Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US | Geriatrics | JAMA Network Open | JAMA Network
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    Original Investigation
    Health Policy
    February 10, 2021

    Factors Associated With Racial Differences in Deaths Among Nursing Home Residents With COVID-19 Infection in the US

    Author Affiliations
    • 1Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
    • 2Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois
    • 3Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, Illinois
    JAMA Netw Open. 2021;4(2):e2037431. doi:10.1001/jamanetworkopen.2020.37431
    Key Points

    Question  Are case mix, nursing home characteristics, and community spread of coronavirus disease 2019 (COVID-19) associated with racial differences in deaths among nursing home residents with COVID-19 infection in the US?

    Findings  In this cross-sectional study of 13 312 nursing homes in the US, deaths among nursing home residents with COVID-19 infection were higher in facilities that had low proportions (<60%) of White residents compared with those that had high proportions (>97%) of White residents. This difference in mortality was associated with a combination of differences in facility characteristics and location.

    Meaning  The study’s findings suggest that the inequalities underlying racial disparities in COVID-19 infection and mortality in the general population may also be associated with differences in mortality among nursing home residents with COVID-19 infection.


    Importance  It is important to understand differences in coronavirus disease 2019 (COVID-19) deaths by nursing home racial composition and the potential reasons for these differences so that limited resources can be distributed equitably.

    Objective  To describe differences in the number of COVID-19 deaths by nursing home racial composition and examine the factors associated with these differences.

    Design, Setting, and Participants  This cross-sectional study of 13 312 nursing homes in the US used the Nursing Home COVID-19 Public File from the Centers for Medicare and Medicaid Services, which contains COVID-19 cases and deaths among nursing home residents as self-reported by nursing homes beginning between January 1, 2020, and May 24, 2020, and ending on September 13, 2020. Data were analyzed from July 28 to December 18, 2020.

    Exposures  Confirmed or suspected COVID-19 infection. Confirmed cases were defined as COVID-19 infection confirmed by a diagnostic laboratory test. Suspected cases were defined as signs and/or symptoms of COVID-19 infection or patient-specific transmission-based precautions for COVID-19 infection.

    Main Outcomes and Measures  Deaths associated with COVID-19 among nursing home residents. Death counts were compared by nursing home racial composition, which was measured as the proportion of White residents.

    Results  Among 13 312 nursing homes included in the study, the overall mean (SD) age of residents was 79.5 (6.7) years. A total of 51 606 COVID-19–associated deaths among residents were reported, with a mean (SD) of 3.9 (8.0) deaths per facility. The mean (SD) number of deaths in nursing homes with the lowest proportion of White residents (quintile 1) vs nursing homes with the highest proportions of White residents (quintile 5) were 5.6 (9.2) and 1.7 (4.8), respectively. Facilities in quintile 1 experienced a mean (SE) of 3.9 (0.2) more deaths than those in quintile 5, representing a 3.3-fold higher number of deaths in quintile 1 compared with quintile 5. Adjustment for the number of certified beds reduced the mean (SE) difference between these 2 nursing home groups to 2.2 (0.2) deaths. Controlling for case mix measures and other nursing home characteristics did not modify this association. Adjustment for county-level COVID-19 prevalence further reduced the mean (SE) difference to 1.0 (0.2) death.

    Conclusions and Relevance  In this study, nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those of facilities with the highest proportions of White residents. These differences were associated with factors such as larger nursing home size and higher infection burden in counties in which nursing homes with high proportions of non-White residents were located. Focusing limited available resources on facilities with high proportions of non-White residents is needed to support nursing homes during potential future outbreaks.