Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes

ObjectivesThe objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers.DesignRetrospective cohort study.Setting and ParticipantsA 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care.MethodsWe measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics.ResultsFull-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider.Conclusions and ImplicationsThe percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.     

Geographic Variation in Anticoagulant Use and Resident,Nursing Home,and County Characteristics Associated With Treatment Among US Nursing Home Residents

ObjectivesTo quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population.DesignA repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016.Setting and ParticipantsSecondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded.MethodsMultilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated.ResultsAmong 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation.Conclusions and ImplicationsIn this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.     

Time Trends in Opioid Use by Dementia Severity in Long-Term Care Nursing Home Residents

ObjectiveCurrent information on opioid use in nursing home residents, particularly those with dementia, is unknown. We examined the temporal trends in opioid use by dementia severity and the association of dementia severity with opioid use in long-term care nursing home residents.DesignRepeated measures cross-sectional study.SettingLong-term care nursing homes.ParticipantsUsing 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term care residents (n = 734,739) from each year who had 120 days of consecutive stay. In a secondary analysis, we included residents who had an emergency department visit for a fracture (n = 12,927).MeasurementsDementia was classified as no, mild, moderate, and severe based on the first MDS assessment each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged (>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents with a fracture, opioid use was measured within 7 days after emergency department discharge. Association of dementia severity with opioid use was evaluated using logistic regression.ResultsOverall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups. Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate, and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose opioids decreased with increasing severity of dementia. For example, severe dementia reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval (CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose (1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids.Conclusions and ImplicationsUse of opioids declined in nursing home residents from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population.     

Greater Opioid Use Among Nursing Home Residents in Ontario,Canada During the First 2 Waves of the COVID-19 Pandemic

ObjectivesTo examine the association between the COVID-19 pandemic and opioid use among nursing home residents followed up to March 2021, and possible variation by dementia and frailty status.DesignPopulation-based cohort study with an interrupted time series analysis.Setting and ParticipantsLinked health administrative databases for residents of all nursing homes (n = 630) in Ontario, Canada were examined. Residents were divided into consecutive weekly cohorts (first observation week was March 5 to 11, 2017 and last was March 21 to March 27, 2021).MethodsThe weekly proportion of residents dispensed an opioid was examined overall and by strata defined by the presence of dementia and frailty. Autoregressive Integrated Moving Average models with step and ramp intervention functions tested for immediate level and slope changes in weekly opioid use after the onset of the pandemic (March 1, 2020) and were fit on prepandemic data for projected trends.ResultsThe average weekly cohort ranged from 76,834 residents (prepandemic) to 69,359 (pandemic period), with a consistent distribution by sex (69% female) and age (54% age 85 + years). There was a statistically significant increased slope change in the weekly proportion of residents dispensed opioids (parameter estimate (β) = 0.035; standard error (SE) = 0.005, P < .001). Although significant for all 4 strata, the increased slope change was more pronounced among nonfrail residents (β = 0.038; SE = 0.008, P < .001) and those without dementia (β = 0.044; SE = 0.008, P < .001). The absolute difference in observed vs predicted opioid use in the last week of the pandemic period ranged from 1.25% (frail residents) to 2.28% (residents without dementia).Conclusions and ImplicationsAmong Ontario nursing home residents, there was a statistically significant increase in opioid dispensations following the onset of the pandemic that persisted up to 1 year later. Investigations of the reasons for increased use, potential for long-term use and associated health consequences for residents are warranted.     

Younger Individuals Increase Their Use of Nursing Homes Following ACA Medicaid Expansion

ObjectivesThis study examines the effect of Medicaid eligibility expansion under the Affordable Care Act (ACA) on the utilization of nursing home services by younger individuals and those covered by Medicaid.DesignCompared the age of nursing home residents, proportion of individuals covered by Medicaid, annual nursing home admissions in those younger than 65, and nursing home length of stay in states that expanded Medicaid eligibility through the ACA to states that did not. We used data from LTCFocus (nursing home level), the Minimum Data Set (individual level), and Medicaid expansion status from the Kaiser Family Foundation.Setting and ParticipantsThe study included 15,005,888 nursing home admissions, 2,446,950 of which were residents younger than 65, across 14,132 nursing homes between 2009 and 2016.MethodsA time-varying difference-in-difference model including state and year fixed effects with effect modification by pre-2014 nursing home occupancy.ResultsFacilities in expansion states with a pre-ACA occupancy rate of more than 70% increased the fraction of residents younger than 65 by 2.74% to 6.32%, compared with similar facilities in nonexpansion states. Medicaid admissions varied, with an increase in year 2 after expansion compared with nonexpansion states. Among residents entering from an acute care hospital, the proportion younger than 65 increased in facilities with pre-2014 occupancy rates of more than 70%, compared with similar facilities in nonexpansion states, an increase of up to 6.51%. Median nursing home length of stay for individuals younger than 65 decreased relative to nonexpansion states across all occupancy categories, ranging from 1.68 to 6.06 days after Medicaid expansion.Conclusions and ImplicationsMedicaid expansion increased access to nursing home post-acute care for individuals younger than 65. It remains unclear if the benefit of post-acute care is the same among this group, or if the needs of younger individuals can be adequately met in this setting.     

The Burden and Treatment of Chronic Constipation Among US Nursing Home Residents

ObjectiveTo evaluate the burden of chronic constipation (CC) and the use of drugs to treat constipation (DTC) in 2 complementary data sources.DesignRetrospective cohort study.Setting and ParticipantsUS nursing home residents aged ≥65 years with CC.MethodsWe conducted 2 retrospective cohort studies in parallel using (1) 2016 electronic health record (EHR) data from 126 nursing homes and (2) 2014-2016 Medicare claims, each linked with the Minimum Data Set (MDS). CC was defined as (1) the MDS constipation indicator and/or (2) chronic DTC use. We described the prevalence and incidence rate of CC and the use of DTC.ResultsIn the EHR cohort, we identified 25,739 residents (71.8%) with CC during 2016. Among residents with prevalent CC, 37% received a DTC, with an average duration of use of 19 days per resident-month during follow-up. The most frequently prescribed DTC classes included osmotic (22.6%), stimulant (20.9%), and emollient (17.9%) laxatives. In the Medicare cohort, a total of 245,578 residents (37.5%) had CC. Among residents with prevalent CC, 59% received a DTC and slightly more than half (55%) were prescribed an osmotic laxative. Duration of use was shorter (10 days per resident-month) in the Medicare (vs EHR) cohort.Conclusions and ImplicationsThe burden of CC is high among nursing home residents. The differences in the estimates between the EHR and Medicare data confirm the importance of using secondary data sources that include over-the-counter drugs and other treatments unobservable in Medicare Part D claims to assess the burden of CC and DTC use in this population.     

Changes in Long-Term Care Markets: Assisted Living Supply and the Prevalence of Low-Care Residents in Nursing Homes

ObjectivesTo assess the effect of changes in assisted living (AL) capacity within a market on prevalence of residents with low care needs in nursing homes.DesignRetrospective, longitudinal analysis of nursing home markets.Setting and participantsTwelve thousand two hundred fifity-one nursing homes in operation during 2007 and 2014.MeasurementsWe analyzed the percentage of residents in a nursing home who qualified as low-care. For each nursing home, we constructed a market consisting of AL communities, Medicare beneficiaries, and competing nursing homes within a 15-mile radius. We estimated the effect of change in AL beds on prevalence of low-care residents using multivariate linear models with year and nursing home fixed effects.ResultsThe supply of AL beds increased by an average 258 beds per nursing home market (standard deviation = 591) during the study period. The prevalence of low-care residents decreased from an average of 13.0% (median 10.5%) to 12.2% (median 9.5%). In adjusted models, a 100-bed increase in AL supply was associated with a decrease in low-care residents of 0.041 percentage points (P = .026), controlling for changes in market and nursing home characteristics, county demographics, and year and nursing home fixed effects. In markets with a high percentage of its Medicare beneficiaries (≥14%) dual eligible for Medicaid, the effect of AL is stronger, with a 0.066–percentage point decrease per 100 AL beds (P = .026) vs a 0.016–percentage point decrease in low-duals markets (P = .48).Conclusions and implicationsOur analysis suggests that some of the growth in AL capacity serves as a substitute for nursing homes for patients with low care needs. Furthermore, the effects are concentrated in markets with an above-average proportion of beneficiaries with dual Medicaid eligibility.     

Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents

ObjectivesDescribe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents.DesignAnalysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017.Setting and participantsResidents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP).MethodsEIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home–specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4.ResultsAmong 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home–specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used.Conclusions and ImplicationsOne in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home–specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.     

Institutional Factors Associated with Residents’ Malnutrition in Nursing Homes: A Cross-Sectional Study

ObjectivesMalnutrition is frequent in older adults, associated with increased morbidity, mortality, and higher costs. Nursing home residents are especially affected, and evidence on institutional factors associated with malnutrition is limited. We calculated the prevalence of malnutrition in Swiss nursing home residents and investigated which structure and process indicators of nursing homes are associated with residents’ malnutrition.DesignSubanalysis of the Swiss Nursing Homes Human Resources Project 2018, a multicenter, cross-sectional study conducted from 2018 to 2019 in Switzerland.Setting and ParticipantsThis study included 76 nursing homes with a total of 5047 residents.MethodsMalnutrition was defined as a loss of bodyweight of ≥5% in the last 30 days or ≥10% in the last 180 days. Binomial generalized estimating equations (GEE) were applied to examine the association between malnutrition and structural (staffing ratio, grade mix, presence of a dietician, malnutrition guideline, support during mealtimes) and process indicators (awareness of malnutrition, food administration process). GEE models were adjusted for institutional (profit status, facility size) and specific resident characteristics.ResultsThe prevalence of residents with malnutrition was 5%. A higher percentage of units per nursing home having a guideline on prevention and treatment of malnutrition was significantly associated with more residents with weight loss (OR 2.47, 95% CI 1.31-4.66, P = .005). Not having a dietician in a nursing home was significantly associated with a higher rate of residents with weight loss (OR 1.60, 95% CI 1.09-2.35, P = .016).Conclusions and ImplicationsHaving a dietician as part of a multidisciplinary team in a nursing home is an important step to address the problem of residents’ malnutrition. Further research is needed to clarify the role of a guideline on prevention and treatment of malnutrition to improve the quality of care in nursing homes.     

Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018

ObjectiveBurgeoning rates of antibiotic resistance have resulted in a shift in national focus to improve infection prevention and control programs in US nursing homes (NHs). We sought to evaluate the changes in nursing home infection prevention and control programs over time.DesignRetrospective comparative analysis of national nursing home survey data from 2014 and 2018.Setting and participantsWe used survey data from 2 nationally representative samples of US nursing homes (945 NHs in 2014 and 888 in 2018).MethodsThree indices measuring antibiotic stewardship, outbreak control, and urinary tract infection prevention (ranging from 0 to 100) were developed to measure the change in infection prevention and control programs. Multivariable linear regression models were used to identify facility and infection preventionist characteristics associated with each index. Decomposition models were used to identify contributions of factors on the differences in each index over time.ResultsFrom 2014 to 2018, we saw strengthening of antibiotic stewardship practices by 33 percentage points, outbreak control practices by 13 percentage points, and urinary tract infection prevention practices by 6 percentage points. Although we found several predictors of these improvements, much of the improvement was due to the difference in time.Conclusions and ImplicationsPolicy mandates and greater national attention are likely important factors in improving nursing home infection prevention and control practices. Further work is needed to evaluate the effect of these programs on resident outcomes.     

Racial inequities in receipt of influenza vaccination among nursing home residents in the United States, 2008-2009: a pattern of low overall coverage in facilities in which most residents are black

ObjectivesNationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents.DesignCross-sectional study with multilevel modeling.Setting and ParticipantsStates in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare &; Medicaid Service’s Minimum Data Set for October 1, 2008, through March 31, 2009.MeasurementsResidents’ influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination).ResultsStates with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage.ConclusionInequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.     

Prevalence of Vision Loss and Associations With Age-Related Eye Diseases Among Nursing Home Residents Aged ≥65 Years

ObjectivesTo examine data from Delaware nursing homes to determine prevalence of age-related eye diseases (AREDs), vision impairment, and blindness and to compare the findings with the results of 11 US investigations of vision and eye health in nursing homes.DesignThis is a cross-sectional, retrospective study of nursing home patients.Setting and ParticipantsTwenty nursing homes in Delaware participated in the study, yielding comprehensive eye examination records for 2019 study participants.MethodsSummary statistics and regression analyses.ResultsThe overall prevalence of vision impairment or blindness was 63.8% and was above 60% for each age, sex, and race category. Prevalence of vision impairment or blindness was 68.4% among patients with cataracts, 69.4% among patients with macular degeneration, 70.5% among patients with glaucoma, and 68.4% among patients with diabetic retinopathy. Prevalence of blindness was 14.1%. Among patients with AREDs, prevalence of blindness ranged from 15.0% for patients with cataracts to 22.6% for patients with diabetic retinopathy. When compared with other investigations, we found wide variation in vision and eye factors reported and wide variation in the prevalence of those factors. Only 4 studies diagnosed both AREDs and visual function. Seven studies reported AREDs, and 7 reported vision impairment and/or blindness. Vision impairment or blindness ranged from 29% to 67%; cataract ranged from 32% to 83%; macular degeneration ranged from 4.6% to 70.7%. Glaucoma ranged from 5.3% to 41.4%; diabetic retinopathy ranged from 1.7% to 3.1%.Conclusions and ImplicationsComprehensive eye examinations showed that vision impairment and blindness affected 63.8% of nursing home residents. Compared with other studies, there was a wide range of vision factors reported and wide variation in the prevalence of vision impairment or blindness and AREDs. This investigation suggests the importance of eye care in nursing homes and the importance of reporting standard vision and eye health factors to inform policy and practice.     

Impact of an Antimicrobial Stewardship Program on Resistance to Fluoroquinolones of Urinary Enterobacteriaceae Isolated From Nursing Home Residents: A Retrospective Cohort Study

ObjectivesThis study investigated the impact of an antimicrobial stewardship program on fluoroquinolone (FLQ) resistance in urinary Enterobacteriaceae isolated from residents of 3 French nursing homes.DesignA multicentric retrospective before-and-after study was conducted.Setting and ParticipantsAll the first urinary Enterobacteriaceae isolates obtained from nursing home residents were included. Two time frames were analyzed: 2013-2015 and 2016-2017.MethodsThe antimicrobial stewardship program started in 2015 and was based on (1) 1-day training for use of an “antimicrobial stewardship kit for nursing homes;” and (2) daily support and training of the coordinating physician by an antibiotic mobile team (AMT) in 2 of 3 nursing homes.ResultsOverall, 338 urinary isolates were analyzed. Escherichia coli was the most frequent species (212/338, 63%). A significant reduction of resistance to ofloxacin was observed between 2013-2015 and 2016-2017 in general (Δ = −16%, P = .004) and among isolates obtained from patients hospitalized in the county nursing home with AMT support (Δ = −28%, P < .01). A nonstatistically significant reduction in ofloxacin resistance was also observed in the hospital nursing home with AMT support (Δ = −18%, P = .06).Conclusions and ImplicationsOur antimicrobial stewardship program resulted in a decrease in resistance to FLQ among urinary Enterobacteriaceae isolated from nursing home residents. The support of an AMT along with continuous training of the coordinating physician seems to be an important component to ensure efficacy of the intervention.     

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations

ObjectivesNursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use.DesignObservational propensity-matched study.Setting and ParticipantsMedicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration.MethodsACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending.ResultsNearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents’ attribution status switched (14.6%), either into or out of an ACO.Conclusions and ImplicationsACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.     

Absence of COVID-19 Disease Among Chronically Ventilated Nursing Home Patients

ObjectiveTo describe the experience of COVID-19 disease among chronically ventilated and nonventilated nursing home patients living in 3 separate nursing homes.DesignObservational study of death, respiratory illness and COVID-19 polymerase chain reaction (PCR) results among residents and staff during nursing home outbreaks in 2020.Setting and Participants93 chronically ventilated nursing home patients and 1151 nonventilated patients living among 3 separate nursing homes on Long Island, New York, as of March 15, 2020. Illness, PCR results, and antibody studies among staff are also reported.MeasurementsData were collected on death rate among chronically ventilated and nonventilated patients between March 15 and May 15, 2020, compared to the same time in 2019; prevalence of PCR positivity among ventilated and nonventilated patients in 2020; reported illness, PCR positivity, and antibody among staff.ResultsTotal numbers of deaths among chronically ventilated nursing home patients during this time frame were similar to the analogous period 1 year earlier (9 of 93 in 2020 vs 8 of 100 in 2019, P = .8), whereas deaths among nonventilated patients were greatly increased (214 of 1151 in 2020 vs 55 of 1189 in 2019, P < .001). No ventilated patient deaths were clinically judged to be COVID-19 related. No clusters of COVID-19 illness could be demonstrated among ventilated patients. Surveillance PCR testing of ventilator patients failed to reveal COVID-19 positivity (none of 84 ventilator patients vs 81 of 971 nonventilator patients, P < .002). Illness and evidence of COVID-19 infection was demonstrated among staff working both in nonventilator and in ventilator units.Conclusions and ImplicationsCOVID-19 infection resulted in illness and death among nonventilated nursing home residents as well as among staff. This was not observed among chronically ventilated patients. The mechanics of chronic ventilation appears to protect chronically ventilated patients from COVID-19 disease.     

Ecological Analysis of the Decline in Incidence Rates of COVID-19 Among Nursing Home Residents Associated with Vaccination,United States,December 2020-January 2021

ObjectiveTo evaluate if facility-level vaccination after an initial vaccination clinic was independently associated with COVID-19 incidence adjusted for other factors in January 2021 among nursing home residents.DesignEcological analysis of data from the CDC's National Healthcare Safety Network (NHSN) and from the CDC's Pharmacy Partnership for Long-Term Care Program.Setting and ParticipantsCMS-certified nursing homes participating in both NHSN and the Pharmacy Partnership for Long-Term Care Program.MethodsA multivariable, random intercepts, negative binomial model was applied to contrast COVID-19 incidence rates among residents living in facilities with an initial vaccination clinic during the week ending January 3, 2021 (n = 2843), vs those living in facilities with no vaccination clinic reported up to and including the week ending January 10, 2021 (n = 3216). Model covariates included bed size, resident SARS-CoV-2 testing, staff with COVID-19, cumulative COVID-19 among residents, residents admitted with COVID-19, community county incidence, and county social vulnerability index (SVI).ResultsIn December 2020 and January 2021, incidence of COVID-19 among nursing home residents declined to the lowest point since reporting began in May, diverged from the pattern in community cases, and began dropping before vaccination occurred. Comparing week 3 following an initial vaccination clinic vs week 2, the adjusted reduction in COVID-19 rate in vaccinated facilities was 27% greater than the reduction in facilities where vaccination clinics had not yet occurred (95% confidence interval: 14%-38%, P < .05).Conclusions and ImplicationsVaccination of residents contributed to the decline in COVID-19 incidence in nursing homes; however, other factors also contributed. The decline in COVID-19 was evident prior to widespread vaccination, highlighting the benefit of a multifaced approach to prevention including continued use of recommended screening, testing, and infection prevention practices as well as vaccination to keep residents in nursing homes safe.     

Evaluating Perspectives of Relatives of Nursing Home Residents on the Nursing Home Visiting Restrictions During the COVID-19 Crisis: A Dutch Cross-Sectional Survey Study

ObjectivesCoronavirus disease 2019 (COVID-19) has caused many nursing homes to prohibit resident visits to prevent viral spread. Although visiting restrictions are instituted to prolong the life of nursing home residents, they may detrimentally affect their quality of life. The aim of this study was to capture perspectives from the relatives of nursing home residents on nursing home visiting restrictions.DesignA cross-sectional online survey was conducted.Setting and ParticipantsA convenience sample of Dutch relatives of nursing home residents (n = 1997) completed an online survey on their perspectives regarding nursing home visiting restrictions.MethodsThe survey included Likert-item, multiselect, and open-answer questions targeting 4 key areas: (1) communication access to residents, (2) adverse effects of visiting restrictions on residents and relatives, (3) potential protective effect of visiting restrictions, (4) important aspects for relatives during and after visiting restrictions.ResultsSatisfaction of communication access to nursing home residents was highest when respondents had the possibility to communicate with nursing home residents by nurses informing them via telephone, contact behind glass, and contact outside maintaining physical distance. Satisfaction rates increased when respondents had multiple opportunities to stay in contact with residents. Respondents were concerned that residents had increased loneliness (76%), sadness (66%), and decreased quality of life (62%), whereas study respondents reported personal sadness (73%) and fear (26%). There was no consensus among respondents if adverse effects of the visiting restrictions outweighed the protective effect for nursing home residents. Respondents expressed the need for increased information, communication options, and better safety protocols.Conclusion and ImplicationsProviding multiple opportunities to stay in touch with nursing home residents can increase satisfaction of communication between residents and relatives. Increased context-specific information, communication options, and safety protocols should be addressed in national health policy.     

Health Outcomes of Immigrants in Nursing Homes: A Population-Based Retrospective Cohort Study in Ontario,Canada

ObjectiveOlder adults account for a significant portion of Canadian immigrants, yet characteristics and health outcomes of older immigrants in nursing homes have not been studied. We aimed to describe the prevalence of immigrants living in nursing homes, their characteristics, and their hospitalization and mortality rates compared to long-term residents in the first year of entry to nursing homes.DesignPopulation-based, retrospective cohort study using linked health administrative databases.Setting and ParticipantsWe assessed all incident admissions into publicly funded nursing homes in Ontario between April 2013 and March 2016. Immigrants were defined as those who arrived in Canada after 1985; long-term residents are those who arrived before 1985 or are Canadian-born.MethodsThe primary outcome was all-cause hospitalization and mortality rates within 1 year of nursing home entry. Nested Cox proportional hazards models were estimated to explore the associations of facility, demographic, and clinical characteristics to the primary outcomes.ResultsImmigrants comprised 4.4% of residents in Ontario's nursing homes, compared to 13.9% in the general population. The majority were from East and Southeast Asia (52.2%), and more than half (53.9%) had no competency in either official language on arrival in Canada. At the time of nursing home entry, immigrants were younger than long-term residents but had greater functional and cognitive impairments. Immigrants had a lower rate of mortality [hazard ratio 0.58, 95% confidence interval (CI) 0.51, 0.68; P < .001] but were more likely to be hospitalized (hazard ratio 1.14, 95% CI 1.06, 1.23; P < .001). Adjusting for language ability, the effect of immigrant status on hospitalization was not statistically significant.Conclusions and ImplicationsDespite greater functional and cognitive impairments, immigrants in nursing homes had lower mortality than long-term residents, potentially reflecting the “healthy immigrant effect.” Inability to speak English was associated with increased risk of hospitalization, highlighting the need for strategies to overcome communication barriers.     

Decline in Veterans’ Admissions to Nursing Homes during COVID-19: Fewer Beds,More Fear,and Finding Alternative Care Settings

ObjectiveExamine the decline in admission to community nursing homes among Veterans that occurred following the onset of the COVID-19 pandemic.DesignMultimethods study using Department of Veterans Affairs (VA) purchasing records to examine trends in total admissions and semistructured interviews with staff connected to the VA community nursing home program to contextualize observed trends.Setting and participantsAll VA-paid admissions to community nursing homes (N = 56,720 admissions) and national data on nursing home admissions from LTCFocUS. Semistructured interviews were conducted with 9 VA staff from 4 VA medical centers working in the VA community nursing home program, including social workers, nurses, and program coordinators.ResultsBetween April and December 2020, community nursing home admissions among Veterans were 35% lower compared with the same period in 2019. Nationally, total nursing home admissions decreased by 19.6%. VA community nursing home program staff described 3 themes that contributed to this decline: (1) fewer nursing home beds available, (2) lower admissions due to fear of Veterans being exposed to COVID-19 in nursing homes, and (3) leaving nursing homes in favor of living at home with home-based care.Conclusions and ImplicationsThe decline in nursing home admissions among Veterans raises questions about how replacing nursing home care in favor of home- and community-based care affects the health outcomes and well-being of Veterans and their caregivers.