COVID-19 Pandemic and Racial and Ethnic Disparities in Long-Term Nursing Home Stay or Death Following Hospital Discharge

Abstract

Importance: Long-term nursing home stay or death (long-term NH stay or death), defined as new long-term residence in a nursing home or death following hospital discharge, is an important patient-centered outcome.

Objective: To examine whether the COVID-19 pandemic was associated with changes in long-term NH stay or death among older adults with sepsis, and whether these changes were greater in individuals from racial and ethnic minoritized groups.

Design, setting, and participants: This cross-sectional study used patient-level data from the Medicare Provider Analysis and Review File, the Master Beneficiary Summary File, and the Minimum Data Set. Community-dwelling individuals aged at least 65 years hospitalized with sepsis between January 2016 and June 2021 were included. Data were analyzed from May to November 2024.

Exposure: Race and ethnicity and the COVID-19 pandemic.

Main outcomes and measures: Patients discharged alive experienced long-term NH stay or death if they resided in a nursing home more than 100 days after hospital discharge and had no period at home greater than 30 days, or died more than 30 days following hospital discharge. Interrupted time series analysis was used to evaluate the association between long-term NH stay or death and the pandemic and race and ethnicity.

Results: A total of 2 964 517 hospitalizations for sepsis of community-dwelling patients discharged alive (1 468 754 [49.5%] female; 19 549 [0.7%] American Indian or Alaska Native, 95 308 [3.2%] Asian or Pacific Islander, 282 646 [9.5%] Black, 279 011 [9.4%] Hispanic, 2 288 003 [71.2%] White individuals; mean [SD] age, 76 [8.3] years) were included. Compared with non-Hispanic White individuals, Black individuals were more likely to experience long-term NH stay or death (adjusted odds ratio [aOR], 1.33; 95% CI, 1.30-1.37; P < .001), while Asian or Pacific Islander (aOR, 0.79; 95% CI, 0.75-0.83; P < .001), Hispanic (aOR, 0.72; 95% CI, 0.70-0.74; P < .001), and American Indian or Alaska Native (aOR, 0.79; 95% CI, 0.72-0.87; P < .001) individuals were less likely to experience long-term NH stay or death. Long-term NH stay or death declined from 13.5% in the first quarter of 2016 to 6.9% in the first quarter of 2020. After adjustment, long-term NH stay or death decreased each quarter (aOR, 0.958; 95% CI, 0.957-0.959; P < .001) before the pandemic. The pandemic was associated with increased risk of long-term NH stay or death over time (aOR, 1.03; 95% CI, 1.02-1.04; P < .001 [each quarter]) compared with before the pandemic for non-Hispanic White individuals. The pandemic was not associated with differential changes in long-term NH stay or death for minoritized individuals compared with non-Hispanic White individuals.

Conclusions and relevance: In this cross-sectional study, older adults hospitalized with sepsis experienced an approximately 50% reduction in long-term NH stay or death over a 5-year period before the pandemic. These results suggest that during the pandemic, all individuals, regardless of race and ethnicity, experienced increased long-term NH stay or death compared with before the pandemic.

Figure 1.. Association Between Long-Term Nursing Home Stay or Death and COVID-19 Pandemic

These findings are based on an interrupted time-series model. The unadjusted model is adjusted for age, sex, and race and ethnicity. The adjusted model is adjusted for age, sex, race, ethnicity, comorbidities, in-hospital complications, and hospital characteristics (see Methods). aOR indicates adjusted odds ratio; OR, odds ratio.

Figure 2.. Estimated Long-Term Nursing Home Stay or Death

These findings are based on the interrupted series analysis after adjusting for race and ethnicity, patient demographics, frailty, social determinants of health, comorbidities, COVID-19, prior procedures, in-hospital complications, and hospital characteristics. The counterfactual represents the estimated underlying time trend in the absence of the pandemic.

Figure 3.. Observed Long-Term Nursing Home Stay or Death

Figure 4.. Estimated Long-Term Nursing Home Stay or Death, Stratified by Race and Ethnicity

These findings are based on the interrupted series analysis after adjusting for patient demographics, frailty, social determinants of health, comorbidities, COVID-19, prior procedures, in-hospital complications, and hospital characteristics.