzed from July 28 to December 18, 2020. Exposures: Confirmed or suspected COVID-19 infection. Confirmed cases were defined as COVID-19 infection confirmed by a diagnostic laboratory test. Suspected cases were defined as signs and/or symptoms of COVID-19 infection or patient-specific transmission-based precautions for COVID-19 infection. Main Outcomes and Measures: Deaths associated with COVID-19 among nursing home residents. Death counts were compared by nursing home racial composition, which was measured as the proportion of White residents. Results: Among 13 312 nursing homes included in the study, the overall mean (SD) age of residents was 79.5 (6.7) years. A total of 51 606 COVID-19-associated deaths among residents were reported, with a mean (SD) of 3.9 (8.0) deaths per facility. The mean (SD) number of deaths in nursing homes with the lowest proportion of White residents (quintile 1) vs nursing homes with the highest proportions of White residents (quintile 5) were 5.6 (9.2) and 1.7 (4.8), respectively. Facilities in quintile 1 experienced a mean (SE) of 3.9 (0.2) more deaths than those in quintile 5, representing a 3.3-fold higher number of deaths in quintile 1 compared with quintile 5. Adjustment for the number of certified beds reduced the mean (SE) difference between these 2 nursing home groups to 2.2 (0.2) deaths. Controlling for case mix measures and other nursing home characteristics did not modify this association. Adjustment for county-level COVID-19 prevalence further reduced the mean (SE) difference to 1.0 (0.2) death. Conclusions and Relevance: In this study, nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those of facilities with the highest proportions of White residents. These differences were associated with factors such as larger nursing home size and higher infection burden in counties in which nursing homes with high proportions of non-White residents were located. Focusing limited available resources on facilities with high proportions of non-White residents is needed to support nursing homes during potential future outbreaks.