COVID-19 Infections and Deaths Among Connecticut Nursing Home Residents: Facility Correlates

Yue Li, PhD; Helena Temkin-Greener, PhD; Gao Shan, MS; Xueya Cai, PhD

Disclosures

J Am Geriatr Soc. 2020;68(9):1899-1906. 

In This Article

Results

In all 215 Connecticut nursing homes (Table 1) and by April 16, 2020, the average number of confirmed cases was 8 per nursing home (interquartile range [IQR] = 0–12), but the number ranged from zero for about half of all nursing homes (n = 107) to as high as 69 in one nursing home. The number of confirmed deaths was 1.7 per nursing home on average (IQR = 0–2), ranging from zero for 131 nursing homes to 15 in two nursing homes. Nursing homes with fewer confirmed cases tended to have a higher RN staffing level (.8 hours per resident day for facilities with zero cases and .6 hours per resident day for facilities with 1–10 and 11–69 cases), lower five-star ratings, and higher concentrations of Medicaid and racial/ethnic minority residents. Similar trends were found for confirmed deaths. Nursing homes with more confirmed cases or deaths were also more likely to be large for-profit facilities affiliated with a chain and having a higher resident census.

Table 2 shows that by April 16, the cumulative number of confirmed cases was 3.0 per 1,000 population in Connecticut but ranged from .7 to 7.2 over the eight counties; the cumulative number of COVID-19 deaths was .2 per 1,000 population with a range of .01 to .4 over counties. The number of confirmed cases of Connecticut nursing home residents was 5.2 per 100 nursing home beds (range = 0–8.9 over counties), and the number of COVID-19 deaths was 1.2 per 100 nursing home beds (range = 0–2.6 over counties). The proportion of confirmed cases who were nursing home residents in Connecticut was 11.2% (ranging from 0% to 19.5% over counties), but the corresponding proportion for deaths was 38.7% in the state with a range from 0% to 50% over counties (Supplementary Figure S1).

Multivariable analyses showed that RN staffing, five-star ratings, and concentrations of Medicaid and racial/ethnic minority residents in the nursing home were not statistically significantly associated with the likelihood of having one or more confirmed cases in the facility, after controlling for facility and county covariates (Table 3). However, among facilities with at least one case, these facility characteristics were significantly associated with the count of cases. Every 20 minutes (per resident day) increase in RN staffing was associated with a 22% reduction in confirmed cases (incidence rate ratio [IRR] = .78; 95% confidence interval [CI] = .68–.89; P < .001). Compared with one- to three-star facilities, four- or five-star facilities showed 13% fewer confirmed cases (IRR = .87; 95% CI = .78–.97; P < .015). Nursing homes with a high concentration of Medicaid residents (IRR = 1.16; 95% CI = 1.02–1.32; P = .025) or racial/ethnic minority residents (IRR = 1.15; 95% CI = 1.03–1.29; P = .026) had 16% and 15% fewer confirmed cases, respectively, compared with their counterparts.

Figure 1A shows the predicted number of confirmed cases combining estimates from both parts of the two-part model and demonstrates strong negative association between RN staffing and predicted count (P = .001 based on a joint test on estimates of the two parts). Supplementary Figure S2, panel A, similarly shows the predicted number of confirmed cases from the two-part model and demonstrates more confirmed cases in lower star nursing homes and nursing homes with higher concentrations of sociodemographically disadvantaged residents.

Figure 1.

Predicted numbers of COVID-19 (A) confirmed cases and (B) deaths among Connecticut nursing home residents (as of April 16, 2020) versus registered nurse (RN) staffing hours (P values are for the independent associations of RN staffing with predicted counts that were derived from the joint tests of the two-part regression models).

Table 3 also shows that these key nursing home characteristics were not significantly associated with the likelihood of one or more COVID-19 deaths in a nursing home. However, among facilities with at least one death, every 20-minute increase in RN staffing of the nursing home significantly predicted a 26% reduction in COVID-19 deaths (IRR = .74; 95% CI = .55–1.00; P = .047). Furthermore, RN staffing level was negatively associated with the overall predicted number of deaths (P = .067 in a joint test of the two-part model; Figure 1B). Supplementary Figure S2 shows the tendencies of higher predicted numbers of deaths in lower star nursing homes and nursing homes with a higher concentration of sociodemographically disadvantaged residents, although group differences were not statistically significant.

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