County-Level Social Determinants of Health and COVID-19 in Nursing Homes, United States, June 1, 2020-January 31, 2021.

OBJECTIVES: Nursing homes are a primary setting of COVID-19 transmission and death, but research has primarily focused only on factors within nursing homes. We investigated the relationship between US nursing home-associated COVID-19 infection rates and county-level and nursing home attributes. METHODS: We constructed panel data from the Centers for Medicare & Medicaid Services (CMS) minimum dataset, CMS nursing home data, 2010 US Census data, 5-year (2012-2016) American Community Survey estimates, and county COVID-19 infection rates. We analyzed COVID-19 data from June 1, 2020, through January 31, 2021, during 7 five-week periods. We used a maximum likelihood estimator, including an autoregressive term, to estimate effects and changes over time. We performed 3 model forms (basic, partial, and full) for analysis. RESULTS: Nursing homes with nursing (0.005) and staff (0.002) shortages had high COVID-19 infection rates, and locally owned (-0.007) or state-owned (-0.025) and nonprofit (-0.011) agencies had lower COVID-19 infection rates than privately owned agencies. County-level COVID-19 infection rates corresponded with COVID-19 infection rates in nursing homes. Racial and ethnic minority groups had high nursing home-associated COVID-19 infection rates early in the study. High median annual personal income (-0.002) at the county level correlated with lower nursing home-associated COVID-19 infection rates. CONCLUSIONS: Communities with low rates of nursing home infections had access to more resources (eg, financial resources, staffing) and likely had better mitigation efforts in place earlier in the pandemic than nursing homes that had access to few resources and poor mitigation efforts. Future research should address the social and structural determinants of health that are leaving racial and ethnic minority populations and institutions such as nursing homes vulnerable during times of crises.

Associations of BNT162b2 vaccination with SARS-CoV-2 infection and hospital admission and death with covid-19 in nursing homes and healthcare workers in Catalonia: prospective cohort study.

OBJECTIVE: To determine associations of BNT162b2 vaccination with SARS-CoV-2 infection and hospital admission and death with covid-19 among nursing home residents, nursing home staff, and healthcare workers. DESIGN: Prospective cohort study. SETTING: Nursing homes and linked electronic medical record, test, and mortality data in Catalonia on 27 December 2020. PARTICIPANTS: 28 456 nursing home residents, 26 170 nursing home staff, and 61 791 healthcare workers. MAIN OUTCOME MEASURES: Participants were followed until the earliest outcome (confirmed SARS-CoV-2 infection, hospital admission or death with covid-19) or 26 May 2021. Vaccination status was introduced as a time varying exposure, with a 14 day run-in after the first dose. Mixed effects Cox models were fitted to estimate hazard ratios with index month as a fixed effect and adjusted for confounders including sociodemographics, comorbidity, and previous medicine use. RESULTS: Among the nursing home residents, SARS-CoV-2 infection was found in 2482, 411 were admitted to hospital with covid-19, and 450 died with covid-19 during the study period. In parallel, 1828 nursing home staff and 2968 healthcare workers were found to have SARS-CoV-2 infection, but fewer than five were admitted or died with covid-19. The adjusted hazard ratio for SARS-CoV-2 infection after two doses of vaccine was 0.09 (95% confidence interval 0.08 to 0.11) for nursing home residents, 0.20 (0.17 to 0.24) for nursing home staff, and 0.13 (0.11 to 0.16) for healthcare workers. Adjusted hazard ratios for hospital admission and mortality after two doses of vaccine were 0.05 (0.04 to 0.07) and 0.03 (0.02 to 0.04), respectively, for nursing home residents. Nursing home staff and healthcare workers recorded insufficient events for mortality analysis. CONCLUSIONS: Vaccination was associated with 80-91% reduction in SARS-CoV-2 infection in all three cohorts and greater reductions in hospital admissions and mortality among nursing home residents for up to five months. More data are needed on longer term effects of covid-19 vaccines.

Comparison of Medication Prescribing Before and After the COVID-19 Pandemic Among Nursing Home Residents in Ontario, Canada.

Importance: COVID-19 has had devastating effects on the health and well-being of older adult residents and health care professionals in nursing homes. Uncertainty about the associated consequences of these adverse effects on the use of medications common to this care setting remains. Objective: To examine the association between the COVID-19 pandemic and prescription medication changes among nursing home residents. Design, Setting, and Participants: This population-based cohort study with an interrupted time-series analysis used linked health administrative data bases for residents of all nursing homes (N = 630) in Ontario, Canada. During the observation period, residents were divided into consecutive weekly cohorts. The first observation week was March 5 to 11, 2017; the last observation week was September 20 to 26, 2020. Exposures: Onset of the COVID-19 pandemic on March 1, 2020. Main Outcomes and Measures: Weekly proportion of residents dispensed antipsychotics, benzodiazepines, antidepressants, anticonvulsants, opioids, antibiotics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme (ACE) inhibitors. Autoregressive integrated moving average models with step and ramp intervention functions tested for level and slope changes in weekly medication use after the onset of the pandemic and were fit on prepandemic data for projected trends. Results: Across study years, the annual cohort size ranged from 75 850 to 76 549 residents (mean [SD] age, 83.4 [10.8] years; mean proportion of women, 68.9%). A significant increased slope change in the weekly proportion of residents who were dispensed antipsychotics (parameter estimate [ß] = 0.051; standard error [SE] = 0.010; P < .001), benzodiazepines (ß = 0.026; SE = 0.003; P < .001), antidepressants (ß = 0.046; SE = 0.013; P < .001), trazodone hydrochloride (ß = 0.033; SE = 0.010; P < .001), anticonvulsants (ß = 0.014; SE = 0.006; P = .03), and opioids (ß = 0.038; SE = 0.007; P < .001) was observed. The absolute difference in observed vs estimated use in the last week of the pandemic period ranged from 0.48% (for anticonvulsants) to 1.52% (for antipsychotics). No significant level or slope changes were found for antibiotics, ARBs, or ACE inhibitors. Conclusions and Relevance: In this population-based cohort study, statistically significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids followed the onset of the COVID-19 pandemic, although absolute differences were small. There were no significant changes for antibiotics, ARBs, or ACE inhibitors. Studies are needed to monitor whether changes in pharmacotherapy persist, regress, or accelerate during the course of the pandemic and how these changes affect resident-level outcomes.

Admissions of COVID-positive patients to US nursing homes with personal protective equipment or staffing shortages.

BACKGROUND: US nursing homes are required to follow Centers for Disease Control guidance for COVID-19 transmission-based precautions (TBP) when admitting COVID-positive patients. OBJECTIVE: To assess how frequently nursing homes had shortages of personal protective equipment (PPE) or staffing in weeks when they admitted COVID-positive patients, which likely made it more difficult to follow TBP, and to compare facility characteristics by admissions practices. DESIGN AND SETTING: Facility-level data from the Nursing Home COVID-19 Public File for the period between June 7, 2020 and March 7, 2021 was combined with additional data. The percentages of nursing homes that admitted COVID-positive patients and that had shortages when admitting were calculated for each week. Descriptive statistics and logistic regression models were used to examine the relationship between facility characteristics and the likelihood of admitting COVID-positive patients. MEASUREMENTS: Facilities were categorized as having admitted COVID-positive patients in a week if one or more admissions requiring TBP were reported for that week. Facilities that reported having less than a 1-week supply of any type of PPE or being short any type of staff in a week were defined, respectively, as having a PPE shortage or staffing shortage in that week. RESULTS: Over the 40-week study period, 39% of US nursing homes admitted COVID-positive patients in at least 1 week in which they were experiencing PPE or staffing shortages. Facilities that admitted COVID-positive patients with shortages generally had lower Centers for Medicare and Medicaid Services overall five-star ratings than other facilities. Only a small percentage of facilities that admitted COVID-positive patients while facing shortages were located in counties with severe shortages of PPE or staffing. In logistic regression models, shortages were not associated with COVID-positive admissions. CONCLUSION: The widespread practice of admitting COVID-positive patients while facing shortages may have put nursing home residents and staff at heightened risk of COVID-19 infection.

COVID-19 disease trajectories among nursing home residents.

INTRODUCTION: Older adults are at greater risk of both infection with and mortality from COVID-19. Many U.S. nursing homes have been devastated by the COVID-19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID-19. SETTING AND METHODS: This is a case series of 74 residents with COVID-19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents. RESULTS: The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID-19 infection. A subset of residents with COVID-19 infection experienced a rapidly progressive, fatal course. DISCUSSION/CONCLUSIONS: Nursing home residents infected with COVID-19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post-disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.

Limited Technology Access Among Residents of Affordable Senior Housing During the COVID-19 Pandemic.

While U.S. adults living in affordable senior housing represent a vulnerable population during the COVID-19 pandemic, affordable housing may provide a foundation for interventions designed to improve technology access to support health. To better understand technology access among residents of affordable senior housing, we surveyed members of a national association of resident service coordinators to assess their experiences working with residents during the pandemic (n = 1,440). While nearly all service coordinators report that most or all residents have reliable phone access, under a quarter report that most or all have reliable internet access; they also report limited access to technology for video calls. Lack of internet access and technology literacy are perceived as barriers to medical visits and food procurement for low-income older adult residents of affordable housing. Policies to expand internet access as well as training and support to enable use of online services are required to overcome these barriers.

Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study.

BACKGROUND: To estimate excess mortality for care home residents during the COVID-19 pandemic in England, exploring associations with care home characteristics. METHODS: Daily number of deaths in all residential and nursing homes in England notified to the Care Quality Commission (CQC) from 1 January 2017 to 7 August 2020. Care home-level data linked with CQC care home register to identify home characteristics: client type (over 65s/children and adults), ownership status (for-profit/not-for-profit; branded/independent) and size (small/medium/large). Excess deaths computed as the difference between observed and predicted deaths using local authority fixed-effect Poisson regressions on pre-pandemic data. Fixed-effect logistic regressions were used to model odds of experiencing COVID-19 suspected/confirmed deaths. RESULTS: Up to 7 August 2020, there were 29,542 (95% CI 25,176 to 33,908) excess deaths in all care homes. Excess deaths represented 6.5% (95% CI 5.5 to 7.4%) of all care home beds, higher in nursing (8.4%) than residential (4.6%) homes. 64.7% (95% CI 56.4 to 76.0%) of the excess deaths were confirmed/suspected COVID-19. Almost all excess deaths were recorded in the quarter (27.4%) of homes with any COVID-19 fatalities. The odds of experiencing COVID-19 attributable deaths were higher in homes providing nursing services (OR 1.8, 95% CI 1.6 to 2.0), to older people and/or with dementia (OR 5.5, 95% CI 4.4 to 6.8), amongst larger (vs. small) homes (OR 13.3, 95% CI 11.5 to 15.4) and belonging to a large provider/brand (OR 1.2, 95% CI 1.1 to 1.3). There was no significant association with for-profit status of providers. CONCLUSIONS: To limit excess mortality, policy should be targeted at care homes to minimise the risk of ingress of disease and limit subsequent transmission. Our findings provide specific characteristic targets for further research on mechanisms and policy priority.

A Study of Universal Severe Acute Respiratory Syndrome Coronavirus 2 RNA Testing Among Residents and Staff in a Large Group of Care Homes in South London.

BACKGROUND: Care homes have experienced a high number of coronavirus disease 2019 (COVID-19)-related deaths among residents since the onset of the pandemic. However, up to May 2020, there has been a lack of information about the extent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among residents and staff in care homes and limited testing in this setting. METHODS: Combined nose and throat swab testing for SARS-CoV-2 RNA was carried out in 2455 residents and staff across 37 care homes in the London Borough of Bromley across a 3-week period. Results were reported within 24 hours of sample delivery, and data were collected on the presence or absence of symptoms. RESULTS: Overall, the point prevalence of SARS-CoV-2 infection was 6.5%, with a higher rate in residents (9.0%) than in staff (4.7%). A key finding was the high proportion of asymptomatic infection detected in staff (69%) and residents (51%), with evidence of underdetection of symptoms by care home staff. CONCLUSIONS: The high proportion of asymptomatic infection combined with underdetection of symptoms by care home staff indicates that offering a test to all residents and staff in care homes with rapid reporting of results would assist accurate identification of infected individuals, facilitating prompt infection prevention and control action.

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.

COVID-19 infections in the Friuli Venezia Giulia Region (Northern Italy): a population-based retrospective analysis.

OBJECTIVES: to study the cumulative incidence, the demographics and health conditions of the population tested for COVID-19, and to map the evolving distribution of individual cases in the population of the Friuli Venezia Giulia Region (North-Eastern Italy). DESIGN: population-based observational study based on a record linkage procedure of databases included in the electronic health information system of the Friuli Venezia Giulia Region. SETTING AND PARTICIPANTS: the study group consisted of individuals who resided in the Friuli Venezia Giulia Region and who underwent COVID-19 testing from 01.03 to 24.04.2020. The study group was identified from the laboratory database, which contains all the microbiological testing performed in regional facilities. Tested people were categorized into positive or negative cases, based on test results. MAIN OUTCOME MEASURES: probability of being tested for and cumulative incidence of COVID-19. RESULTS: the cumulative probability of being tested for COVID-19 was 278/10,000 inhabitants, while the cumulative incidence was 22 cases/10,000. Out of 33,853 tested people, 2,744 (8.1%) turned out to be positive for COVID-19. Women were tested more often than men (337 vs 216/10,000), and they showed a higher incidence of infection than men (25 and 19 infected cases/10,000 residents, respectively). Both cumulative incidence and cumulative probability of being tested were higher in the elderly population. About 25% of infected people was hosted in retirement homes and 9% was represented by healthcare workers. Thirty seven percent of positive cases had hypertension, 15% cardiologic diseases, while diabetes and cancer characterized 11.7% and 10% of the infected population, respectively. The geographic distribution of positive cases showed a faster spread of the infection in the city of Trieste, an urban area with the highest regional population density. CONCLUSIONS: the COVID-19 pandemic did not hit the Friuli Venezia Giulia Region as hard as other Northern Italian Regions. In the early phase, as documented in this study, the COVID-19 pandemic particularly affected women and elderly people, especially those living in retirement homes in Trieste.

Clinical, demographical characteristics and hospitalisation of 3,010 patients with Covid-19 in Friuli Venezia Giulia Region (Northern Italy). A multivariate, population-based, statistical analysis.

OBJECTIVES: to describe the clinical and demographical characteristics of COVID-19 infected people in the Friuli Venezia Giulia Region (FVG, Northern Italy). DESIGN: retrospective cohort study with an individual level record linkage procedure of different administrative databases. SETTING AND PARTICIPANTS: the cohort included 3,010 patients residing in FVG who tested positive for COVID-19 between 1 March and 15 May 2020, 2020. Regional hospital admissions and deaths without hospital admissions up to June 1st, 2020 were analysed. Determinants of the probability of a highly severe illness were investigated in terms of hospitalisations or death without hospital admission. MAIN OUTCOME MEASURES: COVID-19 patients were identified from regional epidemiological data warehouse. Demographical and clinical variables such as gender, age, patient's comorbidities, vaccinations, ARBs/sartans prescriptions, and geographical residence variables were collected by linking different databases. Descriptive analyses were performed. Logistic multivariate regressions were used to estimate the probability of hospitalisation or death, whichever came first. Model coefficients and odds ratios (OR) were reported. RESULTS: COVID-19 population in FVG had a mean age of 60 years and 59% were females. The study found that 37% had hypertension while patients with cardiologic diseases, diabetes, and cancer were around 15%; 22% of the cases were residing in retirement homes. Approximately 30% received flu or pneumococcal vaccination and a similar proportion of patients had at least one prescription of ARBs /sartans in the previous 6 months. Statistical models showed a higher probability of a worst course of disease for males, elderly, highly complicated (in terms of resource use) subjects, in the presence of cardiologic diseases, diabetes, and pneumococcal vaccination. People living in retirement homes had a lower probability of hospitalisation/death without hospital admission. The cohort was divided into two groups: COVID-19 patients infected in the territory and infected in retirement homes. Among COVID-19 patients infected in the territory, the probability of hospitalisation/death was higher for males, for older individuals, and for those with comorbidities. Diabetes resulted to be a risk factor (OR 1.79; 95%CI 1.23-2.62), as well as pneumococcal vaccination (OR 1.64; 95%CI: 1.18-2.29), which is a likely proxy of fragile patients with pulmonary disease. The flu vaccination showed a potential protective effect with a 40% lower probability of hospitalisation or death (OR 0.62; 95%CI 0.44-0.85). Among the retirement homes cohort group, a higher probability of a bad course of disease emerged for males and for more complex patients. CONCLUSIONS: the greatest risk of hospitalisation/death as a measure of more severe illness was confirmed for males, elderly, and for individuals with comorbidities. Flu vaccination seemed to have had a protective effect while pneumococcal vaccination likely identified a group of high-risk patients to be actively monitored. For patients infected in the territory, different hospitalisation strategies were implemented by the regional health districts.

Prevalence of multiple risk factors for poor outcomes associated with COVID-19 among an elderly Australian population.

BACKGROUND AND OBJECTIVES: Increasing age, male sex and various chronic conditions have been identified as important risk factors for poor outcomes from COVID-19. The aim of this study was to examine the prevalence of risk factors for poor outcomes due to COVID-19 infection in an older population. METHOD: The proportion of the population with one or more risk factors and the prevalence of individual risk factors and multiple risk factors were calculated among Department of Veterans' Affairs (DVA) clients aged ≥70 years. RESULTS: There were 103,422 DVA clients included. Of these, 79% in the community and 82% in residential aged care had at least one risk factor for poor outcomes from COVID-19. Hypertension was most prevalent, followed by chronic heart and airways disease. Over half had ≥2 risk factors, and one in five had ≥3 risk factors across multiple body systems. DISCUSSION: A substantial proportion of older Australians are at risk of poor outcomes from COVID-19 because of their multimorbid risk profile. These patients should be prioritised for proactive monitoring to avoid unintentional harm due to potential omission of care during the pandemic.

Health conditions of potential risk for severe Covid-19 in institutionalized elderly people.

The objective of this study was to identify the health conditions considered potential risk factors for severe Covid-19 and analyze its association with the BMI of elderly people living in Long-Term Care Facilities (LTCF). This is a descriptive and cross-sectional study, with a quantitative approach, carried out in eight LTCF in the Metropolitan Region of Natal, Rio Grande do Norte, with a population of 267 elderly people, between the months of February and December 2018. The Elderly Health Handbook was used to collect data on sociodemographic, health and risk factors. The Pearson's Chi-square test and odds ratio were used for the analysis. A higher frequency of low weight was observed in elderly people with cognitive impairment (24.6%), and overweight in those hypertensive (23.3%) and diabetics (12.9%). BMI was associated with the age group of 80 years or over, hypertension and diabetes (p = 0.013; p < 0.001; p = 0.001). Hypertensive elderly people were more likely to have low weight when compared to non-hypertensive individuals (RC = 3.6; 95% CI 1.5-8.6). The institutionalized elderly individuals present health conditions that may contribute to the occurrence of adverse outcomes in case of infection by Covid-19. The importance of protective measures for this population must be reinforced, in view of the devastating action of this disease in these institutions.