Variation in SARS-CoV-2 Prevalence in U.S. Skilled Nursing Facilities

Abstract

Objective: To identify county and facility factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in skilled nursing facilities (SNFs).

Design: Cross-sectional study linking county SARS-CoV-2 prevalence data, administrative data, state reports of SNF outbreaks, and data from Genesis HealthCare, a large multistate provider of post-acute and long-term care. State data are reported as of April 21, 2020; Genesis data are reported as of May 4, 2020.

Setting and participants: The Genesis sample consisted of 341 SNFs in 25 states, including a subset of 64 SNFs that underwent universal testing of all residents. The non-Genesis sample included all other SNFs (n = 3,016) in the 12 states where Genesis operates that released the names of SNFs with outbreaks.

Measurements: For Genesis and non-Genesis SNFs: any outbreak (one or more residents testing positive for SARS-CoV-2). For Genesis SNFs only: number of confirmed cases, SNF case fatality rate, and prevalence after universal testing.

Results: One hundred eighteen (34.6%) Genesis SNFs and 640 (21.2%) non-Genesis SNFs had outbreaks. A difference in county prevalence of 1,000 cases per 100,000 (1%) was associated with a 33.6 percentage point (95% confidence interval (CI) = 9.6-57.7 percentage point; P = .008) difference in the probability of an outbreak for Genesis and non-Genesis SNFs combined, and a difference of 12.5 cases per facility (95% CI = 4.4-20.8 cases; P = .003) for Genesis SNFs. A 10-bed difference in facility size was associated with a 0.9 percentage point (95% CI = 0.6-1.2 percentage point; P < .001) difference in the probability of outbreak. We found no consistent relationship between Nursing Home Compare Five-Star ratings or past infection control deficiency citations and probability or severity of outbreak.

Conclusions: Larger SNFs and SNFs in areas of high SARS-CoV-2 prevalence are at high risk for outbreaks and must have access to universal testing to detect cases, implement mitigation strategies, and prevent further potentially avoidable cases and related complications. J Am Geriatr Soc 68:2167-2173, 2020.

Keywords: COVID-19; SARS-CoV-2; facility; long-term care; nursing home; skilled nursing.

Figure 1

Relationship between skilled nursing facility severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) prevalence and county SARS‐CoV‐2 prevalence among Genesis facilities (n = 341). Note: Skilled nursing facility and county prevalence estimates are based on data as of May 4, 2020. The relationship between the skilled nursing facility and county prevalence is depicted with a loess curve.

Figure 2

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) case fatality rate, by county SARS‐CoV‐2 prevalence among Genesis skilled nursing facilities (SNFs) with at least five cases (n = 104). Note: Case fatality rates were calculated from data available as of May 4, 2020. The percentile rank of all U.S. counties in terms of COVID‐19 prevalence on this date was calculated and assigned to each facility. The case fatality rate for each SNF is the cumulative number of resident deaths in confirmed SARS‐CoV‐2 cases divided by the cumulative number of confirmed SARS‐CoV‐2 resident cases.

Figure 3

Distribution of skilled nursing facilities' expected count of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) resident cases by facility characteristics, for Genesis facilities with one or more cases (n = 154). Note: Expected count of SARS‐CoV‐2 cases is adjusted for facility size, county SARS‐CoV‐2 prevalence, date of first county case, and whether or not the facility underwent universal testing. Estimates were obtained from a robust Poisson regression model (see Methods for details).

Figure 4

Percentage of residents testing positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in universally tested Genesis skilled nursing facilities (N = 64) with at least one confirmed resident case the day before testing (n = 19) (A) and no confirmed resident cases before testing (n = 45) (B). Note: For each day between April 1, 2020, and May, 4, 2020, we calculated the percentile rank of all U.S. counties in terms of SARS‐CoV‐2 prevalence and assigned each facility the percentile rank on the date of universal testing.