Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases | Geriatrics | JAMA | JAMA Network
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Table 1.  Characteristics of High-Performing vs Low-Performing Nursing Homes Across 3 CMS Performance Domainsa
Characteristics of High-Performing vs Low-Performing Nursing Homes Across 3 CMS Performance Domainsa
Table 2.  Association Between Nursing Home Ratings on Health Inspections, Quality Measures, and Nurse Staffing Domains With COVID-19 Cases
Association Between Nursing Home Ratings on Health Inspections, Quality Measures, and Nurse Staffing Domains With COVID-19 Cases
1.
Chidambaram  P. State reporting of cases and deaths due to COVID-19 in long-term care facilities. Kaiser Family Foundation. Published April 23, 2020. Accessed June 30, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
2.
Centers for Medicare & Medicaid Services. Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide. Published April 2020. Accessed June 30, 2020. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf
3.
Grabowski  DC, Joynt Maddox  KE.  Postacute care preparedness for COVID-19: thinking ahead.   JAMA. 2020;323(20):2007-2008. doi:10.1001/jama.2020.4686PubMedGoogle ScholarCrossref
4.
Davidson  PM, Szanton  SL.  Nursing homes and COVID-19: we can and should do better.   J Clin Nurs. 2020;29(15-16):2758-2759. doi:10.1111/jocn.15297PubMedGoogle ScholarCrossref
5.
Grabowski  DC, Mor  V.  Nursing home care in crisis in the wake of COVID-19.   JAMA. Published online May 20, 2020. doi:10.1001/jama.2020.8524PubMedGoogle Scholar
6.
Abbasi  J.  “Abandoned” nursing homes continue to face critical supply and staff shortages as COVID-19 toll has mounted.   JAMA. Published online June 11, 2020. doi:10.1001/jama.2020.10419PubMedGoogle Scholar
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    1 Comment for this article
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    Seeing Through the Fog
    Jeoffry Gordon, MD, MPH | Retired Family Doctor
    This is an important and well conceived study. It does give some guidance for future improvement using a few objective parameters, e.g. nursing staffing ratios. Nonetheless, it mostly explores parameters that have only a tenuous relation to real world function:

    NH star ratings by CMMS are functionally crude, superficial and depend on check lists rather than actual observed function. NHs have every incentive to game them and upgrade themselves whenever possible. There is no "Joint Commission"-like oversight. While better than nothing, the stars have only a tenuous relation to actual quality and caring within a facility. I have tended
    patients in NH with similar "ratings" that range from crude, custodial-oriented care to careful, concerned attentive care. Every physician who tends patients in a NH can tell you which are good and which are poor quality.

    I spent a brief time as a NH inspector and again the system is better than nothing. Generally state oversight is underfunded and understaffed and it is not a particularly gratifying job. NH visits focus on policies and procedures, general considerations like cleanliness (the smell of urine), and reported functionalities (time sheets and patient check lists). Generally the inspections deal with the basic floor of quality rather than motivating competencies and caring. Deficiencies are enforced with fines and specific recommendations that are very focused, but over look management and ownership's attitudes.

    Every article discussing NH quality of care must contain a caveat that in this country we have a policy of warehousing our elderly out of sight generally in commercial facilities managed by companies not interested in patient care but in government-subsidized cash flow, real estate values, and REIT possibilities. In the best of times they overwhelmingly depend on low paid, unskilled, and often uncaring employees with high turnover.

    The incidence and death rates from Covid in 2020 demonstrate the validity of this description.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    August 10, 2020

    Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases

    Author Affiliations
    • 1Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
    • 2Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 3Department of Social and Health Policy, London School of Economics, London, United Kingdom
    JAMA. 2020;324(11):1103-1105. doi:10.1001/jama.2020.14709

    In the US, approximately 27% of deaths due to coronavirus disease 2019 (COVID-19) have occurred among residents of nursing homes (NHs).1 However, why some facilities have been more successful at limiting the spread of infection than others is unclear. For example, those with greater staffing or higher performance on quality measures may be better at containing the spread of COVID-19 among staff and residents.

    We evaluated whether NHs rated highly by the Centers for Medicare & Medicaid Services (CMS) across 3 unique domains—health inspections, quality measures, and nurse staffing—had lower COVID-19 cases than facilities with lower ratings.

    Methods

    We used data from 8 state health departments (California, Connecticut, Florida, Illinois, Maryland, Massachusetts, New Jersey, and Pennsylvania) to determine the total number of COVID-19 cases occurring in NHs between January 1, 2020, and June 30, 2020. We linked these data with CMS Nursing Home Compare, which includes star ratings (range, 1 [low] to 5 [high]) that characterize performance across the 3 domains.2 The health inspection rating is based on the number of deficiencies identified in the 3 most recent state surveys across several areas, including staff-resident interactions and adequate infection control protocols. The quality measures rating is based on the weighted mean of performance across 15 quality measures (eg, avoidable hospitalizations, pressure ulcers, urinary tract infections). The nurse staffing domain is based on the mean staffing hours per resident by qualified nursing staff.

    Given how COVID-19 data are publicly reported across some states, we were limited to grouping NHs into 3 categories: those with 10 or fewer, 11 to 30, or more than 30 COVID-19 cases. We performed 3 separate ordinal logistic regression models to assess the odds of high-performing facilities (4- or 5-star facilities) having more than 30 cases vs 11 to 30 cases vs 10 cases or fewer relative to low-performing facilities (1- to 3-star facilities), adjusting for the number of certified beds and including county fixed effects. The study was conducted using SAS version 9.4 (SAS Institute Inc). Two-sided P values were considered significant at the P < .05 level. The Harvard T. H. Chan School of Public Health Institutional Review Board waived the need for informed consent.

    Results

    Of the 4254 NHs across the 8 states, 4254 (100%) had star ratings for health inspection; 4241 (99.7%), quality measures; and 4225 (99.3%), nurse staffing domains. Within each domain, 1451 (34.1%) were considered high performing for health inspection; 2974 (70.1%) for quality measures; and 1517 (35.9%) for nurse staffing (Table 1). High-performing NHs were less likely to have had more than 30 COVID-19 cases than were low-performing facilities across each domain (health inspections, 348 [24.0%] vs 948 [33.8%]; quality measures, 897 [30.2%] vs 397 [31.3%]; nurse staffing, 382 [25.2%] vs 907 [33.5%]). High-performing NHs had a lower median number of certified beds. After adjustment, NHs with high ratings on nurse staffing were less likely to have more than 30 COVID-19 cases vs facilities with 11 to 30 and vs facilities with 10 or fewer cases than were low-performing NHs (OR, 0.82; 95% CI, 0.70-0.95; P = .01) (Table 2). There was no significant association between high- vs low-performing NHs in the health inspections or quality measures domains with COVID-19 cases.

    Discussion

    Across 8 states, high-performing NHs for nurse staffing had fewer COVID-19 cases than low-performing NHs. In contrast, there was no significant difference in the burden of COVID-19 cases between high- vs low-performing NHs for health inspection or quality measure ratings. These findings suggest that poorly resourced NHs with nurse staffing shortages may be more susceptible to the spread of COVID-19.3,4 Although guidance on best practices on infection control are important, which has been the primary strategy used by CMS to date, policies that provide immediate staffing support may be more effective at mitigating the spread of COVID-19.5,6

    This study has limitations. It included data from only 8 states; however, these states rank among those with the highest COVID-19 burden. The state-reported data used are also more reliable than the national COVID-19 data set recently released by CMS, which reports suggest is incomplete and inaccurate. In addition, high-performing NHs may have greater capacity to test and diagnose cases, which may lead to an underestimate of the association between low performance on the staffing domain and higher COVID-19 cases.

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Jose F. Figueroa, MD, MPH, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Kresge Room 413, Boston, MA 02115 (jfigueroa@hsph.harvard.edu).

    Accepted for Publication: July 22, 2020.

    Published Online: August 10, 2020. doi:10.1001/jama.2020.14709

    Author Contributions: Drs Figueroa and Zheng had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Figueroa, Wadhera, Papanicolas, Jha.

    Acquisition, analysis, or interpretation of data: Figueroa, Wadhera, Riley, Zheng, Orav.

    Drafting of the manuscript: Figueroa, Riley.

    Critical revision of the manuscript for important intellectual content: Figueroa, Wadhera, Papanicolas, Zheng, Orav, Jha.

    Statistical analysis: Papanicolas, Zheng, Orav.

    Obtained funding: Figueroa.

    Administrative, technical, or material support: Figueroa, Riley, Jha.

    Supervision: Figueroa, Jha.

    Conflict of Interest Disclosures: Dr Figueroa reported receiving research support for other work not related to this topic by the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Harvard Center for AIDS Research. Dr Wadhera reported receiving research grant K23HL148525-1 from the National Heart, Lung, and Blood Institute and previously serving as a consultant for Regeneron. Dr Jha reported receiving funding from the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Bill and Melinda Gates Foundation for other work. No other disclosures were reported.

    References
    1.
    Chidambaram  P. State reporting of cases and deaths due to COVID-19 in long-term care facilities. Kaiser Family Foundation. Published April 23, 2020. Accessed June 30, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
    2.
    Centers for Medicare & Medicaid Services. Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide. Published April 2020. Accessed June 30, 2020. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf
    3.
    Grabowski  DC, Joynt Maddox  KE.  Postacute care preparedness for COVID-19: thinking ahead.   JAMA. 2020;323(20):2007-2008. doi:10.1001/jama.2020.4686PubMedGoogle ScholarCrossref
    4.
    Davidson  PM, Szanton  SL.  Nursing homes and COVID-19: we can and should do better.   J Clin Nurs. 2020;29(15-16):2758-2759. doi:10.1111/jocn.15297PubMedGoogle ScholarCrossref
    5.
    Grabowski  DC, Mor  V.  Nursing home care in crisis in the wake of COVID-19.   JAMA. Published online May 20, 2020. doi:10.1001/jama.2020.8524PubMedGoogle Scholar
    6.
    Abbasi  J.  “Abandoned” nursing homes continue to face critical supply and staff shortages as COVID-19 toll has mounted.   JAMA. Published online June 11, 2020. doi:10.1001/jama.2020.10419PubMedGoogle Scholar
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