Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Feb 1;4(2):e2037431.
doi: 10.1001/jamanetworkopen.2020.37431.

Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US

Rebecca J Gorges  1   2 , R Tamara Konetzka  2   3
Affiliations

Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US

Rebecca J Gorges et al. JAMA Netw Open. .

Abstract

Importance: It is important to understand differences in coronavirus disease 2019 (COVID-19) deaths by nursing home racial composition and the potential reasons for these differences so that limited resources can be distributed equitably.

Objective: To describe differences in the number of COVID-19 deaths by nursing home racial composition and examine the factors associated with these differences.

Design, setting, and participants: This cross-sectional study of 13 312 nursing homes in the US used the Nursing Home COVID-19 Public File from the Centers for Medicare and Medicaid Services, which contains COVID-19 cases and deaths among nursing home residents as self-reported by nursing homes beginning between January 1, 2020, and May 24, 2020, and ending on September 13, 2020. Data were analyzed from July 28 to December 18, 2020.

Exposures: Confirmed or suspected COVID-19 infection. Confirmed cases were defined as COVID-19 infection confirmed by a diagnostic laboratory test. Suspected cases were defined as signs and/or symptoms of COVID-19 infection or patient-specific transmission-based precautions for COVID-19 infection.

Main outcomes and measures: Deaths associated with COVID-19 among nursing home residents. Death counts were compared by nursing home racial composition, which was measured as the proportion of White residents.

Results: Among 13 312 nursing homes included in the study, the overall mean (SD) age of residents was 79.5 (6.7) years. A total of 51 606 COVID-19-associated deaths among residents were reported, with a mean (SD) of 3.9 (8.0) deaths per facility. The mean (SD) number of deaths in nursing homes with the lowest proportion of White residents (quintile 1) vs nursing homes with the highest proportions of White residents (quintile 5) were 5.6 (9.2) and 1.7 (4.8), respectively. Facilities in quintile 1 experienced a mean (SE) of 3.9 (0.2) more deaths than those in quintile 5, representing a 3.3-fold higher number of deaths in quintile 1 compared with quintile 5. Adjustment for the number of certified beds reduced the mean (SE) difference between these 2 nursing home groups to 2.2 (0.2) deaths. Controlling for case mix measures and other nursing home characteristics did not modify this association. Adjustment for county-level COVID-19 prevalence further reduced the mean (SE) difference to 1.0 (0.2) death.

Conclusions and relevance: In this study, nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those of facilities with the highest proportions of White residents. These differences were associated with factors such as larger nursing home size and higher infection burden in counties in which nursing homes with high proportions of non-White residents were located. Focusing limited available resources on facilities with high proportions of non-White residents is needed to support nursing homes during potential future outbreaks.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Unadjusted Coronavirus Disease 2019 (COVID-19) Cases and Deaths Among Residents by Nursing Home Racial Composition Quintile
A total of 13 312 facilities were included. The analysis was limited to facilities that reported COVID-19 case data, passed quality assurance reviews from the Centers for Medicare and Medicaid Services, and were not missing data regarding the percentage of White residents. Data were obtained from the Centers for Medicare and Medicaid Services COVID-19 nursing home data set that was released on December 4, 2020. This information was then merged with data from the LTCfocus database and Nursing Home Compare archives. Nursing homes were categorized by racial composition quintile based on the percentage of White residents, with quintile 1 indicating 0% to 59.73%, quintile 2 indicating 59.75% to 80.99%, quintile 3 indicating 81.00% to 91.77%, quintile 4 indicating 91.78% to 97.32%, and quintile 5 indicating 97.33% to 100%. Cases and deaths comprise the total number of confirmed and suspected COVID-19 cases and deaths among nursing home residents through September 13, 2020.
Figure 2.
Figure 2.. Marginal Effects Estimates by Nursing Home Racial Composition Quintile for Number of Coronavirus Disease 2019 (COVID-19) Deaths Among Residents
Marginal effects and 95% CIs were determined using zero-inflated negative binomial regression analysis. Marginal effects were relative to quintile 5, the group of nursing homes with the highest proportion of White residents. Nursing homes were categorized by racial composition quintile based on the percentage of White residents, with quintile 1 indicating 0% to 59.73%, quintile 2 indicating 59.75% to 80.99%, quintile 3 indicating 81.00% to 91.77%, quintile 4 indicating 91.78% to 97.32%, and quintile 5 indicating 97.33% to 100%. The no-adjustment model calculated the differences from quintile 5 by the percentage of quintile in mean death counts. The certified beds model was adjusted for the number of certified beds only. The case mix model was adjusted for the number of certified beds, acuity index, and percentage of residents with hypertension. The nursing home characteristics model was adjusted for the number of certified beds, case mix, and nursing home characteristics (ownership, chain membership, percentage of residents with Medicaid coverage, percentage of residents with Medicare coverage, Nursing Home Compare overall star rating, and adjusted nursing hours per resident per day). The county-level cases model was adjusted for confirmed COVID-19 cases (excluding cases among nursing home residents) per 1000 people per county using the quadratic functional form equation (the sum of x plus x2) in addition to the number of certified beds, case mix, and nursing home characteristics. Errors bars represent 95% CIs.
See this image and copyright information in PMC

References

    1. National Center for Health Statistics. Weekly updates by select demographic and geographic characteristics: provisional death counts for coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention. September 23, 2020. Accessed September 29, 2020. https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm
    1. Conlen M, Ivory D, Yourish K, et al. About 40% of U.S. coronavirus deaths are linked to nursing homes. The New York Times Updated September 16, 2020. Accessed September 29, 2020. https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html
    1. Li Y, Cen X, Cai X, Temkin-Greener H. Racial and ethnic disparities in COVID-19 infections and deaths across U.S. nursing homes. J Am Geriatr Soc. 2020;68(11):2454-2461. doi:10.1111/jgs.16847 - DOI - PMC - PubMed
    1. Konetzka RT, Werner RM. Disparities in long-term care: building equity into market-based reforms. Med Care Res Rev. 2009;66(5):491-521. doi:10.1177/1077558709331813 - DOI - PubMed
    1. Angelelli J, Grabowski DC, Mor V. Effect of educational level and minority status on nursing home choice after hospital discharge. Am J Public Health. 2006;96(7):1249-1253. doi:10.2105/AJPH.2005.062224 - DOI - PMC - PubMed

Publication types