key: cord-0741988-6liqk9ut authors: Travers, Jasmine L.; Agarwal, Mansi; Estrada, Leah V.; Dick, Andrew W.; Gracner, Tadeja; Wu, Bei; Stone, Patricia W. title: Assessment of COVID-19 Infection and Mortality Rates Among Nursing Homes with Different Proportions of Black Residents date: 2021-02-22 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.02.014 sha: 8d356bd915599fff7410e4a664901e65b587defc doc_id: 741988 cord_uid: 6liqk9ut Objective COVID-19 has disproportionately impacted nursing homes (NHs) with large shares of Black residents. We examined the associations between the proportion of Black residents in NHs and COVID-19 infections and deaths, accounting for structural bias (operationalized as county-level factors) and stratifying by urbanicity/rurality. Design This was a cross-sectional observational cohort study using publicly available data from the LTCfocus, Centers for Disease Control and Prevention (CDC) Long-Term Care Facility COVID-19 Module, and the NYTimes county-level COVID-19 database. Four multivariable linear regression models omitting and including facility characteristics, COVID-19 burden, and county-level fixed effects were estimated. Setting and Participants: 11,587 US NHs that reported data on COVID-19 to the CDC and had data in LTCfocus and NYTimes from January 20th, 2020 through July 19th, 2020. Measures Proportion of Black residents in NHs (exposure); COVID-19 infections and deaths (main outcomes). Results The proportion of Black residents in NHs were as follows: none= 3,639 (31.4%), <20%= 1,020 (8.8%), 20-49.9%= 1,586 (13.7%), ≥50= 681 (5.9%), not reported= 4,661 (40.2%). NHs with any Black residents showed significantly more COVID-19 infections and deaths than NHs with no Black residents. There were 13.6 percentage points more infections and 3.5 percentage points more deaths in NHs with ≥50% Black residents than in NHs with no Black residents (p<.001). While facility characteristics explained some of the differences found in multivariable analyses, county-level factors and rurality explained more of the differences. Conclusions and Implications It is likely that attributes of place, such as resources, services, and providers, important to equitable care and health outcomes are not readily available to counties where NHs have greater proportions of Black residents. Structural bias may underlie these inequities. It is imperative that support be provided to NHs that serve greater proportions of Black residents while considering the rurality of the NH setting. Our primary outcomes were (1) number of confirmed COVID-19 infections and (2) number of 80 confirmed or suspected COVID-19 deaths among nursing home residents. Both outcomes were 81 reported at the nursing home level as proportions of the total number of occupied beds. In these 82 data, confirmed resident infections were defined as positive lab tests for COVID-19, regardless 83 of symptomology. Deaths were defined as persons with suspected or laboratory-positive 84 COVID-19 who died. 85 86 Our primary exposure variable was the proportion of Black residents in nursing homes. 87 LTCfocus reports percentage of Black residents from aggregated MDS assessments. Race is 88 selected by the MDS coordinator using information provided by the resident or the family. 17 89 Similar to prior research, we categorized proportions of Black residents in nursing homes as 90 none, <20%, 20-49.9%, ≥50%, or not reported. 3, 18 We combined the 50-79.9% group (n=558), 91 80-94.9% group (n=109), and the 95-100% group (n=14) to provide sufficient power. Not 92 reported denotes nursing homes that had missing data for their percentage of racial/ethnic 93 minorities. Because the most recently available LTCfocus data are from 2017, we examined 94 2011-2017 LTCfocus data to assess the stability of the percentages of Black residents in nursing 95 homes and we found they remained stable during the period. Therefore, we used the 2017 data to 96 characterize the proportion of Black residents in a nursing home. 97 98 Our models included several explanatory variables, choice of which was supported by previous 99 research. 19, 20 First were the facility characteristics. They included bed size (categorized as 0-49, 100 50-149, and 150+ beds), percent of facilities that were part of a chain organization and percent of 101 facilities that were for-profit; percent occupancy; percent Medicaid residents; mean case mix 102 J o u r n a l P r e -p r o o f index; and nurse staffing ratios defined as hours per patient day for registered nurses (RNs), 103 licensed practical nurses (LPNs), and aides, all of which came from the LTCfocus database. We 104 also included percentage of facilities reporting staffing shortages and percentage reporting a lack 105 of personal protection equipment (PPE) supply which originated from the CDC Module. nursing 106 home-level staff shortages included nurse/clinician and aide and lack of a one-week supply of 107 PPE included any of the following: N95 masks, surgical masks, eye protection, gowns, gloves, 108 and hand sanitizer. 20 Supplemental Figure 1 shows the gradient in these changes. 174 175 When stratifying by urbanicity/rurality, we found that COVID-19 infections and deaths increased 176 with increasing proportions of Black residents in both settings (Table 3 ). This association was 177 strongest in nursing homes with ≥50% Black residents in rural settings and these associations 178 were stronger than those observed in the non-stratified models. Changes across models were 179 similar to those reported in the non-stratified models (see Supplemental Figure 2 we found that other unobserved county characteristics, potentially rooted in structural bias, are 213 more important in explaining these disparities. 26 For example, counties with greater proportions 214 of Black citizens may experience scarcity of resources and service availability (e.g., 215 transportation, health services), mistrust in the healthcare system among community members, 216 and low socioeconomic indicators (e.g., education, income). 27 Moreover, resources are provided 217 to communities in the context of a history of racial bias in which communities with higher 218 proportions of Black members generally receive fewer resources. 28 In terms of analytic limitations, we excluded all nursing homes that did not pass CMS's quality 252 assurance checks, but it is possible that this exclusion may have limited our sample to better 253 performing nursing homes. Additionally, we calculated the proportion of infections and deaths 254 per occupied bed, but occupation rates may have been affected broadly by the pandemic and 255 specifically by infections and deaths in nursing homes. We were also unable to build a Model 4 256 in our stratified analysis. The reason for this is we could not account for county fixed effects in 257 these analyses because of the limited number of nursing homes in a rural county. In regard to our 258 sample, forty percent of the nursing homes were missing information on their proportion of 259 Black residents and thereby classified as not reported. A sensitivity analysis that excluded these 260 nursing homes and estimated the models again revealed similar results (data not shown). While 261 we were able to situate the disparities in COVID-19 infections and deaths within potential 262 J o u r n a l P r e -p r o o f structural bias in counties, it is important to note that our access to COVID-19 data were limited 263 to the county level, and county-level analyses lack specificity when drawing conclusions about 264 racial disparities. Future research should consider these issues in more depth when census block 265 data become available. Finally, we examined differences in COVID-19 infections and deaths 266 across nursing homes by proportions of Black residents, but future studies should consider 267 whether these differences exist within nursing homes. 268 As disparities in COVID-19 infections and deaths among nursing homes with higher proportions 270 of Black residents are potentially rooted in long-standing issues related to structural bias within 271 counties, it is important that we dismantle the bias and discriminatory structures that continue to 272 fuel these disparities. Some suggestions based on prior research are as follows: Invest in Black 273 communities where these nursing homes are located. Investment is needed in infrastructure, 274 social services, healthcare, education, housing, and neighborhoods. 30 Note: 95% CI reported. All coefficients expressed relative to the reference group, i.e., "No black residents in a nursing home." Models 2, 3, and 4 are clustered on county and include: bed size, urbanicity/rurality, region, occupancy rate, percent Medicaid, case mix index, nursing staffing ratios, staff shortages and lack of personal protective equipment (Facility Characteristics). Model 3 includes County COVID-19 burden which = proportion of county infections and deaths; County COVID-19 burden was measured by county-level cumulative COVID-19 infections and deaths. Model 4 includes county fixed effects (FE). Growth of racial and ethnic minorities in US nursing homes driven by demographics and possible disparities in options Thirty-year trends in nursing home composition and quality since the passage of the Omnibus Reconciliation Act Racial/ethnic differences in receipt of influenza and pneumococcal vaccination among long stay nursing home residents Association of race and sites of care with pressure ulcers in high-risk nursing home residents Disparities in long-term care: Building equity into marketbased reforms Racial/ethnic disparities in influenza and pneumococcal vaccinations among nursing home residents: A systematic review More than 40% of U.S. Coronavirus deaths are linked to nursing homes. The New York Times Characteristics of US nursing homes with COVID 19 cases Is there a link between nursing home reported quality and COVID-19 cases? Evidence from California skilled nursing facilities COVID 19 infections and deaths among Connecticut nursing home residents: Facility correlates Striking racial divide: How COVID-19 has hit nursing homes. The New York Times The National Institute on Aging health disparities research framework Structural racism: Building upon the insights of John Calmore LTCfocus: Long-term care: Facts on care in the US Brown University School of Public Health National Healthcare Safety Network of the Centers for LTCF COVID-19 Module Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration Driven to tiers: Socioeconomic and racial disparities in the quality of nursing home care. The Milbank Quarterly Nursing home quality and financial performance: Does the racial composition of residents matter? Health services research Covid-19 cases jump in sunbelt nursing homes. The Wall Street Area, class and health: Should we be focusing on places or people Unequal gain of equal resources across racial groups Assessing the Impact of the Covid-19 pandemic on US mortality: A county-level analysis Rurality and nursing home quality: Evidence from the 2004 National Nursing Home Survey Nursing home quality: A comparative analysis using CMS Nursing Home Compare data to examine differences between rural and nonrural facilities Models 2 and 3 are clustered on county and include: bed size, urbanicity/rurality, region, occupancy rate, percent Medicaid, case mix index, nursing staffing ratios, staff shortages and lack of personal protective equipment (Facility Characteristics) County COVID-19 burden was measured by county-level cumulative COVID-19 infections and deaths Models 2 and 3 are clustered on county and include: bed size, urbanicity/rurality, region, occupancy rate, percent Medicaid, case mix index, nursing staffing ratios, staff shortages and lack of personal protective equipment (Facility Characteristics) County COVID-19 burden was measured by county-level cumulative COVID-19 infections and deaths The authors have no conflicts of interest to disclose. 288 J o u r n a l P r e -p r o o f