Managing the Impact of COVID-19 in Nursing Homes and Long-Term Care Facilities: An Update

Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine “booster” doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector.     

Racial/Ethnic Differences in Risk Factors Associated With Severe COVID-19 Among Older Adults With ADRD

ObjectiveTo examine racial/ethnic differences in risk factors, and their associations with COVID-19–related outcomes among older adults with Alzheimer’s disease and related dementias (ADRD).DesignObservational study.Setting and ParticipantsNational Medicare claims data and the Minimum Data Set 3.0 from April 1, 2020, to December 31, 2020, were linked in this study. We included community-dwelling fee-for-service Medicare beneficiaries with ADRD, diagnosed with COVID-19 between April 1, 2020, and December 1, 2020 (N = 138,533).MethodsTwo outcome variables were defined: hospitalization within 14 days and death within 30 days of COVID-19 diagnosis. We obtained information on individual sociodemographic characteristics, chronic conditions, and prior health care utilization based on the Medicare claims and the Minimum Dataset. Machine learning methods, including lasso regression and discriminative pattern mining, were used to identify risk factors in racial/ethnic subgroups (ie, White, Black, and Hispanic individuals). The associations between identified risk factors and outcomes were evaluated using logistic regression and compared across racial/ethnic subgroups using the coefficient comparison approach.ResultsWe found higher risks of COVID-19–related outcomes among Black and Hispanic individuals. The areas under the curve of the models with identified risk factors were 0.65 to 0.68 for mortality and 0.61 to 0.62 for hospitalization across racial/ethnic subgroups. Although some identified risk factors (eg, age, gender) for COVID-19–related outcomes were common among all racial/ethnic subgroups, other risk factors (eg, hypertension, obesity) varied by racial/ethnic subgroups. Furthermore, the associations between some common risk factors and COVID-19–related outcomes also varied by race/ethnicity. Being male was related to 138.2% (95% CI: 1.996–2.841), 64.7% (95% CI: 1.546–1.755), and 37.1% (95% CI: 1.192–1.578) increased odds of death among Hispanic, White, and Black individuals, respectively. In addition, the racial/ethnic disparity in COVID-19–related outcomes could not be completely explained by the identified risk factors.Conclusions and ImplicationsRacial/ethnic differences were detected in the likelihood of having COVID-19–related outcomes, specific risk factors, and relationships between specific risk factors and COVID-19–related outcomes. Future research is needed to elucidate the reasons for these differences.     

Staffing and Protective Equipment Access Mitigated COVID-19 Penetration and Spread in US Nursing Homes During the Third Surge

ObjectivesDuring the last quarter of 2020—despite improved distribution of personal protective equipment (PPE) and knowledge of COVID-19 management—nursing homes experienced the greatest increases in cases and deaths since the pandemic's beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic.DesignCross-sectional analysis.Setting and ParticipantsFacility-level data from 13,156 US nursing home facilities.MethodsTwo series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020.ResultsNursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%; n = 10,592) of facilities reported at least 1 COVID-19 case, 49.44% (n = 6504) reported at least 1 hospitalization, and 49.76% (n = 6546) reported at least 1 death during this third surge. N95 mask shortages were associated with increased odds of at least 1 COVID-19 case [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.05-1.40] and hospitalization (1.26, 95% CI 1.13-1.40), as well as larger numbers of hospitalizations (1.11, 95% CI 1.02-1.20). Nursing aide shortages were associated with lower odds of at least 1 COVID-19 death (1.23, 95% CI 1.12-1.34) and higher hospitalizations (1.09, 95% CI 1.01-1.17). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50-bed) and midsized (50- to 150-bed) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates >75% increased odds of experiencing a COVID-19 case (1.48, 95% CI 1.35-1.62) or death (1.25, 95% CI 1.17-1.34).Conclusions and ImplicationsAdequate staffing and PPE—along with reduced occupancy and smaller facilities—mitigate incidence and magnitude of COVID-19 cases and sequelae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.     

The Role of the Medical Director in Ontario Long-Term Care Homes: Impact of COVID-19

ObjectivesThe pandemic has uncovered a broad lack of understanding of the role of the Medical Director in Canadian Long-Term Care (LTC) Homes. Our objectives were to identify the current demographics and practices of LTC Medical Directors, discover how the pandemic affected their practice habits, and inform the content of the Ontario Long-Term Care Clinicians Medical Director Course, to ensure that Medical Directors have the requisite knowledge of the responsibilities of their role.DesignEmail survey.Setting and ParticipantsMedical directors in Ontario long-term care homes.MethodsResponses to open-ended, close-ended, multiple-choice, and free-text questions.ResultsA total of 156 medical directors (approximately 24%) completed the survey. Ninety-four percent were family physicians. Approximately 40% of participants had been a medical director for fewer than 5 years, whereas more than 11% have been in the role for greater than 30 years. More than 60% spend fewer than 2 hours per week in their administrative role, with fewer than 23% completing formal evaluations of the attending clinicians. Greater than 75% are either satisfied or extremely satisfied in their medical director role, citing excellent engagement and collaboration with team members. Feelings of dissatisfaction were associated with pandemic stress, increased hours and responsibility, inadequate remuneration, lack of ability to make decisions and lack of acknowledgement that physicians add value to the interdisciplinary team.Conclusion and ImplicationsIt is clear that medical directors are in a unique position to impact the care of residents within LTC. It is imperative to engage medical directors as integral members of the LTC health care team. This can be achieved by acknowledging their medical expertise for improving outcomes, providing them with the authority for decision making, compensating them appropriately, and clearly defining the role. By making these changes, we can ensure that there is a higher likelihood to sustain effective medical leadership in LTC.     

Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition

ObjectivesTo estimate pain reporting among residents with cancer in relation to metropolitan area segregation and NH racial and ethnic composition.DesignCross-sectional study.Setting and Participants383,757 newly admitted black (B), Hispanic (H), or white (W) residents with cancer in 12,096 US NHs (2011-2013).MethodsUsing the Minimum Data Set 3.0, pain in past 5 days was determined by self-report or use of pain management. The Theil entropy index, a measure of metropolitan area segregation, was categorized [high (up to 0.20), very high (0.20-0.30), or extreme (0.30-0.53)].ResultsPain prevalence decreased across segregation level (black: high = 77%, very high = 75%, extreme = 72%; Hispanic: high = 79%, very high = 77%, extreme = 70%; white: high = 80%, very high = 77%, extreme = 74%). In extremely segregated areas, all residents were less likely to have recorded pain [adjusted prevalence ratios: blacks, 4.6% less likely, 95% confidence interval (CI) 3.1%-6.1%; Hispanics, 6.9% less likely, 95% CI 4.2%-9.6%; whites, 7.4% less likely, 95% CI 6.5%-8.2%] than in the least segregated areas. At all segregation levels, pain was recorded more frequently for residents (black or white) in predominantly white (>80%) NHs than in mostly black (>50%) NHs or residents (Hispanic or white) in predominantly white NHs than mostly Hispanic (>50%) NHs.Conclusions and ImplicationsWe observed decreased pain recording in metropolitan areas with greater racial and ethnic segregation. This may occur through the inequitable distribution of resources between NHs, resident-provider empathy, provider implicit bias, resident trust, and other factors.     

A Local COVID-19 Support Platform for Nursing Homes: Feedback and Perspectives

The COVID-19 pandemic has had a major impact on nursing homes (NHs), which were not prepared to manage infections among their at-risk patient populations. In order to comply with the French government's guidelines, we rapidly set up a local support platform (LSP) to help NHs manage their cases of COVID-19. The LSP comprised multidisciplinary decision support, a specialist phone hotline, mobile geriatric medicine teams, and videoconferences on COVID-19.We first quantified the LSP's interventions in 63 local NHs since the start of the first wave of COVID-19 (March 2020): 9 instances of multidisciplinary decision support, 275 calls to the specialist phone hotline, 84 interventions by mobile geriatric medicine teams, and 16 videoconferences. The LSP had been used during and between the first and second waves of the epidemic, and all had evolved to meet the NHs' needs.     

Stronger Impact of COVID-19 in Nursing Homes of a French Region During the Second Pandemic Wave

ObjectivesQuantify the effects of characteristics of nursing homes and their surroundings on the spread of COVID-19 outbreaks and assess the changes in resident protection between the first 2 waves (March 1 to July 31 and August 1 to December 31, 2020).DesignAn observational study was carried out on data on COVID-19 outbreaks extracted from a database that monitored the spread of the virus in nursing homes.Setting and ParticipantsThe study concerned all 937 nursing homes with >10 beds in Auvergne-Rhône-Alpes region, France.MethodsThe rate of nursing homes with at least 1 outbreak and the cumulative number of deaths were modeled for each wave.ResultsDuring the second (vs the first wave), the proportion of nursing homes that reported at least 1 outbreak was higher (70% vs 56%) and the cumulative number of deaths more than twofold (3348 vs 1590). The outbreak rate was significantly lower in public hospital–associated nursing homes than in private for-profit ones. During the second wave, it was lower in public and private not-for-profit nursing homes than in private for-profit ones. During the first wave, the probability of outbreak and the mean number of deaths increased with the number of beds (P < .001). During the second wave, the probability of outbreak remained stable in >80-bed institutions and, under proportionality assumption, the mean number of deaths was less than expected in >100-bed institutions. The outbreak rate and the cumulative number of deaths increased significantly with the increase in the incidence of hospitalization for COVID-19 in the surrounding populations.Conclusions and ImplicationsThe outbreak in the nursing homes was stronger during the second than the first wave despite better preparedness and higher availabilities of tests and protective equipment. Solutions for insufficient staffing, inadequate rooming, and suboptimal functioning should be found before future epidemics.     

Implementation of an Algorithm of Cohort Classification to Prevent the Spread of COVID-19 in Nursing Homes

Older adults living in nursing homes are the most vulnerable group of the COVID-19 pandemic. There are many difficulties in isolating residents and limiting the spread in this setting. We have developed a simple algorithm with a traffic light format for resident classification and sectorization within nursing homes, based on basic diagnostic tests, surveillance of symptoms onset, and close contact monitoring. We have implemented the algorithm in several centers with good data on adherence. Suggestions for implementation and evaluation are discussed.     

Protecting Nursing Homes and Long-Term Care Facilities From COVID-19: A Rapid Review of International Evidence

ObjectivesThe COVID-19 pandemic has highlighted the extreme vulnerability of older people and other individuals who reside in long-term care, creating an urgent need for evidence-based policy that can adequately protect these community members. This study aimed to provide synthesized evidence to support policy decision making.DesignRapid narrative review investigating strategies that have prevented or mitigated SARS-CoV-2 transmission in long-term care.Setting and ParticipantsResidents and staff in care settings such as nursing homes and long-term care facilities.MethodsPubMed/Medline, Cochrane Library, and Scopus were systematically searched, with studies describing potentially effective strategies included. Studies were excluded if they did not report empirical evidence (eg, commentaries and consensus guidelines). Study quality was appraised on the basis of study design; data were extracted from published reports and synthesized narratively using tabulated data extracts and summary tables.ResultsSearches yielded 713 articles; 80 papers describing 77 studies were included. Most studies were observational, with no randomized controlled trials identified. Intervention studies provided strong support for widespread surveillance, early identification and response, and rigorous infection prevention and control measures. Symptom- or temperature-based screening and single point-prevalence testing were found to be ineffective, and serial universal testing of residents and staff was considered crucial. Attention to ventilation and environmental management, digital health applications, and acute sector support were also considered beneficial although evidence for effectiveness was lacking. In observational studies, staff represented substantial transmission risk and workforce management strategies were important components of pandemic response. Higher-performing facilities with less crowding and higher nurse staffing ratios had reduced transmission rates. Outbreak investigations suggested that facility-level leadership, intersectoral collaboration, and policy that facilitated access to critical resources were all significant enablers of success.Conclusions and ImplicationsHigh-quality evidence of effectiveness in protecting LTCFs from COVID-19 was limited at the time of this study, though it continues to emerge. Despite widespread COVID-19 vaccination programs in many countries, continuing prevention and mitigation measures may be required to protect vulnerable long-term care residents from COVID-19 and other infectious diseases. This rapid review summarizes current evidence regarding strategies that may be effective.     

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.     

Advance Care Planning in Dutch Nursing Homes During the First Wave of the COVID-19 Pandemic

ObjectivesTo explore how physicians in Dutch nursing homes practiced advance care planning (ACP) during the first wave of the COVID-19 pandemic, and to explore whether and how ACP changed during the first wave of the pandemic.DesignQualitative analysis of an online, mainly open-ended questionnaire on ACP among physicians working in nursing homes in the Netherlands during the first wave of the COVID-19 pandemic.Setting and ParticipantsPhysicians in Dutch nursing homes.MethodsRespondents were asked to describe a recent case in which they had a discussion on anticipatory medical care decisions and to indicate whether ACP was influenced by the COVID-19 pandemic in that specific case and in general. Answers were independently coded and a codebook was compiled in which the codes were ordered by themes that emerged from the data.ResultsA total of 129 questionnaires were filled out. Saturation was reached after analyzing 60 questionnaires. Four main themes evolved after coding the questionnaires: reasons for ACP discussion, discussing ACP, topics discussed in ACP, and decision making in ACP. COVID-19–specific changes in ACP indicated by respondents included (1) COVID-19 infection as a reason for initiating ACP, (2) a higher frequency of ACP discussions, (3) less face-to-face contact with surrogate decision makers, and (4) intensive care unit admission as an additional topic in anticipatory medical decision making.Conclusions and ImplicationsACP in Dutch nursing homes has changed because of the COVID-19 pandemic. Maintaining frequent and informal contact with surrogate decision makers fosters mutual understanding and aids the decision-making process in ACP.     

The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being

ObjectiveQuantify the effects of the COVID-19 pandemic on nursing home resident well-being.DesignQuantitative analysis of resident-level assessment data.Setting and participantsLong-stay residents living in Connecticut nursing homes.MethodsWe used Minimum Data Set assessments to measure nursing home resident outcomes observed in each week between March and July 2020 for long-stay residents (eg, those in the nursing home for at least 100 days) who lived in a nursing home at the beginning of the pandemic. We compared outcomes to those observed at the beginning of the pandemic, controlling for both resident characteristics and patterns for outcomes observed in 2017-2019.ResultsWe found that nursing home resident outcomes worsened on a broad array of measures. The prevalence of depressive symptoms increased by 6 percentage points relative to before the pandemic in the beginning of March—representing a 15% increase. The share of residents with unplanned substantial weight loss also increased by 6 percentage points relative to the beginning of March—representing a 150% increase. We also found significant increases in episodes of incontinence (4 percentage points) and significant reductions in cognitive functioning. Our findings suggest that loneliness and isolation play an important role. Though unplanned substantial weight loss was greatest for those who contracted COVID-19 (about 10% of residents observed in each week), residents who did not contract COVID-19 also physically deteriorated (about 7.5% of residents in each week).Conclusions and ImplicationsThese analyses show that the pandemic had substantial impacts on nursing home residents beyond what can be quantified by cases and deaths, adversely affecting the physical and emotional well-being of residents. Future policy changes to limit the spread of COVID-19 or other infectious disease outbreaks should consider any additional costs beyond the direct effects of morbidity and mortality due to COVID-19.     

Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020

ObjectiveTo measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff.DesignRetrospective cross-sectional study.Setting and ParticipantsCenters for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts).MethodsWe estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics.ResultsOf the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant.Conclusions and ImplicationsThese findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.     

Prognostic Value of Lung Ultrasonography in Older Nursing Home Residents Affected by COVID-19

ObjectivesLung ultrasonographic (LUS) imaging may play an important role in the management of patients with COVID-19–associated lung injury, particularly in some special populations. However, data regarding the prognostic role of the LUS in nursing home residents, one of the populations most affected by COVID-19, are not still available.DesignRetrospective.Settings and ParticipantsNursing home residents affected by COVID-19 were followed up with an LUS from April 8 to May 14, 2020, in Chioggia, Venice.MethodsCOVID-19 was diagnosed through a nasopharyngeal swab. LUS results were scored using a 12-zone method. For each of the 12 zones (2 posterior, 2 anterior, 2 lateral, for both left and right lungs), the possible score ranged from 0 to 3 (1 = presence of B lines, separated, with <50% of space from the pleural line; 2 = presence of B lines, separated, with >50% of space from the pleural line; 3 = lung thickening with tissuelike aspect). The total score ranged from 0 to 36. Mortality was assessed using administrative data. Data regarding accuracy (and related parameters) were reported.ResultsAmong 175 nursing home residents, 48 (mean age: 84.1 years; mainly female) were affected by COVID-19. Twelve died during the follow-up period. The mean LUS score was 3. The area under the curve of LUS in predicting mortality was 0.603 [95% confidence interval (CI): 0.419-0.787], and it increased to 0.725 (95% CI: 0.41-0.99) after including follow-up LUS controls. Taking an LUS score ≥4 as exposure variable and mortality as outcome, the sensitivity was 58.33% and specificity 63.89%, with a positive likelihood ratio of 1.62 and a negative of 0.65.Conclusions and ImplicationsLUS is able to significantly predict mortality in nursing home residents affected by COVID-19, suggesting that this simple tool can be routinely used in this setting instead of more invasive techniques available only in hospital.     

Risk of Death in Nursing Home Residents After COVID-19 Vaccination

ObjectivesIn the first months of 2021, the Dutch COVID-19 vaccination campaign was disturbed by reports of death in Norwegian nursing homes (NHs) after vaccination. Reports predominantly concerned persons >65 years of age with 1 or more comorbidities. Also, in the Netherlands adverse events were reported after COVID-19 vaccination in this vulnerable group. Yet, it was unclear whether a causal link between vaccination and death existed. Therefore, we investigated the risk of death after COVID-19 vaccination in Dutch NH residents compared with the risk of death in NH residents prior to the COVID-19 pandemic.DesignPopulation-based longitudinal cohort study with electronic health record data.Setting and ParticipantsWe studied Dutch NH residents from 73 NHs who received 1 or 2 COVID-19 vaccination(s) between January 13 and April 16, 2021 (n = 21,762). As a historical comparison group, we included Dutch NH residents who were registered in the same period in 2019 (n = 27,591).MethodsData on vaccination status, age, gender, type of care, comorbidities, and date of NH entry and (if applicable) discharge or date of death were extracted from electronic health records. Risk of death after 30 days was evaluated and compared between vaccinated residents and historical comparison residents with Kaplan-Meier and Cox regression analyses. Regression analyses were adjusted for age, gender, comorbidities, and length of stay.ResultsRisk of death in NH residents after one COVID-19 vaccination (regardless of whether a second vaccination was given) was decreased compared with historical comparison residents from 2019 (adjusted HR 0.77, 95% CI 0.69-0.86). The risk of death further decreased after 2 vaccinations compared with the historical comparison group (adjusted HR 0.57, 95% CI 0.50-0.64).Conclusions and ImplicationsWe found no indication that risk of death in NH residents is increased after COVID-19 vaccination. These results indicate that COVID-19 vaccination in NH residents is safe and could reduce fear and resistance toward vaccination.     

SARS-CoV-2 and Wisconsin Nursing Homes: Temporal Dynamics During the COVID-19 Pandemic

ObjectivesEvidence suggests that quality, location, and staffing levels may be associated with COVID-19 incidence in nursing homes. However, it is unknown if these relationships remain constant over time. We describe incidence rates of COVID-19 across Wisconsin nursing homes while examining factors associated with their trajectory during 5 months of the pandemic.DesignRetrospective cohort study.Setting/ParticipantsWisconsin nursing homes.MethodsPublicly available data from June 1, 2020, to October 31, 2020, were obtained. These included facility size, staffing, 5-star Medicare rating score, and components. Nursing home characteristics were compared using Pearson chi-square and Kruskal-Wallis tests. Multiple linear regressions were used to evaluate the effect of rurality on COVID-19.ResultsThere were a total of 2459 COVID-19 cases across 246 Wisconsin nursing homes. Number of beds (P < .001), average count of residents per day (P < .001), and governmental ownership (P = .014) were associated with a higher number of COVID-19 cases. Temporal analysis showed that the highest incidence rates of COVID-19 were observed in October 2020 (30.33 cases per 10,000 nursing home occupied-bed days, respectively). Urban nursing homes experienced higher incidence rates until September 2020; then incidence rates among rural nursing homes surged. In the first half of the study period, nursing homes with lower-quality scores (1-3 stars) had higher COVID-19 incidence rates. However, since August 2020, incidence was highest among nursing homes with higher-quality scores (4 or 5 stars). Multivariate analysis indicated that over time rural location was associated with increased incidence of COVID-19 (β = 0.05, P = .03).Conclusions and ImplicationsHigher COVID-19 incidence rates were first observed in large, urban nursing homes with low-quality rating. By October 2020, the disease had spread to rural and smaller nursing homes and those with higher-quality ratings, suggesting that community transmission of SARS-CoV-2 may have propelled its spread.     

Racial/Ethnic Disparities in Food Pantry Use and Barriers in Massachusetts during the First Year of the COVID-19 Pandemic

This study sought to describe racial disparities in food insecurity, food pantry use, and barriers to and experiences with food pantries during the first year of the COVID-19 pandemic. We surveyed 2928 adults in Massachusetts regarding food access in the year before and during the first year of the pandemic. Weighted multivariable logistic regression models assessed racial differences in barriers to and experiences with pantry use during the pandemic. Black and Latino adults experienced the highest prevalence of food insecurity and pantry use. Additionally, Black and Latino adults reported more barriers to, but less stigma around, pantry use compared to White adults. Latino adults were less likely to know about pantry hours/locations and encounter staff who spoke their language. Black and Latino adults were also more likely to find pantry hours/locations inconvenient and have difficulty with transportation. The COVID-19 pandemic resulted in increased food insecurity, and food access inequities persisted. Programmatic policies to improve pantry access in communities of color could include increasing the hours/days that pantries are open, increasing bilingual staff, providing transportation or delivery, and creating multilingual public awareness campaigns on how to locate pantries.     

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

ObjectiveTo examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.DesignRetrospective cross-sectional study.Setting and ParticipantsThe study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.Methods2010–2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a “choice” set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.ResultsAmong the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).Conclusions and ImplicationsBlack individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.     

Racial and ethnic disparities in COVID-19 vaccine uptake: A mediation framework

BackgroundPrevious research suggests that racial and ethnic minority groups especially Black Americans showed stronger COVID-19 vaccine hesitancy and resistance, which may result from a lack of trust toward the government and vaccine manufacturers, among other sociodemographic and health factors.ObjectivesThe current study explored potential social and economic, clinical, and psychological factors that may have mediated racial and ethnic disparities in COVID-19 vaccine uptake among US adults.MethodsA sample of 6078 US individuals was selected from a national longitudinal survey administered in 2020–2021. Baseline characteristics were collected in December 2020, and respondents were followed up to July 2021. Racial and ethnic disparities in time to vaccine initiation and completion (based on a 2-dose regimen) were first assessed with the Kaplan-Meier Curve and log-rank test, and then explored with the Cox proportional hazards model adjusting for potential time-varying mediators, such as education, income, marital status, chronic health conditions, trust in vaccine development and approval processes, and perceived risk of infection.ResultsPrior to mediator adjustment, Black and Hispanic Americans had slower vaccine initiation and completion than Asian Americans and Pacific Islanders and White Americans (p’s < 0.0001). After accounting for the mediators, there were no significant differences in vaccine initiation or completion between each minoritized group as compared to White Americans. Education, household income, marital status, chronic health conditions, trust, and perceived infection risk were potential mediators.ConclusionRacial and ethnic disparities in COVID-19 vaccine uptake were mediated through social and economic conditions, psychological influences, and chronic health conditions. To address the racial and ethnic inequity in vaccination, it is important to target the social, economic, and psychological forces behind it.