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. 2021 Apr;36(4):990-997.
doi: 10.1007/s11606-020-06518-2. Epub 2021 Jan 28.

Early Acceleration of COVID-19 in Areas with Larger Nursing Homes and Certificate of Need Laws

Cyrus M Kosar  1   2 , Momotazur Rahman  3   4
Affiliations

Early Acceleration of COVID-19 in Areas with Larger Nursing Homes and Certificate of Need Laws

Cyrus M Kosar et al. J Gen Intern Med. 2021 Apr.

Abstract

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have become common in large nursing homes, placing not only residents but also staff and community members at risk for infection. However, the relationship between larger nursing homes and the community spread of SARS-CoV-2 has not yet been documented.

Objective: To examine the association between county average nursing home bed size and presence of certificate of need (CON) laws, which influence nursing home size, with county-level SARS-CoV-2 prevalence over time.

Design: Cross-sectional study using county-level data from March 11 through June 12, 2020.

Participants: All US counties with at least one nursing home (n = 2,883).

Main measures: The main explanatory variables were county average nursing home bed size and presence of a CON law. The main outcome was the cumulative number of SARS-CoV-2 cases on each day of the study period adjusted for county population size and density, demographic and socioeconomic characteristics, total nursing home bed supply, other health care supply measures, epidemic stage, and census region.

Key results: By June 12, a between-county difference in average nursing home size equal to 1 bed was associated with 3.92 additional SARS-COV-2 cases (95% CI = 2.14 to 5.69; P < 0.001), on average, and counties subject to CON laws had 104.53 additional SARS-CoV-2 cases (95% CI = 7.68 to 201.38; P < 0.05), on average. Counties with larger nursing homes also demonstrated higher growth in the frequency of SARS-COV-2 throughout the study period.

Conclusions: At the county level, average nursing home size and CON law presence was associated with a greater frequency of SARS-CoV-2 cases. Controlling the impact of the coronavirus 2019 pandemic may require additional resources for communities with larger nursing homes and more attention towards long-term care policies.

Keywords: COVID-19; certificate of need law; community spread; long-term care; nursing homes.

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Conflict of interest statement

The authors were supported by a grant from the National Institute on Aging (3P01AG027296-11S1). The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Figures

Figure 1
Figure 1
Nursing home size in counties located in states with and without certificate of need laws. (a) Average nursing home size. (b) Proportion of beds in small, medium, and large nursing homes. Notes: NH= Nursing home; CON= certificate of need law. Small nursing homes are defined as those with less than 90 beds. Large nursing homes are defined as those with greater than 120 beds. Trend lines were estimated via locally weighted scatterplot smoothing (local linear regression). To improve visual clarity, 11 counties with population densities greater than 5,000 were excluded from the plot.
Figure 2
Figure 2
State-level adjusted SARS-CoV-2 prevalence on June 12 by average nursing home size and certificate of need law presence. Notes: SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; No., number of; CON, certificate of need law. Prevalence estimates were derived from a Poisson regression model including robust standard errors. The set of covariates were population size, population density (persons per square land mile), metropolitan versus rural county status, census region, % of residents aged 65 and over, % female, % Black, % college educated, median household income, the poverty rate, nursing home bed supply, bed supply of small-, medium-, and large-sized hospitals, number of home health agencies, number of medical doctors, number of housing units, and date of the first SARS-CoV-2 case.
Figure 3
Figure 3
Trends in county-level adjusted SARS-CoV-2 cumulative prevalence by (a) average nursing home size and (b) presence of a certificate of need law. Notes: SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; No., number of; CI, confidence interval. Point estimates and 95% confidence intervals were derived from a Poisson regression model including robust standard errors. The set of covariates were population size, population density (persons per square land mile), metropolitan versus rural county status, census region, % of residents aged 65 and over, % female, % Black, % college educated, median household income, the poverty rate, nursing home bed supply, bed supply of small-, medium-, and large-sized hospitals, number of home health agencies, number of medical doctors, number of housing units, and date of the first SARS-CoV-2 case. For panel A, average nursing home size was included in the model (below 90 beds, 90 to 120 beds, 121 ore more beds). For panel B, certificate of need law presence was included as a covariate.
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