U.S. Nursing Home Quality Ratings Associated with COVID-19 Cases and Deaths Introduction

Khairat, Saif; Zalla, Lauren C.; Adler-Milstein, Julia; Kistler, Christine

Objectives To inform future policies and disaster preparedness plans in the vulnerable nursing home setting, we need greater insight into the relationship between nursing homes’ (NH) quality and the spread and severity of COVID-19 in NH facilities. We therefore extend current evidence on the relationships between NH quality and resident COVID-19 infection rates and deaths, taking into account NH structural characteristics and community characteristics. Design Cross-sectional study. Setting and Participants 15,390 Medicaid/Medicare-certified nursing homes. Methods We obtained and merged the following data sets: (1) COVID-19 weekly data reported by each nursing home to the CDC National Healthcare Safety Network (NHSN), (2) CMS Five Star Quality Rating System, (3) county-level COVID-19 case counts, (4) county-level population data, and (5) county-level socio-demographic data. Results Among 1-star NHs, there were an average of 13.19 cases and 2.42 deaths per 1,000 residents per week between May 25 and December 20, 2020. Among 5-star NHs, there were an average of 9.99 cases and 1.83 deaths per 1,000 residents per week. The rate of confirmed cases of COVID-19 was 31% higher among 1-star NHs compared to 5-star NHs (Model 1: IRR 1.31, 95% CI: 1.23-1.39), and the rate of COVID-19 deaths was 30% higher (IRR: 1.30, 95% CI: 1.20, 1.41). These associations were only partially explained by differences in community spread of COVID-19, case mix, and the for-profit status and size of NHs. Conclusions and Implications We found that COVID-19 case and death rates were substantially higher among NHs with lower star ratings, suggesting that NHs with quality much below average are more susceptible to the spread of COVID-19. This relationship – particularly with regard to case rates – can be partially attributed to external factors: lower-rated NHs are often located in areas with greater COVID-19 community spread, and serve more socioeconomically vulnerable residents than higher-rated NHs.