key: cord-0996200-ibvzbns3
authors: Khairat, Saif; Zalla, Lauren C.; Adler-Milstein, Julia; Kistler, Christine
title: U.S. Nursing Home Quality Ratings Associated with COVID-19 Cases and Deaths Introduction
date: 2021-08-07
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.07.034
sha: d9a78125587d6c4f5bb185f02ce8a529ce8d5d77
doc_id: 996200
cord_uid: ibvzbns3

Objectives To inform future policies and disaster preparedness plans in the vulnerable nursing home setting, we need greater insight into the relationship between nursing homes’ (NH) quality and the spread and severity of COVID-19 in NH facilities. We therefore extend current evidence on the relationships between NH quality and resident COVID-19 infection rates and deaths, taking into account NH structural characteristics and community characteristics. Design Cross-sectional study. Setting and Participants 15,390 Medicaid/Medicare-certified nursing homes. Methods We obtained and merged the following data sets: (1) COVID-19 weekly data reported by each nursing home to the CDC National Healthcare Safety Network (NHSN), (2) CMS Five Star Quality Rating System, (3) county-level COVID-19 case counts, (4) county-level population data, and (5) county-level socio-demographic data. Results Among 1-star NHs, there were an average of 13.19 cases and 2.42 deaths per 1,000 residents per week between May 25 and December 20, 2020. Among 5-star NHs, there were an average of 9.99 cases and 1.83 deaths per 1,000 residents per week. The rate of confirmed cases of COVID-19 was 31% higher among 1-star NHs compared to 5-star NHs (Model 1: IRR 1.31, 95% CI: 1.23-1.39), and the rate of COVID-19 deaths was 30% higher (IRR: 1.30, 95% CI: 1.20, 1.41). These associations were only partially explained by differences in community spread of COVID-19, case mix, and the for-profit status and size of NHs. Conclusions and Implications We found that COVID-19 case and death rates were substantially higher among NHs with lower star ratings, suggesting that NHs with quality much below average are more susceptible to the spread of COVID-19. This relationship – particularly with regard to case rates – can be partially attributed to external factors: lower-rated NHs are often located in areas with greater COVID-19 community spread, and serve more socioeconomically vulnerable residents than higher-rated NHs.

Between May and December 2020, more than 92,000 deaths from the novel coronavirus 41 disease 2019 (COVID-19) occurred in nursing homes (NHs), accounting for 30% of all 19 deaths in the U.S. 1, 2 However, within these high levels, there was substantial variation in both 43 deaths and case rates across nursing homes, suggesting that some were either better positioned or 44 better able to respond to the pandemic. We have a limited understanding of which factors may 45 drive such variation. In eight states, NHs with nurse staffing shortages were found to be more 46 susceptible to the spread of COVID-19 during the initial phase of the pandemic. 3 NHs with high 47

proportions of non-White residents experienced COVID-19 death counts that were three times 48 higher than those of facilities with the highest proportions of White residents. 4 Significant 49 inequities are present in COVID-19 infection rates in nursing homes with larger proportions of 50 racial minority residents. 5 Prior work has found that NHs with higher quality ratings had lower 51 COVID-19 cases particularly when adjusted for NH size and resident characteristics, but these 52 studies were conducted early in the pandemic and only within specific regions of the U.S. 3, 6-8 It 53 is therefore not clear whether these relationships persist at a national level and at a later period 54 after NHs were able to address some of the immediate challenges at the start of the pandemic. 9 55

To the extent that we find that these relationships persist, it suggests that COVID-19 case and 56 death rates may be associated with NH quality ratings. Therefore, we hypothesized that COVID-57 19 case and death rates would differ based on NH star rating even after adjusting for differences 58 in NH and community characteristics. 59

To inform future policies and disaster preparedness plans in the vulnerable nursing home 60 setting, we need greater insight into the relationship between NH quality and the spread and 61 the relationships between NH quality (based on CMS Star Rating) and resident COVID-19 63 infection rates and deaths, taking into account NH structural characteristics and community 64 characteristics. 65

We conducted a cross-sectional study of nursing homes in the US. We merged data from 67 the following sources: (1) Five Star Quality Rating data provided before the holdas of October 1, 2020. 13 We included 75 data from nursing homes that submitted data to the NHSN and passed its quality assurance check 76 at least once in 2020. Data quality checks are performed regularly by the CDC and CMS to 77 identify data entry errors, such as facilities entering cumulative case counts over time instead of 78 incident cases, or other outliers. 1 Facilities that submitted erroneous data were given a value "N" 79 in the "Passed Quality Assurance Check" column. For this analysis, we excluded all data that did 80 not pass the quality assurance check. 81

The primary outcomes of the study were confirmed cases of COVID-19 and deaths from 82 COVID-19 per 1,000 NH residents per week between May 25 and December 20, 2020. The 83 primary exposure was NH star rating (1 to 5). We calculated "excess" cases and deaths among 1-84 J o u r n a l P r e -p r o o f star NHs)×total resident-weeks]. 86

In estimating the association between NH star rating and NH burden of COVID-19 cases 87 and deaths during the pre-vaccination period in the US, we sought to examine potential 88 confounders likely to be associated with both star rating and burden of COVID-19 by expanding 89 on prior literature that used three community characteristics to examine COVID-19 case rates in 90 high and low performing NHs during the initial periods of the pandemic and within specific 91 regions of the U.S. 3 First, to address confounding due to greater community spread in the 92 neighborhoods surrounding lower-rated NHs, we considered total county-level COVID-19 cases, 93 minus county-level cases at NHs, per 100,000 population in 2020. Second, to address 94 confounding by case mix, defined as the characteristics of NH residents that may be associated 95 with higher infection and mortality rates at lower-rated NHs, we considered socio-demographic 96 characteristics measured at the county level, including median household income, percent less 97 than high school education, percent non-Hispanic White, and designation as a Medically 98

Underserved Area. Finally, we considered two factors hypothesized to be highly correlated with 99 both NH rating and NH burden of COVID-19: for-profit status and size of the NH. 100

We fit a series of negative binomial regression models to estimate the associations 101 between NH star rating and rates of confirmed cases and deaths from COVID-19. We estimated 102 unadjusted associations in Model 1. In Model 2, we adjusted for community spread of COVID-103 19. In Model 3, we further adjusted for county-level sociodemographic characteristics (as proxies 104 for case mix). Finally, in Model 4, we adjusted for NH for-profit status and number of certified 105 beds. 106

For each model, we present incidence rate ratios (IRRs) comparing the average rate of 107 COVID-19 cases or deaths per 1,000 residents per week among 1-, 2-, 3-, and 4-star NHs to that 108 of 5-star NHs. In a supplemental analysis, we calculated IRRs for all possible comparisons of 109 NH star rating (e.g., 1-star vs. 4-star, 1-star vs. 2-star, etc.). These comparisons are adjusted for 110 all covariates included in Model 4 of the main analysis; results are reported in Table A1 of the 111

Appendix. To quantify the uncertainty around our estimates, we estimated robust standard errors 112 and constructed 95% confidence intervals (CI). Confidence intervals that exclude the null value 113

of 1 indicate that a given estimate is statistically significant at an alpha level of 0.05. Confidence 114 intervals that include 1 indicate a lack of statistical significance (i.e., p>=0.05). 115

This study was deemed exempt from review by the institutional review board at the 116 University of North Carolina at Chapel Hill. All analyses were conducted using SAS 9.4 (SAS 117

Institute, Cary, NC). 118

Of 15,390 NHs, 12,808 NHs (83%) submitted data and passed the quality assurance in 120 all 30 weeks of the reporting period; 14,281 (93%) submitted data and passed the quality 121 assurance check at least 29 weeks out of 30. Of the 14,944 NHs that passed the quality assurance 122 check at least once, 14,690 (98.3%) had a star rating (Table 1) . A greater proportion of 1-star 123

NHs were for-profit (87%) compared to 2-star (79%), 3-star (74%), 4-star (68%), and 5-star NHs 124 (54%). On average, 1-star NHs had 36 more certified beds and 1.2 fewer nursing staff hours per 125 resident than 5-star NHs. NHs with lower star ratings tended to be located in counties with lower 126 median household income, a lower proportion of the population with a high school diploma, and 127 a lower proportion of the population identifying as non-Hispanic White. Lower-rated NHs were 128 also more likely than higher-rated NHs to report staff shortages in 2020. We did not observe 129 substantial differences in reported shortages of personal protection equipment (PPE). The rate of confirmed cases of COVID-19 was 31% higher among 1-star NHs compared 139

to 5-star NHs (Model 1: IRR 1.31, 95% CI: 1.23-1.39). This statistically significant association 140 was partially explained by differences in community spread of COVID-19, case mix, and the for-141 profit status and size of NHs. After adjusting for these factors, the case rate remained 17% higher 142 among 1-star NHs compared to 5-star NHs (Model 2: IRR 1.17, 95% CI 1.10, 1.25). A similar 143 pattern was observed for 2-star, 3-star, and 4-star NHs, all of which had significantly higher case 144 rates than 5-star NHs even after adjustment for community spread, case mix, for-profit status and 145 size ( Table 2) . Appendix A1 presents all pairwise comparisons by star rating after adjustment for 146 the same set of covariates. Unsurprisingly, IRRs comparing NHs with more similar star ratings 147 tend to be smaller. While there remain statistically significant differences for 1-and 3-star 148 The rate of deaths from COVID-19 was 30% higher among 1-star NHs compared to 5-151 star NHs (Model 3: IRR 1.30, 95% CI: 1.20-1.41). This association was only slightly attenuated 152 after accounting for community spread, case mix, and the for-profit status and size of NHs 153 (Model 4: IRR 1.26, 95% CI 1.16, 1.37). A similar pattern was observed for 2-star, 3-star, and 4-154 star NHs. Pairwise comparisons of death rates by star rating reveal statistically significant 155 differences between 1-, 2-, and 3-star NHs compared to 4-star NHs, but no significant 156 differences among 1-, 2-, and 3-star NHs. This suggests that our results are not being driven only 157 by 5-star NHs. 158

Our cross-sectional study of nursing homes in the US examined differences in COVID-19 160 case and death rates by CMS Star Rating. We found that COVID-19 case and death rates were 161 substantially higher among NHs with lower star ratings, suggesting that NHs with quality much 162 below average are more susceptible to the spread of COVID-19. If all NHs had achieved the 163 lower case and death rates of 5-star NHs, nearly 13% of all cases and 14% of all deaths among 164 NH residents in the US would have been averted. 165

We found that the relationship between star rating and COVID-19 case rates was partially 166 attributable to external factors: lower-rated NHs are often located in areas with greater COVID-167 19 community spread, and serve more socioeconomically vulnerable residents than higher-rated 168

NHs. Additionally, lower-rated NHs have more beds, making them more susceptible to 169 outbreaks, and are more likely to be for-profit than higher-rated NHs, whose affiliations with 170 nonprofit organizations and academic medical centers may have improved their access to PPE 171 and other resources to prevent the spread of COVID-19. However, significant associations 172 between NH star rating and COVID-19 case and death rates remained even after accounting for 173 J o u r n a l P r e -p r o o f these factors, suggesting that 1-star or 5-star rating is a revealing indicator of NH vulnerability to 174 COVID-19. Moreover, differences in death rates by star rating were only slightly attenuated after 175 accounting for these factors, which suggests either uncontrolled confounding, such as differences 176 in individual patient characteristics and health conditions, or a stronger relationship with NH 177 quality for deaths than for cases. 178

We observed differences in the percentage of weeks in which NHs experienced staff 180 shortages by star rating, suggesting that staff shortages may have contributed to higher case and 181 death rates among lower-rated NHs. Lower rating nursing homes may experience substantially 182 higher rates of staff shortages because they include larger number of occupied beds and because 183 they are typically for-profit in nature. We did not observe differences in shortages of personal 184 protective equipment (PPE) between nursing homes with different star ratings. Future disaster 185 preparedness plans may consider prioritizing the distribution of human and other resources to 186 lower-rated NHs, which experience higher infection and death rates than higher-rated NHs, even 187 among NHs located in areas with similar levels of community spread, with similar resident case 188 mix, and of similar size and for-profit status. Although the allocation of more resources may be 189 looked upon as reward to NHs with below average performance, the striking difference in 190 infection and mortality rates shows the importance of sufficient staffing and resource for a better 191 disaster response among lower rated NHs. reports that because NHs are tied to geographic locations, county characteristics play a role in 198 health disparities within NHs related to residential segregation. 19 Future studies should further 199 investigate the relationship between the individual components of the 5-star system and COVID-200 19 reported outcomes. For example, it will be important to understand whether staffing rating, 201 measured based on the combination of nursing hours per resident day and total staffing hours per 202 resident day, is associated with COVID-19 case rates among NH residents as this suggests a 203 potential mechanism (increasing staffing) through which NHs could achieve better outcomes in a 204

Limitations 206

Nursing home populations are typically aging adults with chronic conditions, which may be a 207 confounding factor to COVID-19 deaths. CMS quality assurance checks were not validated for 208 accuracy. Additionally, we used county-level rather than resident-level data to account for 209 confounding by resident case mix, which allowed us to account for socio-economic status and 210 important contextual factors that determine vulnerability to COVID-19 but may result in residual 211 confounding by resident age and comorbidities particularly given that 1-star NHs typically serve 212 sicker patients. To the extent this is true, the reported COVID-19 death rates in 1-star NH may be 213 confounded by the poor health status of residents. To the extent this is true, the reported COVID-214 19 death rates in 1-star NH may be confounded by the poor health status of residents. Another 215 limitation was the absence of the proportion of Medicaid patients within nursing homes, which 216 was not included in the data provided by CMS. Since private insurers pay more for nursing 217 homes residents compared to Medicaid, nursing homes with larger proportion of Medicaid 218 patients may have different characteristics that may influence COVID-19 case and death rates. 20 219 J o u r n a l P r e -p r o o f

This cross-sectional study of nursing homes in the US provides real-time information 221 about the association between the quality of NHs and their vulnerability to COVID-19. The 222 spread of COVID-19 within the nursing home's neighborhood, case mix, and the for-profit status 223 and the size of beds were contributing factors to the higher rates of COVID-19 cases in lower 224 star rating nursing homes. These factors alone do not account for the strong association between 225 NH star rating and rates of COVID-19 deaths among NH residents. Our findings suggest that 226 --IRR: incidence rate ratio; CI: confidence interval a Model 1 is unadjusted; Model 2 adjusts for total county-level COVID-19 cases minus county-level cases at NHs per 100,000 population in 2020; Model 3 further adjusts for county-level median household income, percent less than high school education, percent non-Hispanic White, percent ages 65+ and designation as a Medically Underserved Area; Model 4 additionally adjusts for NH for-profit status and number of certified beds. 1 --IRR: incidence rate ratio; CI: confidence interval a Adjusted for total county-level COVID-19 cases minus county-level cases at NHs per 100,000 population in 2020, county-level median household income, percent less than high school education, percent non-Hispanic White, percent ages 65+, designation as a Medically Underserved Area, NH for-profit status, and number of certified beds.

COVID-19 Nursing Home Dataset

Home/COVID-19-Nursing-Home-Dataset/s2uc-8wxp 243 2

United States COVID-19 Cases and Deaths by State

248 4. Gorges RJ, Konetzka RT. Factors Associated With Racial Differences in Deaths Among 249 Nursing Home Residents With COVID-19 Infection in the US

With Resident COVID-19 Morbidity in Communities With High Infection Rates

Characteristics and Quality of US Nursing 255

Homes Reporting Cases of Coronavirus Disease 2019 (COVID-19)

Is There a Link between Nursing Home Reported Quality and 258 COVID-19 Cases? Evidence from California Skilled Nursing Facilities

Risk Factors Associated With SARS-CoV-2 Infections

Hospitalization, and Mortality Among US Nursing Home Residents

Understanding the Pharmacy Partnership for 264

Front-line Nursing Home Staff Experiences 267 During the COVID-19 Pandemic

Shortages of Staff in Nursing Homes During the COVID-270 19 Pandemic: What are the Driving Factors? Journal of the American Medical Directors 271 Association

Severe Staffing And Personal Protective 274 Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic

Coronavirus (Covid-19) Data in the United States

Meaningful Use Of 288

EHRs Among Hospitals Ineligible For Incentives Lags Behind That Of Other Hospitals

Gloves 4 (13) 4 (13) 4 (12) 4 (12) 4 (12) 4 (13)Hand Sanitizer 4 (13) 4 (13) 4 (13) 3 (12) 4 (13) 4 (13) COVID-19 Cases and Deaths among Residents