COVID-19 has severely affected nursing homes. As of now, over 139,270 residents and 2,155 nursing home staff have died from COVID-19. This post provides insight on the questions researchers are asking to understand the impact of nursing facility factors on COVID-19.
A Perfect Storm
The combination of a frail, aging population, close living quarters, and in some cases a lack of resources has contributed to a “perfect storm” [PDF] of COVID-19 cases and deaths in US nursing homes. However, researchers are still determining which nursing home characteristics might contribute to COVID-19 cases.
Since the beginning of the pandemic, researchers have sought to identify actionable steps nursing homes can take to prevent the spread of COVID-19. In particular, researchers are asking which facility-related factors are associated with COVID-19 outcomes. Could quality measures or star ratings, such as those reported on Care Compare, be correlated? Is ownership type correlated with COVID-19 cases and deaths? Are nursing homes with a higher proportion of racial and ethnic minorities experiencing worse COVID-19 outcomes?
A systematic review published in the Journal of the American Geriatrics Society examines recent literature on the association between nursing home characteristics and COVID-19 outcomes. The authors identified 36 studies published between January 1, 2020 – June 15, 2021 focused on nursing home factors and COVID-19 cases and deaths. This post summarizes some of the key findings from their literature review as well as additional literature related to nursing home characteristics and COVID-19.
Changes in Research Focus and Methodology
Before reviewing study findings, it is important to understand how research related to COVID-19 and nursing homes has evolved over the course of the pandemic. In particular, early pandemic studies may have included flawed or limited data. The focus of research also shifted as COVID-19 became more widespread.
Effective May 8, 2020, nursing homes were required to report COVID-19 cases and deaths to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network. The Office of the Inspector General conducted an audit of data for a one-month period in the summer of 2020. They found the vast majority of nursing homes reported required data, but data was incomplete or inaccurate for about 5% of nursing homes.
Since data first became available in May 2020, researchers have explored the correlation between nursing home characteristics, quality information, and COVID-19 outcomes. However, in addition to incomplete or flawed data for some nursing homes, lack of widespread testing in the beginning of the pandemic may have resulted in underreporting of COVID-19 cases and deaths. Early pandemic studies noted this limitation and tried to account for potential data inaccuracies by examining the probability of at least one COVID-19 case. As testing became increasingly widespread, studies shifted to examining mortality and counts of cases as opposed to just one case. In Fall 2020, as the pandemic spread rapidly throughout the country, research focused less on the introduction of COVID-19 in nursing homes, and more on nursing homes’ ability to stop the spread of the virus once introduced.
Care Compare Five-Star Ratings and COVID-19 Outcomes
The Centers for Medicare and Medicaid (CMS) Care Compare website reports star ratings (on a scale of 1 – 5, with 5 being best) for Health Inspections, Staffing, and Quality domains for nursing homes. CMS also reports an overall star rating that combines data from all three categories.
- In all, 16 studies covered in the systematic review focused on the relationship between Care Compare nursing home overall star ratings and COVID-19 cases and deaths.
- Studies tended to measure either the probability of one case/death or cumulative case counts or mortality rates.
- A majority of studies found no meaningful relationship between the facility’s overall star rating and COVID-19 outcomes.
- Five studies in the literature review concluded that higher star ratings were associated with fewer COVID-19 cases.
- However, four of those studies used data from one state and, were thus were not generalizable.
- Several studies focused on Care Compare star ratings for the Health Inspections, Staffing, and Quality domains.
- These studies found no association or inconsistent relationships between star ratings in the three domains and COVID-19 outcomes.
One recent study examined how the relationship between nursing home quality and COVID-19 mortality may have changed over the course of the pandemic. Using Care Compare overall star ratings, they found lower risk of COVID-19 mortality in facilities with higher overall star ratings, but this association diminished over time. The authors propose possible explanations for this trend:
- Nursing homes with a lower star rating at the beginning of the study period may have implemented best practices as the pandemic progressed.
- Processes implemented in higher-quality nursing homes, as measured by star ratings, may have eroded as the pandemic created staffing shortages.
The results of this study, as well as others, are too inconsistent to prove a relationship between Care Compare star ratings and COVID-19.
Staffing and Resources
Several studies explored the association between COVID-19 outcomes and staffing. Studies that focused on Care Compare Staffing star ratings were mixed, but the majority found no relationship. Researchers also investigated the impact of staffing hours per resident per day, using data from prior to the pandemic.
- Two studies found that fewer cases and deaths occurred in facilities with higher staffing levels of specific nurses (such as certified nursing assistants and registered nurses).
- Effects were small relative to facility size and county prevalence of COVID-19.
- Several studies concluded that larger staff size increased the risk of COVID-19 outbreaks.
- However, in facilities with known cases of COVID-19, fewer deaths occurred in facilities with larger staff size and more CNAs/total nurse staffing.
Research has also focused on the impact of resource limitations, such as staff shortages or personal protective equipment (PPE) shortages.
- One study examined PPE and staffing shortages in nursing homes during Summer 2020.
- Facilities that were government-owned, had more Medicaid patients, lower overall star ratings on Care Compare, and any staff cases of COVID-19 were more likely to report staffing shortages across the study periods.
- Another study found facilities with a fewer stars were more likely to admit COVID-19 positive patients during PPE or staffing shortages.
While these studies do not necessarily examine associations with COVID-19 outcomes, staffing shortages could lead to worse quality of care.
Ownership and Other Characteristics
Nursing home ownership type (i.e., non-profit vs. for-profit) has long been an area of research interest. Two studies that examined facility ownership found no association between for-profit status and worse COVID-19 outcomes. In fact, one of the studies concluded that for-profit facilities had fewer cases than other ownership types.
An overwhelming number of studies found that larger facilities, as well as those in areas with a higher concentration of COVID-19 cases, were more likely to experience worse outcomes. The literature review identified 20 studies that found a significant association with area concentration of cases. In addition, 16 studies found a signification association with a higher number of beds.
Racial and Ethnic Disparities
Throughout the pandemic, a large swath of research has focused on the racial and ethnic disparities in COVID-19 outcomes. However, in recent literature on nursing homes, outcomes vary by resident racial composition. Studies using data from spring 2020 through early fall 2020 found that facilities with more Black and Hispanic residents had worse COVID-19 outcomes. However, research using data from Fall 2020 onward had varying results.
One study, for example, explored changes in COVID-19 mortality in nursing homes with a high proportion of racial and ethnic minority residents over a 30-week period (June 2020 – December 2020).
- During the first six weeks of the study period, nursing homes serving more Black residents reported higher COVID-19 mortality, followed by nursing homes with more Hispanic residents.
- Between seven to 12 weeks in the study period, this trend shifted. Nursing homes serving more Hispanic residents reported more deaths.
- After 23 weeks, nursing homes serving more White residents reported higher mortality than nursing homes serving more Black and Hispanic residents.
The authors postulated that changes may be due to geographic differences in the timing of COVID-19 outbreaks, with the pandemic spreading early in metropolitan areas before dispersing to rural areas.
Strongest Predictors for COVID-19 Cases and Deaths
The literature review found two characteristics that were consistently and strongly associated with COVID-19 cases and deaths: a higher number of beds and location in an area with a high concentration of cases. The results suggest readily available measures of quality, such as those reported on Care Compare, may not be correlated with COVID-19 outcomes. Rather, the presence of COVID-19 in the community and a larger concentration of residents put patients at increased risk.
In response to the COVID-19 pandemic, CMS and other state and federal agencies have adopted efforts to improve infection control, reduce administrative burden, and provide more resources to nursing homes. We need further research to better understand the drivers impacting COVID-19 outcomes in nursing homes. Research can also inform potential changes that could improve COVID-19 outcomes.
Kathryn Foster