key: cord-0740740-6i8w1p4p
authors: Cai, Shubing; Yan, Di; Intrator, Orna
title: COVID-19 cases and death in nursing homes: the role of racial/ethnic composition of facilities and their communities
date: 2021-05-09
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.05.002
sha: cd9689bbb3ac4582520e41253dbfd49f55828bd8
doc_id: 740740
cord_uid: 6i8w1p4p

Objectives To examine the extent to which the racial/ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs; and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial/ethnic composition of the community in which a NH is located. Design Centers for Medicare and Medicare Services (CMS) Nursing Home COVID-19 data were linked with other NH- or community-level data (e.g. Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey). Setting and Participants NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of 06/07/2020 and 08/23/2020. Measurements/ Model Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percent of Black/Hispanic residents in a NH, stratified by the percent of Blacks/Hispanics in the community in which the NH was located. A set of linear probability models with NH random-effects and robust standard errors were estimated, accounting for other covariates. Results The racial/ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial/ethnic composition of the community played an independent role in the likelihood of COVID-19 cases/death in NHs, even after accounting for the COVID-19 infection rate in the community (i.e. daily cases per 1000 people in the county). Moreover, the racial/ethnic composition of a community modified the relationship between NH characteristics (e.g. staffing) and the likelihoods of COVID-19 cases/death. Conclusions and Implications To curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial/ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.

after accounting for the COVID-19 infection rate in the community (i.e. daily cases per 1000 23 people in the county). Moreover, the racial/ethnic composition of a community modified the 24 J o u r n a l P r e -p r o o f relationship between NH characteristics (e.g. staffing) and the likelihoods of COVID-19 25 cases/death. 26 Conclusions and Implications. To curb the COVID-19 outbreaks in NHs and protect vulnerable 27 populations, efforts may be especially needed in communities with a higher concentration of 28 racial/ethnic minorities. Efforts may also be needed to reduce structural racism and address 29 social risk factors to improve quality of care and population health in communities of color. 45 Nursing home (NH) residents have been disproportionally affected by the COVID-19 46 pandemic. 1-3 Racial/ethnic minority NH residents may even have exacerbated risks of COVID-47 19 infection and death. There have been long-standing concerns that racial/ethnic minority NH 48 residents experience lower quality of care than their white counterparts. [4] [5] [6] Indeed, recent studies 49 have suggested that NHs with a higher proportion of racial/ethnic minorities had higher rates of 50 COVID-19 infection and related death. 7-12 However, current studies on NH COVID-19 outbreaks 51 offer mixed findings on the relationship between NH characteristics, such as NH staffing and its 52 overall quality rating, and COVID-19 outbreaks. 9,10,13-15 For example, some studies found that 53 more registered nurse (RN) hours per resident day 12 and lower star rating 16 were related to 54 higher likelihood of COVID-19 cases, while other studies found a negative relationship between 55 RN hours and COVID-19 cases, 14 and no consistent relationship between NH star rating and 56 COVID infection. 17 The inconsistency is partly due to the different populations and study periods 57 in these studies. In addition, some studies used the early NH COVID-19 data reported by the 58 Centers for Medicare and Medicaid Services (CMS), 7 which may be less accurate as NHs may 59 have needed time to become familiar with the reporting process. 18 Thus, more evidence is needed. 60 In addition to the relationship between NH racial/ethnic composition and COVID-19 61 outbreaks, communities where a NH is located were found to also contribute to the outbreak of 62 COVID-19 in NHs. 15 Although it has been suggested that communities with a higher proportion 63 of racial/ethnic minorities have a higher rate of COVID-19 infection, 19 and community 64 transmission is related to COVID-19 outbreak in NHs, 20 it is unknown whether and how factors with COVID-19 outbreaks in NHs. For example, communities with a higher percentage 68 of racial/ethnic minorities are more likely to be economically deprived. 21 NHs in these 69 communities may not have adequate infection control, supplies or protocols and may be less 70 prepared for and the pandemic. In addition, NHs in high-minority communities may have 71 amplified risks of outbreak of COVID-19 as their staffing, especially direct care workers, and 72 delivery personnel may be more likely to be exposed to Therefore, the main objectives of this study were to examine the extent to which were more likely to correct recently reported data, we also excluded the last three weeks of data 93 to minimize the concern of potential data inaccuracy. In total, we included 12 weeks of data 94 (between the week of June 7 and the week of August 23) for 13,123 NHs in the U.S.

Variables: Two outcome variables were determined based on the CMS COVID-19 data: whether 96 a NH had any new COVID-19 cases in a week and whether a NH had any COVID-19 related 97 deaths in a week. Key independent variables included the racial/ethnic composition of a NH, 98 defined as the percent of residents who were either Black or Hispanic in a NH, based on 2018 99 MDS; and the racial/ethnic composition of the community in which the NH was located, based 100 on the ACS data. We categorized NHs into three mutually exclusive groups based on the percent 101 of racial/ethnic minorities: NHs with low-(0 to <2.63%), moderate-(2.63% to <16.26%) or 102 high-(≥16.26%) percent minorities, with each accounting for approximately 33% of all NHs. We and death to vary across high-, moderate-, and low-minority NHs. We then stratified the analyses 123 by high-versus low-minority communities to examine whether and how the relationship between 124 NH characteristic and the probabilities of COVID-19 cases and COVID-19 death varied across 125 these communities. To facilitate the interpretation, we calculated the adjusted weekly 126 probabilities of COVID-19 cases and death for each of the three NH groups in high-versus low-127 minority communities.

Table-1 compares characteristics of NHs, by three groups of NHs and by communities.

As shown in the Table, the rate of COVID-19 cases, death, and characteristics of NHs varied 131 across three types of NHs and between communities. For example, the unadjusted rate of any 132 COVID-19 cases in low-, moderate-and high-minority NHs were 5.5%, 11.1% and 14.8% in 133 low-minority communities, and 10.6%, 14.5%, and 20.4% in high-minority communities. Table- 134 J o u r n a l P r e -p r o o f 2 presents the findings from the regression analyses, stratified by racial/ethnic composition of the 135 community. NHs with a high proportion of minorities (i.e. Blacks/Hispanics) had 5.0 to 7.2 136 percentage points higher (P<0.05) likelihood of COVID-19 cases and 2.6 to 6.4 percentage 137 points higher death than NHs with low proportion of minorities at baseline. Lastly, the relationship between NH characteristics and the probability of COVID-19 153 cases or death varied with the racial/ethnic composition of the community (Table-2) . For 154 example, although an hour increase in RN hours per resident per day was associated with 2.8 155 percentage points reduction in the probability of COVID-19 cases in NHs located in high-156 minority communities (P<0.01), such relationship was smaller in low-minority communities (0.9 157 J o u r n a l P r e -p r o o f percentage point, P<0.01). We also observed that a higher CNA staffing level was associated 158 with a higher probability of COVID-19 cases (coefficient=0.026, P<0.01) or death 159 (coefficient=0.014, P<0.01) in NHs located in high-minority communities, but there was no 160 statistically significant relationship between CNA and the likelihood of COVID cases or death in 161 low-minority communities. In addition, we found that a higher star rating of NHs was associated 162 with a higher likelihood of COVID-19 cases in NHs located in low-minority communities, but 163 not in NHs located in high-minority communities.

This study examined the relationship between racial/ethnic composition of a NH and its 166 community and the probabilities of COIVD-19 cases and death in NHs. We found that 167 racial/ethnic composition of the community also had an impact on the likelihood of COVID-19 168 cases or death in a NH, additional to the racial/ethnic composition of a NH, and importantly, that 169 the community racial/ethnic composition modified the relationship between NH characteristics 170 and COVID-19 cases/death.

While recent studies indicated that NH COVID-19 outbreaks were related to where the 172 NH was located with respect to the area's prevalence of COVID-19, 10,20,28 our study suggested 173 the independent role of racial/ethnic composition of the community in the outbreak of COVID-174 19 in NHs, after accounting for the COVID-19 infection rate in the county and other covariates. 175 Moreover, the variation in the likelihood of NH COVID-19 cases/death between high-versus 176 low-minority communities appeared to be large. These findings may be related to the different 177 NH characteristics between communities, as well as community behavioral factors. For example,

NHs located in poor communities are more likely to be resource deprived, 6 and thus may face 179 even greater challenges in dealing with the pandemic. In addition, it has been reported that On the other hand, we found that higher CNA staffing was associated with a higher 195 probability of COVID-19 infection and death in NHs located in high-minority communities, but There are some limitations to this study. First, although this study examined the 208 probabilities of COVID-19 cases and deaths across NHs and communities with different 209 racial/ethnic composition, we were unable to determine the underlying reasons that led to such 210 variations. Second, this was a facility-level analysis, and we were unable to account for 211 individual resident characteristics, which may also be related to the likelihood of COVID-19 212 infection or death. Third, NH staffing is likely to change with the COVID-19 outbreak in NHs. 213 We were only able to account for staffing level prior to the pandemic, and were not able to There has long been a great concern that structural racism and social factors are 226 intertwined with the unequal health care and health outcomes among people of color. 38 Poor 227 living condition, barriers in access to care, limited access to education in these communities may 228 contribute to the higher COVID-19 infection rates in the community. This paper shows that these 

NH=nursing home; SD=standard deviation; CNA=Certified Nurse Assistant

J o u r n a l P r e -p r o o f Figure- 1 Weekly predicted probability of any COVID-19 case (Panel A) and COVID-19 death (Panel B) in a nursing home (NH), adjusting for facility and community characteristics.Predicted probabilities are presented for high-(squares), moderate-(triangles), and low-(circles) minority NHs located in high-minority (solid line) versus low-minority (dashed line) communities.