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Comparative Study
. 2021 Sep 1;4(9):e2122885.
doi: 10.1001/jamanetworkopen.2021.22885.

Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data

Karen Shen  1 , Lacey Loomer  2 , Hannah Abrams  3 , David C Grabowski  4 , Ashvin Gandhi  5
Affiliations
Comparative Study

Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data

Karen Shen et al. JAMA Netw Open. .

Abstract

Importance: Federal data underestimate the impact of COVID-19 on US nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020.

Objective: To assess the magnitude of unreported cases and deaths in the National Healthcare Safety Network (NHSN) and provide national estimates of cases and deaths adjusted for nonreporting.

Design, setting, and participants: This is a cross-sectional study comparing COVID-19 cases and deaths reported by US nursing homes to the NHSN with those reported to state departments of health in late May 2020. The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021.

Exposures: Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state.

Main outcomes and measures: The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN.

Results: Among 15 415 US nursing homes, including 4599 with state case data and 7405 with state death data, a mean (SE) of 43.7% (1.4%) of COVID-19 cases and 40.0% (1.1%) of COVID-19 deaths prior to May 24 were not reported in the first NHSN submission in sample states, suggesting that 68 613 cases and 16 623 deaths were omitted nationwide, representing 11.6% of COVID-19 cases and 14.0% of COVID-19 deaths among nursing home residents in 2020.

Conclusions and relevance: These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Loomer reported receiving personal fees from the American Health Care Association outside the submitted work. Dr Grabowski reported receiving personal fees from naviHealth, Medicare Payment Advisory Commission, RTI International, Abt Associates, Analysis Group, and Compass Lexecon and grants from the National Institutes on Aging (NIA), Agency for Healthcare Research and Quality, the Arnold Foundation, and the Warren Alpert Foundation outside the submitted work. Dr Gandhi reported receiving grants from the NIA through the National Bureau of Economic Research, National Institute for Health Care Management, University of California, Los Angeles (UCLA), Ziman Center for Real Estate, UCLA Fink Center for Finance & Investment, UCLA Price Center for Entrepreneurship, the UCLA Morrison Center for Marketing and Data Analytics, Harvard Institute for Quantitative Social Sciences, and Harvard University Lab for Economic Applications Policy outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Percentages of Cases and Deaths as of May 24 Not Reported to the National Healthcare Safety Network by Facility Characteristic
Estimated means (in percentages) from case- and death-level linear regression of the probability of not being reported to National Healthcare Safety Network on facility characteristics, in which SEs are clustered by facility. Squares indicate estimates; whiskers, 95% CIs.
Figure 2.
Figure 2.. Percentage of Cases and Deaths Not Reported to the National Healthcare Safety Network (NHSN) in Sample States by State
Each state is shaded according to the share of deaths as of May 24 (A and B) or December 27 (C and D) that were not reported to the National Healthcare Safety Network.
Figure 3.
Figure 3.. National Estimates of Cumulative Nursing Home Cases and Deaths
This figure reports estimates of cumulative national cases and deaths in nursing home settings on the date of the first National Healthcare Safety Network (NHSN) submission (May 24) and the end of 2020 (December 27). Raw NHSN estimates are shown in light blue, and estimates of the cases and deaths unreported owing to the delay in required reporting (derived from state health department data from a sample of 20 states and extrapolated to all states) are shown in dark blue.
Figure 4.
Figure 4.. Estimated and Reported National Cumulative Cases and Deaths in Nursing Homes
The dark blue area shows cumulative cases and deaths using our adjusted measure, which uses the share of nonreporting in sample states to compute an estimate of cumulative cases and deaths before May 24 then uses data from The New York Times on population cases and deaths to distribute this estimate across weeks prior to May 24. The light blue area shows cumulative cases and deaths using the National Healthcare Safety Network data.
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