Early Acceleration of COVID-19 in Areas with Larger Nursing Homes and Certificate of Need Laws.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have become common in large nursing homes, placing not only residents but also staff and community members at risk for infection. However, the relationship between larger nursing homes and the community spread of SARS-CoV-2 has not yet been documented. OBJECTIVE: To examine the association between county average nursing home bed size and presence of certificate of need (CON) laws, which influence nursing home size, with county-level SARS-CoV-2 prevalence over time. DESIGN: Cross-sectional study using county-level data from March 11 through June 12, 2020. PARTICIPANTS: All US counties with at least one nursing home (n = 2,883). MAIN MEASURES: The main explanatory variables were county average nursing home bed size and presence of a CON law. The main outcome was the cumulative number of SARS-CoV-2 cases on each day of the study period adjusted for county population size and density, demographic and socioeconomic characteristics, total nursing home bed supply, other health care supply measures, epidemic stage, and census region. KEY RESULTS: By June 12, a between-county difference in average nursing home size equal to 1 bed was associated with 3.92 additional SARS-COV-2 cases (95% CI = 2.14 to 5.69; P < 0.001), on average, and counties subject to CON laws had 104.53 additional SARS-CoV-2 cases (95% CI = 7.68 to 201.38; P < 0.05), on average. Counties with larger nursing homes also demonstrated higher growth in the frequency of SARS-COV-2 throughout the study period. CONCLUSIONS: At the county level, average nursing home size and CON law presence was associated with a greater frequency of SARS-CoV-2 cases. Controlling the impact of the coronavirus 2019 pandemic may require additional resources for communities with larger nursing homes and more attention towards long-term care policies.

Comparing Receipt of Prescribed Post-acute Home Health Care Between Medicare Advantage and Traditional Medicare Beneficiaries: an Observational Study.

BACKGROUND: Medicare Advantage (MA) covers more than 1/3rd of all Medicare beneficiaries. MA plans are required to provide the same benefits as Traditional Medicare (TM), but can impose utilization management tools to control costs. OBJECTIVE: To assess differences between TM and MA enrollees in the probability of receiving prescribed post-acute home health (HH) care and to describe MA plan characteristics associated with HH receipt. DESIGN: Retrospective cross-sectional analysis of claims data, HH patient assessment data, and MA plan data from 2011 to 2017. PARTICIPANTS: Medicare beneficiaries aged 66 and older with an incident hospitalization for joint replacement, pneumonia, chronic obstructive pulmonary disease, stroke, urinary tract infection, septicemia, acute renal failure, or congestive heart failure. MAIN MEASURES: Receipt of prescribed HH as indicated by a HH discharge code and corresponding HH patient assessment within 14 days of hospital discharge. KEY RESULTS: There were 2,723,245 beneficiaries prescribed HH at discharge (68% TM, 32% MA). About 75% of TM enrollees and 62% of MA enrollees received prescribed post-acute HH. In adjusted analyses, MA enrollees had an -11.7 percentage point (pp) (95% confidence interval (CI): -16.8, -6.5) lower probability of receiving HH compared with TM enrollees. In adjusted analyses, HMO enrollees in plans with cost sharing (- 8.4 pp; 95% CI: - 14.3, - 2.5), referrals (- 3.7 pp; 95% CI: - 6.1, - 1.2), and pre-authorization (- 5.1 pp; 95% CI: - 8.3, - 2.0) were less likely to receive prescribed HH. In adjusted analyses, PPO enrollees in plans with cost sharing were -7.0 pp (95% CI: - 12.7, - 1.4) less likely to receive HH, but there was no difference for those with referrals (1.1 pp; 95% CI, - 1.5, 3.7) or pre-authorization (1.6 pp; 95% CI: - 0.6, - 3.9). CONCLUSIONS: Among Medicare beneficiaries, MA enrollees were less likely to receive prescribed post-acute HH compared with TM. As enrollment in MA continues to grow, it is important to examine how differences in utilization relate to outcomes.

Positive Beliefs and the Likelihood of Successful Community Discharge From Skilled Nursing Facilities.

OBJECTIVES: To examine the association of patient and direct-care staff beliefs about patients' capability to increase independence with activities of daily living (ADL) and the probability of successful discharge to the community after a skilled nursing facility (SNF) stay. DESIGN: Retrospective cohort study of SNF patients using 100% Medicare inpatient claims and Minimum Data Set resident assessment data. Linear probability models were used to estimate the probability of successful discharge based on patient and staff beliefs about the patient's ability to improve in function, as well as patient and staff beliefs together. Estimates were adjusted for demographics, health status, functional characteristics, and SNF fixed effects. PARTICIPANTS: Fee-for-service Medicare beneficiaries (N=526,432) aged 66 years or older who were discharged to an SNF after hospitalization for stroke, hip fracture, or traumatic brain injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Successful community discharge (discharged alive within 90d of SNF admission and remaining in the community for ≥30d without dying or health care facility readmission). RESULTS: Patients with positive beliefs about their capability to increase independence with ADLs had a higher adjusted probability of successful discharge than patients with negative beliefs (positive, 63.8%; negative, 57.8%; difference, 6.0%, 95% confidence interval [CI], 5.4-6.6). This remained true regardless of staff beliefs, but the difference in successful discharge probability between patients with positive and negative beliefs was larger when staff had positive beliefs. Conversely, the association between staff beliefs and successful discharge varied based on patient beliefs. If patients had positive beliefs, the difference in the probability of successful discharge between positive and negative staff beliefs was 2.5% (95% CI, 1.0-4.0). If patients had negative beliefs, the difference between positive and negative staff beliefs was -4.6% (95% CI, -6.0 to -3.2). CONCLUSIONS: Patients' beliefs have a significant association with the probability of successful discharge. Understanding patients' beliefs is critical to appropriate goal-setting, discharge planning, and quality SNF care.

Association of Diagnosis Coding With Differences in Risk-Adjusted Short-term Mortality Between Critical Access and Non-Critical Access Hospitals.

Importance: Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes. Objective: To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding. Design, Setting, and Participants: Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017. Exposure: Admission to a CAH vs non-CAH. Main Outcomes and Measures: Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses. Results: There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02). Conclusions and Relevance: For rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities.

Head circumference as a useful surrogate for intracranial volume in older adults.

BACKGROUND: Intracranial volume (ICV) has been proposed as a measure of maximum lifetime brain size. Accurate ICV measures require neuroimaging which is not always feasible for epidemiologic investigations. We examined head circumference as a useful surrogate for ICV in older adults. METHODS: 99 older adults underwent Magnetic Resonance Imaging (MRI). ICV was measured by Statistical Parametric Mapping 8 (SPM8) software or Functional MRI of the Brain Software Library (FSL) extraction with manual editing, typically considered the gold standard. Head circumferences were determined using standardized tape measurement. We examined estimated correlation coefficients between head circumference and the two MRI-based ICV measurements. RESULTS: Head circumference and ICV by SPM8 were moderately correlated (overall r = 0.73, men r = 0.67, women r = 0.63). Head circumference and ICV by FSL were also moderately correlated (overall r = 0.69, men r = 0.63, women r = 0.49). CONCLUSIONS: Head circumference measurement was strongly correlated with MRI-derived ICV. Our study presents a simple method to approximate ICV among older patients, which may prove useful as a surrogate for cognitive reserve in large scale epidemiologic studies of cognitive outcomes. This study also suggests the stability of head circumference correlation with ICV throughout the lifespan.

The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients.

INTRODUCTION: As the relationship between delirium and long-term cognitive decline has not been well-explored, we evaluated this association in a prospective study. METHODS: SAGES is an ongoing study involving 560 adults age 70 years or more without dementia scheduled for major surgery. Delirium was assessed daily in the postoperative period using the Confusion Assessment Method. General Cognitive Performance (GCP) and the Informant Questionnaire for Cognitive Decline in the Elderly were assessed preoperatively then repeatedly out to 36 months. RESULTS: On average, patients with postoperative delirium had significantly lower preoperative cognitive performance, greater immediate (1 month) impairment, equivalent recovery at 2 months, and significantly greater long-term cognitive decline relative to the nondelirium group. Proxy reports corroborated the clinical significance of the long-term cognitive decline in delirious patients. DISCUSSION: Cognitive decline after surgery is biphasic and accelerated among persons with delirium. The pace of long-term decline is similar to that seen with mild cognitive impairment.

Does Apolipoprotein E Genotype Increase Risk of Postoperative Delirium?

OBJECTIVE: To determine whether apolipoprotein E (ApoE) is associated with postoperative delirium incidence, severity, and duration in older patients free of dementia at baseline. METHODS: The authors examined 557 nondemented patients aged 70 years or older undergoing major noncardiac surgery enrolled in the Successful Aging after Elective Surgery Study. Three ApoE measures were considered: ε2, ε4 carriers versus noncarriers, and a three-category ApoE measure. Delirium was determined using the Confusion Assessment Method (CAM) and chart review. We used generalized linear models to estimate the association between ApoE and delirium incidence, severity (peak CAM Severity [CAM-S] score), and days. RESULTS: ApoE ε2 and ε4 was present in 15% and 19%, respectively, and postoperative delirium occurred in 24%. Among patients with delirium, the mean peak CAM-S score was 8.0 (standard deviation: 4), with most patients experiencing 1 or 2 delirium days (51% or 28%, respectively). After adjusting for age, sex, surgical procedure, and preoperative cognitive function, ApoE ε4 and ε2 carrier status were not associated with postoperative delirium: RR for ε4=1.0, 95% CI: 0.7-1.5 and RR for ε2=0.9, 95% CI: 0.6-1.4. No association between ApoE and delirium severity or number of delirium days was observed. CONCLUSION: In older surgery patients free of dementia, our findings do not support the hypothesis that the ApoE genotype does not confer either risk or protection in postoperative delirium incidence, severity, or duration. Thus, an important genetic risk factor for Alzheimer disease does not affect risk of delirium.

The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts.

BACKGROUND: Quantifying the severity of delirium is essential to advancing clinical care by improved understanding of delirium effect, prognosis, pathophysiology, and response to treatment. OBJECTIVE: To develop and validate a new delirium severity measure (CAM-S) based on the Confusion Assessment Method. DESIGN: Validation analysis in 2 independent cohorts. SETTING: Three academic medical centers. PATIENTS: The first cohort included 300 patients aged 70 years or older scheduled for major surgery. The second included 919 medical patients aged 70 years or older. MEASUREMENTS: A 4-item short form and a 10-item long form were developed. Association of the maximum CAM-S score during hospitalization with hospital and posthospital outcomes related to delirium was evaluated. RESULTS: Representative results included adjusted mean length of stay, which increased across levels of short-form severity from 6.5 days (95% CI, 6.2 to 6.9 days) to 12.7 days (CI, 11.2 to 14.3 days) (P for trend < 0.001) and across levels of long-form severity from 5.6 days (CI, 5.1 to 6.1 days) to 11.9 days (CI, 10.8 to 12.9 days) (P for trend < 0.001). Representative results for the composite outcome of adjusted relative risk of death or nursing home residence at 90 days increased progressively across levels of short-form severity from 1.0 (referent) to 2.5 (CI, 1.9 to 3.3) (P for trend < 0.001) and across levels of long-form severity from 1.0 (referent) to 2.5 (CI, 1.6 to 3.7) (P for trend < 0.001). LIMITATION: Data on clinical outcomes were measured in an older data set limited to patients aged 70 years or older. CONCLUSION: The CAM-S provides a new delirium severity measure with strong psychometric properties and strong associations with important clinical outcomes. PRIMARY FUNDING SOURCE: National Institute on Aging.

The Language of Delirium: Keywords for Identifying Delirium from Medical Records.

Electronic medical records (EMRs) offer the opportunity to streamline the search for patients with possible delirium. The purpose of the current study was to identify words and phrases commonly noted in charts of patients with delirium. The current study included 67 patients (nested within a cohort study of 300 patients) ages 70 and older undergoing major elective surgery with evidence of confusion in their medical charts. Eight keywords or phrases had positive predictive values of 60% to 100% for delirium. Keywords were charted more often in nursing notes than physician notes. A brief list of keywords may serve as a building block for a methodology to screen for possible delirium from charts, with particular attention to nursing notes, for research and real-time clinical decision making.

Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia.

Importance: Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown. Objectives: To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations. Design, Setting, and Participants: This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018. Exposures: Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders). Main Outcomes and Measures: Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations. Results: Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority. Conclusions and Relevance: The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma.

Importance: Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective: To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma. Design, Setting, and Participants: Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024. Exposure: Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall. Main Outcomes and Measures: Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions. Results: The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date. Conclusions and Relevance: In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Medicare Advantage Health Risk Assessments Contribute Up To $12 Billion Per Year To Risk-Adjusted Payments.

With Medicare Advantage (MA) enrollment surpassing 50 percent of Medicare beneficiaries, accurate risk-adjusted plan payment rates are essential. However, artificially exaggerated coding intensity, where plans seek to enhance measured health risk through the addition or inflation of diagnoses, may threaten payment rate integrity. One factor that may play a role in escalating coding intensity is health risk assessments (HRAs)-typically in-home reviews of enrollees' health status-that enable plans to capture information about their enrollees. In this study, we evaluated the impact of HRAs on Hierarchical Condition Categories (HCC) risk scores, variation in this impact across contracts, and the aggregate payment impact of HRAs, using 2019 MA encounter data. We found that 44.4 percent of MA beneficiaries had at least one HRA. Among those with at least one HRA, HCC scores increased by 12.8 percent, on average, as a result of HRAs. More than one in five enrollees had at least one additional HRA-captured diagnosis, which raised their HCC score. Potential scenarios restricting the risk-score impact of HRAs correspond with $4.5-$12.3 billion in reduced Medicare spending in 2020. Addressing increased coding intensity due to HRAs will improve the value of Medicare spending and ensure appropriate payment in the MA program.

Risk of Discharge to Lower-Quality Nursing Homes Among Hospitalized Older Adults With Alzheimer Disease and Related Dementias.

Importance: Individuals with Alzheimer disease and related dementias (ADRD) frequently require skilled nursing facility (SNF) care following hospitalization. Despite lower SNF incentives to care for the ADRD population, knowledge on how the quality of SNF care differs for those with vs without ADRD is limited. Objective: To examine whether persons with ADRD are systematically admitted to lower-quality SNFs. Design, Setting, and Participants: Cross-sectional analysis of Medicare beneficiaries hospitalized between January 1, 2017, and December 31, 2019, was conducted. Data analysis was performed from January 15 to May 30, 2022. Participants were discharged to a Medicare-certified SNF from a general acute hospital. Patients younger than 65 years, enrolled in Medicare Advantage, and with prior SNF or long-term nursing home use within 1 year of hospitalization were excluded. Exposures: The quality level of all SNFs available at the patient's discharge, measured using publicly reported 5-star staffing ratings. The 5-star ratings were grouped into 3 levels (1-2 stars [reference category, low-quality], 3 stars [average-quality], and 4-5 stars [high-quality]). Main Outcomes and Measures: The outcome was the SNF a patient entered among the possible SNF destinations available at discharge. Differences in the association between SNF quality and SNF entry for patients with and without ADRD were assessed using a conditional logit model, which simultaneously controls for differences in discharging hospital, residential neighborhood, and the other characteristics (eg, postacute care specialization) of all SNFs available at discharge. Results: The sample included 2 619 464 patients (mean [SD] age, 81.3 [8.6] years; 61% women; 87% were White; 8% were Black; 22% with ADRD). The probability of discharge to higher quality SNFs was lower for patients with ADRD. If the star rating of an SNF was high instead of low, the log-odds of being discharged to it increased by 0.31 for patients with ADRD and by 0.47 for those without ADRD (difference, -0.16; P < .001). The weaker association between quality and entry for patients with ADRD indicates that they are less likely to be discharged to high-quality SNFs. Conclusions and Relevance: The findings of this study suggest that patients with ADRD are more likely to be discharged to lower-quality SNFs. Targeted reforms, such as ADRD-specific compensation adjustments, may be needed to improve access to better SNFs for patients with ADRD.

Incidence and Outcomes of SARS-CoV-2 in Post-Acute Skilled Nursing Facility Care.

OBJECTIVES: To examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death. DESIGN: Cohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive. SETTING AND PARTICIPANTS: The sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded. METHODS: SARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2. RESULTS: The sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment. CONCLUSIONS AND IMPLICATIONS: The absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.

Socioeconomic Disparities in Community Mobility Reduction and COVID-19 Growth.

OBJECTIVE: To examine differences in community mobility reduction and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outcomes across counties with differing levels of socioeconomic disadvantage. METHODS: The sample included counties in the United States with at least one SARS-CoV-2 case between April 1 and May 15, 2020. Outcomes were growth in SARS-CoV-2 cases, SARS-CoV-2-related deaths, and mobility reduction across three settings: retail/recreation, grocery/pharmacy, and workplace. The main explanatory variable was the social deprivation index (SDI), a composite socioeconomic disadvantage measure. RESULTS: Adjusted differences in outcomes between low-, medium-, and high-SDI counties (defined by tertile) were calculated using linear regression with state-fixed effects. Workplace mobility reduction was 1.75 (95% CI, -2.36 to -1.14; P<.001) and 3.48 percentage points (95% CI, -4.21 to -2.75; P<.001) lower for medium- and high-SDI counties relative to low-SDI counties, respectively. Mobility reductions in the other settings were also significantly lower for higher-SDI counties. In analyses adjusted for SARS-CoV-2 prevalence on April 1, medium- and high-SDI counties had 1.39 (95% CI, 0.85 to 1.93; P<.001) and 2.56 (95% CI, 1.77 to 3.34; P<.001) more SARS-CoV-2 cases/1000 population on May 15 compared with low-SDI counties, respectively. Deaths per capita were also significantly higher for higher-SDI counties. CONCLUSION: Counties with higher social deprivation scores experienced greater growth in SARS-CoV-2 cases and deaths, but reduced mobility at lower rates. These findings are consistent with evidence demonstrating that economically disadvantaged communities have been disproportionately impacted by the coronavirus disease 2019 pandemic. Efforts to socially distance may be more burdensome for these communities, potentially exacerbating disparities in SARS-CoV-2-related outcomes.

COVID-19 Mortality Rates Among Nursing Home Residents Declined From March To November 2020.

Improved therapeutics and supportive care in hospitals have helped reduce mortality from COVID-19. However, there is limited evidence as to whether nursing home residents, who account for a disproportionate share of COVID-19 deaths and are often managed conservatively in the nursing home instead of being admitted to the hospital, have experienced similar mortality reductions. In this study we examined changes in thirty-day mortality rates between March and November 2020 among 12,271 nursing home residents with COVID-19. We found that adjusted mortality rates significantly declined from a high of 20.9 percent in early April to 11.2 percent in early November. Mortality risk declined for residents with both symptomatic and asymptomatic infections and for residents with both high and low clinical complexity. The mechanisms driving these trends are not entirely understood, but they may include improved clinical management within nursing homes, improved personal protective equipment supply and use, and genetic changes in the virus.

Short-term impact of nursing home SARS-CoV-2 vaccinations on new infections, hospitalizations, and deaths.

OBJECTIVE: To compare rates of incident SARS-CoV-2 infection and 30-day hospitalization or death among residents with confirmed infection in nursing homes with earlier versus later SARS-CoV-2 vaccine clinics. DESIGN: Matched pairs analysis of nursing homes that had their initial vaccine clinics between December 18, 2020, and January 2, 2021, versus between January 3, 2021, and January 18, 2021. Matched facilities had their initial vaccine clinics between 12 and 16 days apart. SETTING AND PARTICIPANTS: Two hundred and eighty nursing homes in 21 states owned and operated by the largest long-term care provider in the United States. MEASUREMENTS: Incident SARS-CoV-2 infections per 100 at-risk residents per week; hospital transfers and/or deaths per 100 residents with confirmed SARS-CoV-2 infection per day, averaged over a week. RESULTS: The early vaccinated group included 136 facilities with 12,157 residents; the late vaccinated group included 144 facilities with 13,221 residents. After 1 week, early vaccinated facilities had a predicted 2.5 fewer incident SARS-CoV-2 infections per 100 at-risk residents per week (95% CI: 1.2-4.0) compared with what would have been expected based on the experience of the late vaccinated facilities. The rates remained significantly lower for several weeks. Cumulatively over 5 weeks, the predicted reduction in new infections was 5.2 cases per 100 at-risk residents (95% CI: 3.2-7.3). By 5 to 8 weeks post-vaccine clinic, early vaccinated facilities had a predicted 1.1 to 3.8 fewer hospitalizations and/or deaths per 100 infected residents per day, averaged by week than expected based on late vaccinated facilities' experience for a cumulative on average difference of 5 events per 100 infected residents per day. CONCLUSIONS: The SARS-CoV-2 vaccines seem to have accelerated the rate of decline of incident infections, morbidity, and mortality in this large multi-state nursing home population.

Risk Factors Associated With All-Cause 30-Day Mortality in Nursing Home Residents With COVID-19.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing homes. Vulnerable nursing home residents are at high risk for adverse outcomes, but improved understanding is needed to identify risk factors for mortality among nursing home residents. Objective: To identify risk factors for 30-day all-cause mortality among US nursing home residents with COVID-19. Design, Setting, and Participants: This cohort study was conducted at 351 US nursing homes among 5256 nursing home residents with COVID-19-related symptoms who had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by polymerase chain reaction testing between March 16 and September 15, 2020. Exposures: Resident-level characteristics, including age, sex, race/ethnicity, symptoms, chronic conditions, and physical and cognitive function. Main Outcomes and Measures: Death due to any cause within 30 days of the first positive SARS-CoV-2 test result. Results: The study included 5256 nursing home residents (3185 women [61%]; median age, 79 years [interquartile range, 69-88 years]; and 3741 White residents [71%], 909 Black residents [17%], and 586 individuals of other races/ethnicities [11%]) with COVID-19. Compared with residents aged 75 to 79 years, the odds of death were 1.46 (95% CI, 1.14-1.86) times higher for residents aged 80 to 84 years, 1.59 (95% CI, 1.25-2.03) times higher for residents aged 85 to 89 years, and 2.14 (95% CI, 1.70-2.69) times higher for residents aged 90 years or older. Women had lower risk for 30-day mortality than men (odds ratio [OR], 0.69 [95% CI, 0.60-0.80]). Two comorbidities were associated with mortality: diabetes (OR, 1.21 [95% CI, 1.05-1.40]) and chronic kidney disease (OR, 1.33 [95%, 1.11-1.61]). Fever (OR, 1.66 [95% CI, 1.41-1.96]), shortness of breath (OR, 2.52 [95% CI, 2.00-3.16]), tachycardia (OR, 1.31 [95% CI, 1.04-1.64]), and hypoxia (OR, 2.05 [95% CI, 1.68-2.50]) were also associated with increased risk of 30-day mortality. Compared with cognitively intact residents, the odds of death among residents with moderate cognitive impairment were 2.09 (95% CI, 1.68-2.59) times higher, and the odds of death among residents with severe cognitive impairment were 2.79 (95% CI, 2.14-3.66) times higher. Compared with residents with no or limited impairment in physical function, the odds of death among residents with moderate impairment were 1.49 (95% CI, 1.18-1.88) times higher, and the odds of death among residents with severe impairment were 1.64 (95% CI, 1.30-2.08) times higher. Conclusions and Relevance: In this cohort study of US nursing home residents with COVID-19, increased age, male sex, and impaired cognitive and physical function were independently associated with mortality. Understanding these risk factors can aid in the development of clinical prediction models of mortality in this population.

Trends In Hospitals And Skilled Nursing Facilities Sharing Medical Providers, 2008-16.

Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, we found that as SNFs moved increasingly toward using SNF specialists, there was a steady decline in the number of facilities sharing medical providers and in the proportion of SNF primary care delivered by provider practices with both hospital and SNF clinicians (hospital-SNF practices). In SNF fixed effects analyses, we found that SNFs that increased primary care visits by hospital-SNF practices had slightly fewer readmissions, shorter lengths-of-stay, and increased successful community discharges. These findings suggest that SNFs that share medical providers with hospitals may see some benefit from that linkage, although the magnitude of the benefit may be small.

Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults.

Importance: Although people living in rural areas of the United States are disproportionately older and more likely to die of conditions that require postacute care than those living in urban areas, rural-urban differences in postacute care utilization and outcomes have been understudied. Objective: To describe rural-urban differences in postacute care utilization and postdischarge outcomes. Design, Setting, and Participants: This retrospective cohort study used data from Medicare beneficiaries 66 years and older admitted to 4738 US acute care hospitals for stroke, hip fracture, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia between January 1, 2011, and September 30, 2015. Participants were tracked for 180 days after discharge. Data analyses were conducted between October 1, 2018, and May 30, 2019. Exposures: County of residence was classified as urban or rural using the US Department of Agriculture Rural-Urban Continuum Codes. Rural counties were divided into those adjacent and not adjacent to urban counties. Main Outcomes and Measures: Primary outcomes were discharge to community vs a formal postacute care setting (ie, skilled nursing facility, home health care, or inpatient rehabilitation facility) and readmission and mortality within 30, 90, and 180 days of hospital discharge. Results: Among 2 044 231 hospitalizations from 2011 to 2015, 1 538 888 (75.2%; mean [SD] age, 80.4 [8.3] years; 866 540 [56.3%] women) were among patients from urban counties, 322 360 (15.8%; mean [SD] age, 79.6 [8.1] years; 175 806 [54.5%] women) were among patients from urban-adjacent rural counties, and 182 983 (9.0%; mean [SD] age, 79.8 [8.1] years; 98 775 [54.0%] women) were among patients from urban-nonadjacent rural counties. The probability of discharge to community without postacute care did not differ by rurality. However, compared with patients from urban counties, patients from the most rural counties were more frequently discharged to a skilled nursing facility (adjusted difference, 3.5 [95% CI, 2.8-4.3] percentage points), while discharge to an inpatient rehabilitation facility was less common among patients from rural counties than among those from urban counties (urban vs urban-adjacent rural: adjusted difference, -1.9 [95% CI, -2.4 to -1.4] percentage points; urban vs urban-nonadjacent rural: adjusted difference, -1.8 [95% CI, -2.4 to -1.2] percentage points) as was discharge to home health care (urban vs urban-adjacent rural: adjusted difference, -1.7 [95% CI, -2.3 to -1.2] percentage points; urban vs urban-nonadjacent rural: adjusted difference, -2.4 [95% CI, -3.0 to -1.8]). For patients from the most rural counties, adjusted 30-day readmission rates were 0.4 (95% CI, 0.2-0.6) percentage points higher than those of patients from urban counties among those who were discharged to the community but 0.3 (95% CI, -0.6 to -0.1) percentage points lower among patients receiving postacute care. Adjusted 30-day mortality rates were 0.4 (95% CI, 0.3-0.5) percentage points higher for patients from the most rural counties discharged to the community and 2.0 (95% CI, -1.7 to 2.3) percentage points higher among those receiving postacute care. Rural-urban differences in 90-day and 180-day outcomes were similar. Conclusions and Relevance: These findings suggest that rates of discharge to the community and postacute care settings were similar among patients from rural and urban counties. Rural-urban differences in mortality following discharge were much larger for patients receiving postacute care compared with patients discharged to the community setting. Improving postacute care in rural areas may reduce rural-urban disparities in patient outcomes.