State- and Territory-Level Nursing Home and Home Health Care COVID-19 Policies and Disease Burden.

This cross-sectional study creates a dataset and dashboard of US state- and territory-level COVID-19 policies specific to nursing homes and home health care agencies.

Insurance-Based Disparities in Outcomes and ECMO Utilization for Hospitalized COVID-19 Patients.

BACKGROUND: The objective of this study was to examine insurance-based disparities in mortality, non-home discharges, and ECMO utilization in patients hospitalized with COVID-19. METHODS: Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, non-home discharge, and ECMO utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0-5.0%; 5.1-10%, 10.1-20%, 20.1-30%, 30.1%-) was evaluated. Modelling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS: Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had non-home discharges, 75,703 were mechanically ventilated, and 2,642 underwent ECMO. The adjusted odds of death were higher in patients with Medicare (aOR 1.28; [95% CI: 1.21, 1.35]; P<0.0005), dually enrolled (aOR, 1.39; [1.30, 1.50]; P<0.0005), Medicaid (aOR, 1.28; [1.20, 1.36]; P<0.0005), and no insurance (aOR, 1.43; [1.26, 1.62]; P<0.0005) compared to patients with private insurance. Patients with Medicare (aOR, 0.47; [CI: 0.39, 0.58]; P <0.0005), dually enrolled (aOR, 0.32; [0.24, 0.43]; P<0.0005), Medicaid (aOR, 0.70; [ 0.62, 0.79]; P<0.0005), and no insurance (aOR, 0.40; [0.29, 0.56]; P<0.001] were less likely to be placed on ECMO than patients with private insurance. Mortality, non-home discharges, and ECMO utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSION: Among patients with COVID-19, insurance-based disparities in mortality, non-home discharges, and ECMO utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

Nurse state legislators, 2013 to 2023.

BACKGROUND: Electing nurse legislators can help states make sound health policy. PURPOSE: To document the distribution of American nurses elected to state-level offices in 2023 and compare it to data from 2013. METHODS: We developed a directory of 2023 nurses elected to state legislatures. Data collected include state, year elected, party, committees, re-election date, and full/part-time state legislature. FINDINGS: In 2023, there were 72 nurse legislators in 36 states. These nurse legislators' affiliations were divided almost evenly between the two major parties (38 Republicans and 34 Democrats). Sixty legislators serve on health committees; 32 on finance committees. Fourteen serve in states that have full-time legislatures. The majority (n = 60) are up for re-election in 2024. In 2013, there were 97 legislators in 39 states. DISCUSSION: Over the last decade, the number of nurse legislators has declined. CONCLUSION: State legislatures play key roles in funding and regulating health policy. Identifying where nurses currently serve provides actionable information for those seeking to recruit, train, and elect nurse candidates.

Was COVID-19 Associated With Worsening Inequities in Stroke Treatment and Outcomes?

Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.

The COVID-19 Pandemic and Associated Inequities in Acute Myocardial Infarction Treatment and Outcomes.

Importance: The COVID-19 pandemic disrupted usual care for emergent conditions, such as acute myocardial infarction (AMI). Understanding whether Black and Hispanic individuals experiencing AMI had greater increases in poor outcomes compared with White individuals during the pandemic has important equity implications. Objective: To investigate whether the COVID-19 pandemic was associated with increased disparities in treatment and outcomes among Medicare patients hospitalized with AMI. Design, Setting, and Participants: This cross-sectional study used Medicare data for patients hospitalized with AMI between January 2016 and November 2020. Patients were categorized as Hispanic, non-Hispanic Black, and non-Hispanic White. The association between race and ethnicity and outcomes as a function of the proportion of hospitalized patients with COVID-19 was evaluated using interrupted time series. Data were analyzed from October 2022 to June 2023. Exposure: The main exposure was a hospital's proportion of hospitalized patients with COVID-19 on a weekly basis as a proxy for care disruption during the pandemic. Main Outcomes and Measures: Revascularization, 30-day mortality, 30-day readmission, and nonhome discharges. Results: A total of 1 319 273 admissions for AMI (579 817 females [44.0%]; 122 972 Black [9.3%], 117 668 Hispanic [8.9%], and 1 078 633 White [81.8%]; mean [SD] age, 77 [8.4] years) were included. For patients with non-ST segment elevation MI (NSTEMI) overall, the adjusted odds of mortality and nonhome discharges increased by 51% (adjusted odds ratio [aOR], 1.51; 95% CI, 1.29-1.76; P < .001) and 32% (aOR, 1.32; 95% CI, 1.15-1.52; P < .001), respectively, and the odds of revascularization decreased by 27% (aOR, 0.73; 95% CI, 0.64-0.83; P < .001) among patients hospitalized during weeks with a high hospital COVID-19 burden (>30%) vs patients hospitalized prior to the pandemic. Black individuals with NSTEMI experienced a clinically insignificant 7% greater increase in the odds of mortality (aOR, 1.07; 95% CI, 1.00-1.15; P = .04) for each 10% increase in the COVID-19 hospital burden but no increases in readmissions or nonhome discharges or reductions in revascularization rates compared with White individuals. There were no differential increases in adverse outcomes among Hispanic compared with White patients with NSTEMI based on hospital COVID-19 burden. Increases in hospital COVID-19 burden were not associated with changes in outcomes or the use of revascularization in STEMI overall or by racial or ethnic group. Conclusions and Relevance: This study found that while hospital COVID-19 burden was associated with worse treatment and outcomes for NSTEMI, race and ethnicity-associated inequities did not increase significantly during the pandemic. These findings suggest the need for additional efforts to mitigate outcomes associated with the COVID-19 pandemic for patients admitted with AMI when the hospital COVID-19 burden is substantially increased.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia.

Importance: New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care. Objective: To evaluate changes in nursing home use among older adults with dementia following MLTC implementation. Design, Setting, and Participants: This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019. Exposure: Mandatory MLTC enrollment. Main Outcomes and Measures: Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators. Results: This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year). Conclusions and Relevance: The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States.

OBJECTIVE: Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs. DESIGN: Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal. SETTING: Care provided by urban and rural HHAs. METHODS: We conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality. RESULTS: Twelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study). CONCLUSION AND IMPLICATIONS: This review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.

Examining Structural Disparities in US Nursing Homes: National Survey of Health Information Technology Maturity.

BACKGROUND: There are 15,632 nursing homes (NHs) in the United States. NHs continue to receive significant policy attention due to high costs and poor outcomes of care. One strategy for improving NH care is use of health information technology (HIT). A central concept of this study is HIT maturity, which is used to identify adoption trends in HIT capabilities, use and integration within resident care, clinical support, and administrative activities. This concept is guided by the Nolan stage theory, which postulates that a system such as HIT moves through a series of measurable stages. HIT maturity is an important component of the rapidly changing NH landscape, which is being affected by policies generated to protect residents, in part because of the pandemic. OBJECTIVE: The aim of this study is to identify structural disparities in NH HIT maturity and see if it is moderated by commonly used organizational characteristics. METHODS: NHs (n=6123, >20%) were randomly recruited from each state using Nursing Home Compare data. Investigators used a validated HIT maturity survey with 9 subscales including HIT capabilities, extent of HIT use, and degree of HIT integration in resident care, clinical support, and administrative activities. Each subscale had a possible HIT maturity score of 0-100. Total HIT maturity, with a possible score of 0-900, was calculated using the 9 subscales (3 x 3 matrix). Total HIT maturity scores equate 1 of 7 HIT maturity stages (stages 0-6) for each facility. Dependent variables included HIT maturity scores. We included 5 independent variables (ie, ownership, chain status, location, number of beds, and occupancy rates). Unadjusted and adjusted cumulative odds ratios were calculated using regression models. RESULTS: Our sample (n=719) had a larger proportion of smaller facilities and a smaller proportion of larger facilities than the national nursing home population. Integrated clinical support technology had the lowest HIT maturity score compared to resident care HIT capabilities. The majority (n=486, 60.7%) of NHs report stage 3 or lower with limited capabilities to communicate about care delivery outside their facility. Larger NHs in metropolitan areas had higher odds of HIT maturity. The number of certified beds and NH location were significantly associated with HIT maturity stage while ownership, chain status, and occupancy rate were not. CONCLUSIONS: NH structural disparities were recognized through differences in HIT maturity stage. Structural disparities in this sample appear most evident in HIT maturity, measuring integration of clinical support technologies for laboratory, pharmacy, and radiology services. Ongoing assessments of NH structural disparities is crucial given 1.35 million Americans receive care in these facilities annually. Leaders must be willing to promote equal opportunities across the spectrum of health care services to incentivize and enhance HIT adoption to balance structural disparities and improve resident outcomes.

Association Between the COVID-19 Pandemic and Insurance-Based Disparities in Mortality After Major Surgery Among US Adults.

Importance: The COVID-19 pandemic caused significant disruptions in surgical care. Whether these disruptions disproportionately impacted economically disadvantaged individuals is unknown. Objective: To evaluate the association between the COVID-19 pandemic and mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance. Design, Setting, and Participants: This cross-sectional study used data from the Vizient Clinical Database for patients who underwent major surgery at hospitals in the US between January 1, 2018, and May 31, 2020. Exposures: The hospital proportion of patients with COVID-19 during the first wave of COVID-19 cases between March 1 and May 31, 2020, stratified as low (≤5.0%), medium (5.1%-10.0%), high (10.1%-25.0%), and very high (>25.0%). Main Outcomes and Measures: The main outcome was inpatient mortality. The association between mortality after surgery and payer status as a function of the proportion of hospitalized patients with COVID-19 was evaluated with a quasi-experimental triple-difference approach using logistic regression. Results: Among 2 950 147 adults undergoing inpatient surgery (1 550 752 female [52.6%]) at 677 hospitals, the primary payer was Medicare (1 427 791 [48.4%]), followed by commercial insurance (1 000 068 [33.9%]), Medicaid (321 600 [10.9%]), other payer (140 959 [4.8%]), and no insurance (59 729 [2.0%]). Mortality rates increased more for patients undergoing surgery during the first wave of the pandemic in hospitals with a high COVID-19 burden (adjusted odds ratio [AOR], 1.13; 95% CI, 1.03-1.24; P = .01) and a very high COVID-19 burden (AOR, 1.38; 95% CI, 1.24-1.53; P < .001) compared with patients in hospitals with a low COVID-19 burden. Overall, patients with Medicaid had 29% higher odds of death (AOR, 1.29; 95% CI, 1.22-1.36; P < .001) and patients without insurance had 75% higher odds of death (AOR, 1.75; 95% CI, 1.55-1.98; P < .001) compared with patients with commercial insurance. However, mortality rates for surgical patients with Medicaid insurance (AOR, 1.03; 95% CI, 0.82-1.30; P = .79) or without insurance (AOR, 0.85; 95% CI, 0.47-1.54; P = .60) did not increase more than for patients with commercial insurance in hospitals with a high COVID-19 burden compared with hospitals with a low COVID-19 burden. These findings were similar in hospitals with very high COVID-19 burdens. Conclusions and Relevance: In this cross-sectional study, the first wave of the COVID-19 pandemic was associated with a higher risk of mortality after surgery in hospitals with more than 25.0% of patients with COVID-19. However, the pandemic was not associated with greater increases in mortality among patients with no insurance or patients with Medicaid compared with patients with commercial insurance in hospitals with a very high COVID-19 burden.

A Profile of Black and Latino Older Adults Receiving Care in Nursing Homes: 2011-2017.

OBJECTIVE: To identify if disparate trends in the access and use of nursing home (NH) services among Black and Latino older adults compared with White older adults persist. Access was operationalized as the NHs that served Black, Latino, and White residents. Use was operationalized as the utilization of NH services by Black, Latino, and White residents. DESIGN: This was an observational study analyzing facility-level data from LTCfocus for 2011 to 2017. SETTING AND PARTICIPANTS: All NH residents present in US NHs participating in the Centers for Medicare and Medicaid Services program on the first Thursday in April in the years 2011 to 2017. NHs with fewer than 4500 bed-days per year are excluded in the LCTfocus dataset. Black, Latino, and White were the racial/ethnic groups of interest. METHODS: We calculated the mean percentage of each racial/ethnic group in NHs (Black, Latino, White) annually along with the number of NHs that provided care for these groups. We conducted a simple trend analysis using ordinary least squares to estimate the change in NH access and use by racial/ethnic group over time. RESULTS: Our NH sample ranged from 15,564 in 2011 to 14,956 in 2017. Latino residents' use of NHs increased by 20.47% and Black residents increased by 11.42%, whereas there was a 1.36% decrease in White residents' use of NHs. In this 7-year span, there was a 4.44% and 6.41% decline in the number of NHs that serve any Black and Latino older adults, respectively, compared with a 2.26% decline in NHs that serve only White older adults (access). CONCLUSIONS AND IMPLICATIONS: Our findings reveal a continued disproportionate rise in Black and Latino older adults' use of NHs while the number of NHs that serve this population have declined. This work can inform federal and state policies to ensure access to long-term care services and supports in the community for all older adults and prevent inappropriate NH closures.

Association Between the COVID-19 Pandemic and Disparities in Access to Major Surgery in the US.

Importance: Racial minority groups account for 70% of excess deaths not related to COVID-19. Understanding the association of the Centers for Medicare & Medicaid Services' (CMS's) moratorium delaying nonessential operations with racial disparities will help shape future pandemic responses. Objective: To evaluate the association of the CMS's moratorium on elective operations during the first wave of the COVID-19 pandemic among Black individuals, Asian individuals, and individuals of other races compared with White individuals. Design, Setting, and Participants: This cross-sectional study assessed a 719-hospital retrospective cohort of 3 470 905 adult inpatient hospitalizations for major surgery between January 1, 2018, and October 31, 2020. Exposure: The first wave of COVID-19 infections between March 1, 2020, and May 31, 2020. Main Outcomes and Measures: The main outcome was the association between changes in monthly elective surgical case volumes and the first wave of COVID-19 infections as a function of patient race, evaluated using negative binomial regression analysis. Results: Among 3 470 905 adults (1 823 816 female [52.5%]) with inpatient hospitalizations for major surgery, 70 752 (2.0%) were Asian, 453 428 (13.1%) were Black, 2 696 929 (77.7%) were White, and 249 796 (7.2%) were individuals of other races. The number of monthly elective cases during the first wave was 49% (incident rate ratio [IRR], 0.49; 95% CI, 0.486-0.492; P < .001) compared with the baseline period. The relative reduction in unadjusted elective surgery cases for Black (unadjusted IRR, 0.99; 95% CI, 0.97-1.01; P = .36), Asian (unadjusted IRR, 1.08; 95% CI, 1.03-1.14; P = .001), and other race individuals (unadjusted IRR, 0.97; 95% CI, 0.95-1.00; P = .05) during the surge period compared with the baseline period was very close to the change in cases for White individuals. After adjustment for age, sex, comorbidities, and surgical procedure, there was still no evidence that the first wave of the pandemic was associated with disparities in access to elective surgery. Conclusions and Relevance: In this cross-sectional study, the CMS's moratorium on nonessential operations was associated with a 51% reduction in elective operations. It was not associated with greater reductions in operations for racial minority individuals than for White individuals. This evidence suggests that the early response to the pandemic did not increase disparities in access to surgical care.

Influenza vaccination of home health care staff and the impact on patient hospitalizations.

BACKGROUND: Influenza is associated with significant morbidity and mortality for adults aged 65 years and older. Influenza vaccination of health care workers is recommended. There is limited evidence regarding influenza vaccinations among health care workers in the home health care (HHC) setting and their impact on HHC patient outcomes. METHODS: A national survey of HHC agencies was conducted in 2018-2019 and linked with patient data from the Centers for Medicare and Medicaid Services. Adjusted logistic regression models were used to estimate the association between hospital transfers due to respiratory infection during a 60 day HHC episode and staff vaccination policies. RESULTS: Only 26.2% of HHC agencies had staff vaccination requirements and 71.2% agencies had staff vaccination rates higher than 75%. Agency policies for staff influenza vaccination were associated with reduced hospital transfers due to respiratory infection among HHC patients. DISCUSSION: Influenza vaccination rates among HHC staff were low during the 2017-2018 influenza season. Policymakers may consider vaccination mandates to improve health care worker vaccination rates and protect patient safety. CONCLUSIONS: This study sheds light on the potential impact of COVID-19 vaccination among HHC workers on patient outcomes. COVID-19 vaccination mandates could prove to be a vital tool in the fight against COVID-19 variants and infection outbreaks.

The Association Between Nursing Home Information Technology Maturity and Urinary Tract Infection Among Long-Term Residents.

Urinary tract infections (UTIs) are the most common infections among nursing home (NH) residents. Antibiotics are often misused when a UTI is suspected. Using sophisticated information technology (IT) could help in appropriate UTI prevention, diagnosis, and treatment. This repeated cross-sectional study explored relationships between IT maturity and UTI prevalence among long-stay NH residents. Data were from (1) four annual surveys 2013-2017 measuring IT maturity in a random sample of Medicare-certified NHs, (2) Minimum Data Set assessments for resident characteristics, and (3) Certification and Survey Provider Enhanced Reporting data for facility characteristics. In multivariate regressions using NH fixed effects, controlling for resident and NH characteristics, Administrative IT maturity in NHs was associated with decreased odds of UTI (AOR: 0.906, 95% CI: 0.843, 0.973). These results were robust in all sensitivity analyses. Using IT to relieve administrative burden may decrease UTIs.

Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents.

Background: Approximately one-quarter of all deaths in the United States occur in nursing homes (NHs). Palliative care has the potential to improve NH end-of-life care, but more information is needed on the provision of palliative care in NHs serving Black and Hispanic residents. Objective: To determine whether palliative care services in United States NHs are associated with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Design: We conducted a cross-sectional analysis. The outcome was NH palliative care services (measured by an earlier national survey); total scores ranged from 0 to 100 (higher scores indicated more services). Other data included the Minimum Data Set and administrative data. The independent variables were concentration of Black and Hispanic residents (i.e., <3%, 3-10%, >10%), respectively, and models were stratified by region (i.e., Northeast, Midwest, South and West). We compared unadjusted, weighted mean palliative care services by the concentration of Black and Hispanic residents and computed NH-level multivariable linear regressions. Setting/Subjects: Eight hundred sixty-nine (weighted n = 15,020) NHs across the United States. Results: Multivariable analyses showed fewer palliative care services provided in NHs with greater concentrations of Black and Hispanic residents. Fewer palliative care services were reported in NHs in the Northeast, for which >10% of the resident population was Black, and NHs in the West for which >10% was Hispanic versus NHs with <3% of the population being Black and Hispanic (-13.7; p < 0.001 and -9.3; p < 0.05, respectively). Conclusion: We observed differences in NH palliative care by region and with greater concentration of Black and Hispanic residents. Our findings suggest that greater investment in NH palliative care services may be an important strategy to advance health equity in end-of-life care for Black and Hispanic residents.

Examining Nursing Home Information Technology Maturity and Antibiotic Use Among Long-Term Care Residents.

OBJECTIVES: Up to 15% of the 1.4 million US nursing home (NH) residents receive antibiotics daily. Antibiotic use in NHs is often inappropriate, contributing to quality and safety concerns as well as antibiotic resistance. Information technology (IT) maturity-defined as the extent to which facilities possess and use diverse technological devices and software that are integrated across resident care, clinical support, and administrative activities-may improve the tracking and reporting of antibiotic use in NH residents. Thus, this research explores trends in IT maturity over time and associations with antibiotic use in US NHs. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Long-term resident assessments from a random sample of Medicare-certified US NHs over 4 consecutive years (2013-2017). METHODS: Three data sources were used: (1) 4 annual surveys measuring IT maturity, (2) Minimum Data Set (MDS) 3.0 assessments for resident characteristics, and (3) Certification and Survey Provider Enhanced Reporting data for facility characteristics. Nonadmission MDS assessments that were within a 90-day window of the IT survey were eligible. Descriptive statistics were examined. Bivariate and multivariate regressions using NH fixed effects were conducted controlling for resident and NH characteristics. RESULTS: There were 219,461 MDS assessments from 80,237 long-stay residents aged ≥65 years, living in 817 NHs. Trends in IT maturity increased significantly over 4 years. IT integration in administrative processes was positively associated with antibiotic use (AOR 1.072, 95% CI 1.025, 1.122). CONCLUSIONS AND IMPLICATIONS: IT components that integrate administrative activities, which can provide greater access to data sources across the organization as a whole, was associated with changes in antibiotic use. Further evaluation is needed to determine if antibiotic use is more appropriate with higher maturity such that policy makers can encourage IT with these capabilities to promote antibiotic stewardship.

The Effects of Home Health Value-Based Purchasing on Home Health Care Quality in For-Profit and Nonprofit Agencies: A Comparative Interrupted Time-Series Analysis, 2012-2018.

Beginning in 2016, the Home Health Value-Based Purchasing (HHVBP) model incentivized U.S. Medicare-certified home health agencies (HHAs) in nine states to improve quality of patient care and patient experience. Here, we quantified HHVBP effects upon quality over time (2012-2018) by HHA ownership (i.e., for-profit vs. nonprofit) using a comparative interrupted time-series design. Our outcome measures were Care Quality and Patient Experience indices composed of 10 quality of patient care measures and five patient experience measures, respectively. Overall, 17.7% of HHAs participated in the HHVBP model of which 81.4% were for-profit ownership. Each year after implementation, HHVBP was associated with a 1.59 (p < .001) percentage point increase in the Care Quality index among for-profit HHAs and a 0.71 (p = .024) percentage point increase in the Patient Experience index among nonprofits. The differences of quality improvement under the HHVBP model by ownership indicate variations in HHA leadership responses to HHVBP.

Association of Infection-Related Hospitalization With Cognitive Impairment Among Nursing Home Residents.

Importance: Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown. Objective: To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents. Design, Setting, and Participants: This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020. Exposure: Infection-related hospitalization lasting 1 to 14 days. Main Outcomes and Measures: Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment). Results: Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P < .001), or 3%. The increase in scores was greatest among residents aged 85 years or older vs younger residents by approximately 0.022 CFS points (95% CI, 0.004-0.040 points; P < .05). The prevalence of severe cognitive impairment increased by 1.6 percentage points (95% CI, 1.2-2.0 percentage points; P < .001), or 18%; the increases were observed among individuals with ADRD but not among those without it. After an infection-related hospitalization, cognition among residents who had experienced sepsis declined more than for residents who had not by about 0.02 CFS points (95% CI, 0.00-0.04 points; P < .05). All observed differences persisted without an accelerated rate of decline for at least 6 quarters after infection-related hospitalization. No differences were observed by sex. Conclusions and Relevance: In this cohort study, infection-related hospitalization was associated with immediate and persistent cognitive decline among nursing home residents, with the largest increase in CFS scores among older residents, those with ADRD, and those who had experienced sepsis. Identification of NH residents at risk of worsened cognition after an infection-related hospitalization may help to ensure that their care needs are addressed to prevent further cognitive decline.

Assessment of Coronavirus Disease 2019 Infection and Mortality Rates Among Nursing Homes With Different Proportions of Black Residents.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) has disproportionately impacted nursing homes (NHs) with large shares of Black residents. We examined the associations between the proportion of Black residents in NHs and COVID-19 infections and deaths, accounting for structural bias (operationalized as county-level factors) and stratifying by urbanicity/rurality. DESIGN: This was a cross-sectional observational cohort study using publicly available data from the LTCfocus, Centers for Disease Control and Prevention Long-Term Care Facility COVID-19 Module, and the NYTimes county-level COVID-19 database. Four multivariable linear regression models omitting and including facility characteristics, COVID-19 burden, and county-level fixed effects were estimated. SETTING AND PARTICIPANTS: In total, 11,587 US NHs that reported data on COVID-19 to the Centers for Disease Control and Prevention and had data in LTCfocus and NYTimes from January 20, 2020 through July 19, 2020. MEASURES: Proportion of Black residents in NHs (exposure); COVID-19 infections and deaths (main outcomes). RESULTS: The proportion of Black residents in NHs were as follows: none= 3639 (31.4%), <20% = 1020 (8.8%), 20%-49.9% = 1586 (13.7%), ≥50% = 681 (5.9%), not reported = 4661 (40.2%). NHs with any Black residents showed significantly more COVID-19 infections and deaths than NHs with no Black residents. There were 13.6 percentage points more infections and 3.5 percentage points more deaths in NHs with ≥50% Black residents than in NHs with no Black residents (P < .001). Although facility characteristics explained some of the differences found in multivariable analyses, county-level factors and rurality explained more of the differences. CONCLUSIONS AND IMPLICATIONS: It is likely that attributes of place, such as resources, services, and providers, important to equitable care and health outcomes are not readily available to counties where NHs have greater proportions of Black residents. Structural bias may underlie these inequities. It is imperative that support be provided to NHs that serve greater proportions of Black residents while considering the rurality of the NH setting.

Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents?

Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.