COVID-19 Risk Factors and Nursing Home Residents

Long-term care facilities, like nursing homes, have been disproportionality impacted by COVID-19. The COVID Tracking Project reported that despite less than 1% of America’s population living in long-term care facilities (LTCF), they have accounted for 34% of US COVID-19 deaths.

As of March 2021, there have been 1.3 million cases of COVID-19 in LTCFs and 174,474 deaths across over 33,000 facilities. The United States overall has seen 30.6 million cases and 553,907 deaths. Residents in nursing homes are particularly vulnerable to COVID-19 as they are usually older, medically fragile with multiple comorbidities, and the environment can be ripe for transmission for an outbreak of respiratory infection due to close quarters and limited infection prevention resources.

As we hopefully inch closer to a point where COVID-19 numbers are declining and vaccinations are increasing, there is more attention to what risk factors might impact infections, hospitalizations, and mortality. A new study published in JAMA Network Open sought to address these risk factors for those residents in US nursing homes. The authors performed a retrospective longitudinal cohort study in those residents 65 years and older who were residents one of 15,038 US nursing homes and had Medicare’s fee-for-service. The study reviewed patients during April 1 to September 30, 2020. Three outcomes were measured—new diagnosis of COVID-19, hospitalization within 30 days of said diagnosis, and death within thirty days of the diagnosis.

The research cohort included 482,323 residents across over 15,000 nursing homes with a mean age of 82.7 years and nearly 68% were female. Of the 137,119 (28.4%) residents diagnosed with COVID-19 during follow up—21.3% were hospitalized and 19.2% died. The authors noted that “nursing homes explained 37.2% of the variation in risk of infection, while county explained 23.4%.

Risk of infection increased with increasing body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) (eg, BMI>45 vs BMI 18.5-25: adjusted hazard ratio [aHR], 1.19; 95% CI, 1.15-1.24) but varied little by other resident characteristics. Risk of hospitalization after SARS-CoV-2 increased with increasing BMI (eg, BMI>45 vs BMI 18.5-25: aHR, 1.40; 95% CI, 1.28-1.52); male sex (aHR, 1.32; 95% CI, 1.29-1.35); Black (aHR, 1.28; 95% CI, 1.24-1.32), Hispanic (aHR, 1.20; 95% CI, 1.15-1.26), or Asian (aHR, 1.46; 95% CI, 1.36-1.57) race/ethnicity; impaired functional status (eg, severely impaired vs not impaired: aHR, 1.15; 95% CI, 1.10-1.22); and increasing comorbidities, such as renal disease (aHR, 1.21; 95% CI, 1.18-1.24) and diabetes (aHR, 1.16; 95% CI, 1.13-1.18).” Moreover, they found that risk for mortality increased with age, impaired cognition, and functional impairment.

Ultimately, these findings point to the role of county and facility in risk of infection. In terms of hospitalization, it’s not unusual that individual resident characteristics would play a role in risk, but the association with facility is perhaps one of those more insidious truths we’ve struggled to accept. Quality of care is not new, but long-term care facilities can be especially vulnerable to staffing issues, abuse, and unmet resident needs.

COVID-19 has shed additional light on these hurdles and that ultimately, this is an exceedingly vulnerable patient population with little resources for or attention to pandemic preparedness and infection prevention. These findings point to a need for not only additional research, but also increased scrutiny to the quality of various facilities and how this can impact outcomes in patients.