Nursing home quality, COVID-19 deaths, and excess mortality

Addressing Staffing Shortages in Nursing Homes: Does Relaxing Training and Licensing Requirements Increase Nurse Aide Staffing?

OBJECTIVE

To evaluate whether COVID-19-related nurse aide training and licensing relaxation policies improved staffing shortages in nursing homes.

STUDY SETTING AND DESIGN

Staffing shortages have been a long-standing concern in nursing homes, and states are experimenting with different approaches to enhance nurse aide staffing. We use the latest quasi-experimental difference-in-differences methods to evaluate the effect of relaxing training and licensing requirements in 19 states (treatment group) relative to the 31 states that did not implement such policies (control group). We analyze the combined effect of relaxing both training and licensing requirements, as well as the impact of relaxing each policy separately.

DATA SOURCES AND ANALYTIC SAMPLE

We obtain quarterly data on nursing home characteristics, including adjusted nurse aide hours per resident day (HPRD) from 2019 to 2023 from Care Compare, a federal website with quality information on all Medicare/Medicaid-certified nursing homes. After excluding outliers of staffing data (nurse aide HPRD > 5.25, or nurse aide HPRD = 0), our final analytical sample had 278,170 observations.

PRINCIPAL FINDINGS

The average nurse aide HPRD is 2.30 in the treatment group and 2.26 in the control group. Using the difference-in-differences regression analyses, we find no significant effect of the relaxation of training and licensing requirements on nurse aide levels (average treatment effect: -0.0001; p = 0.99). Similarly, separate analyses of training and licensing relaxation policies suggest that neither policy significantly impacts nurse aide staffing. Results are consistent when we adjust for staffing requirements, wage increase policies, and nursing home characteristics.

CONCLUSIONS

Our findings suggest that the relaxation of training and licensing requirements may not lead to improved nurse aide staffing levels in nursing homes. Policymakers need to consider other strategies to address persistent staffing shortages in nursing homes.

Impact of a Collaboration-Focused Intervention to Prevent Healthcare-Associated Infections Before and During the Coronavirus Disease 2019 Pandemic

BACKGROUND

Nursing home (NH) residents are susceptible to healthcare-associated infections (HAIs). Alignment among NHs, hospitals, and health departments is critical for effective implementation of infection prevention efforts. We tested a collaborative model that engaged hospitals and NHs to reduce infections among NH residents.

METHODS

We recruited 92 NHs and 15 hospitals over four 12-month cohorts (2018-2022). The intervention focused on HAI prevention; practices to reduce infection transmission; and effective communication among hospitals, NHs, and state health departments. NHs submitted data on urinary tract infection, catheter-associated urinary tract infection, Clostridioides difficile infection, methicillin-resistant Staphylococcus aureus infection, catheter use, and urine cultures. Changes in outcomes before and during the coronavirus disease 2019 (COVID-19) pandemic were assessed using multilevel negative binomial regression.

RESULTS

A total of 63 NHs (68%) partnered with 18 hospitals and submitted 2 or more months of outcome data. Forty NHs participated before COVID-19 (contributing to 1 364 492 resident-days, 56 258 device-days), and 23 NHs participated during COVID-19 (566 142 resident-days, 29 568 device-days). While reductions in the incidence of urine cultures (incidence rate ratio [IRR], 0.37; P < .001) and total composite infections (IRR, 0.68; P = .03) were observed before COVID-19, these reductions were not sustained during the pandemic.

CONCLUSIONS

Prior to COVID-19 pandemic, collaboration between NHs and referring regional hospitals with engagement from state health departments led to reductions in NH urine cultures and total infections. Although the pandemic significantly impacted our study, we demonstrate the importance of regional networks in promoting infection prevention in NHs.

Association of Texas Nursing Home Non-COVID-19 Mortality Following Winter Storm Uri: A Mixed-Effects Spline Analysis

OBJECTIVES

Nursing Home residents are among the most at-risk populations during disasters. This study aimed to examine changes in nursing home non-COVID-19 mortality in Texas during Winter Storm Uri.

METHODS

Publicly available datasets were examined to determine whether nursing homes in Texas were associated with a change in non-COVID-19 nursing home mortality and a change in non-COVID-19 mortality differences compared to all other states in the 4 weeks following Winter Storm Uri. This study conducted a mixed-effects negative binomial spline analysis of non-COVID-19 mortality during the timeframe.

RESULTS

Although Texas suffered fewer deaths overall compared to the rest of the country, Texas experienced a 20% increase in non-COVID-19 deaths in the first 7 days of Winter Storm Uri, and a reduction in the change of deaths compared to all other states, indicating a 19% decrease in the difference between the 2 directly following the storm.

CONCLUSIONS

Texas suffered a significant increase in non-COVID-19 nursing home mortality during Winter Storm Uri, but overall lower levels of mortality compared to the rest of the nation. Future research should examine other states or counties that experienced significant energy outages for a more comprehensive understanding of the storm's effects.

Adaptive immune responses against common viruses are sustained and functional in end-of-life patients

Viral infections occur with increased frequency in patients in palliative care, impacting their quality of life and increasing mortality rates. Still, the function of the immune system has never been thoroughly studied at the end of life. We investigated virus-specific humoral and cellular immune responses in elderly end-of-life patients (n = 38) and controls (n = 28). Virus-specific T cell responses were characterized using high-parameter flow cytometry, after stimulation with cytomegalovirus (CMV) and human coronavirus OC43 peptides. Although some virus-specific T cells from patients exhibited elevated expression of costimulatory and coinhibitory molecules, their functional profile remained largely intact compared to controls. The expression of the cytotoxic markers Granzyme B, CD107a, and 2B4 on CMV-specific T cells correlated closely with survival time. Significantly, our data demonstrate that both humoral and cellular immunity remain responsive and functional against common viruses in end-of-life patients.

Place-Based Disparities Among Nursing Homes During the COVID-19 Pandemic: A Systematic Literature Review

Introduction

Disasters have disproportionately impacted nursing home (NH) residents. COVID-19 impacted NH more so than the community-dwelling population, but there was much variation in mortality rates among NH residents. These disparities have been studied, but place-based disparities have received less attention. Place-based disparities are differences in health due to physical location, including factors like rurality, local socioeconomic conditions, and the physical environment.

Methods

We searched three databases for peer-reviewed studies of place-based factors associated with mortality in U.S. NHs during the COVID-19 pandemic, ending in January 2024. Data were organized using the National Institute on Minority Health and Health Disparities research framework.

Results

We identified 27 articles that included individual, interpersonal, community, and societal place-based factors associated with mortality during the pandemic. Differences in mortality were related to local community socioeconomic factors, staff neighborhood socioeconomic factors, urbanity, community viral spread, and state-level factors, including political leaning and social distancing policies. Rurality was associated with lower mortality but was also associated with racial disparities.

Discussion

Place-based disparities at the individual, organizational, community, and societal levels were identified. Rurality and local COVID-19 spread were the most commonly studied place-based factors associated with NH deaths during the pandemic. Neighborhood factors may be most impactful through the impact on NH staff. Racial disparities were linked with location, highlighting the effects of historical systemic racism on NHs. Policies to protect NH residents during disasters must be sensitive to local characteristics.

Management of a COVID-19 outbreak using a multidisciplinary approach and infection prevention control practices at a community living center in Veterans Administration Hospital, North Texas

Background

The increase in severe acute respiratory coronavirus virus 2 (SARS-CoV-2) cases due to the omicron strain led to reduced acute care hospital beds at the Veterans Administration (VA) Hospital, North Texas; veterans with non-severe coronavirus disease 2019 (COVID-19) disease were managed at a community living center (CLC), a VA nursing home. The management of non-severe COVID-19 in VA nursing homes has not been extensively described.

Methods

We describe resident characteristics and outcomes, and infection control practices implemented during 2 COVID-19 outbreak periods (January 12-February 15, 2022, June 28-July 14, 2023). Serial testing of all CLC residents was conducted, and residents with polymerase chain reaction-confirmed SARS-CoV-2 (COVID-19) infection were included in the analysis. Resident data were ascertained from the COVID-19 facility dashboard and medical record system.

Results

From January 12 to February 15, 2022, and June 28-July 14, 2023, 62 adults residing at the CLC were diagnosed with COVID-19. Overall, the median age was 75 years [interquartile range, 71-80], and 57 (91.9%) were men. Residents were cohorted by COVID-19 test results. A multidisciplinary team was convened, and staff were fit tested for appropriate personal protective equipment (PPE) and received refresher training on hand hygiene, donning, and doffing of PPE. Thirty-seven (59.7%) residents were symptomatic. Overall, 55 (88.7%) residents were documented to have received the SARS-CoV-2 primary vaccination series. Most residents were managed at the CLC, while 12 (19.3%) were hospitalized in acute care.

Conclusions

It is feasible to manage high-risk residents with non-severe COVID-19 disease in a CLC utilizing a multidisciplinary approach and implementing Infection Prevention and Control strategies.

Measures to Prevent and Control COVID-19 in Skilled Nursing Facilities: A Scoping Review

Importance

Skilled nursing facilities (SNFs) experienced high mortality during the COVID-19 pandemic, leading them to adopt preventive measures to counteract viral spread. A critical appraisal of these measures is essential to support SNFs in managing future infectious disease outbreaks.

Objective

To perform a scoping review of data and evidence on the use and effectiveness of preventive measures implemented from 2020 to 2024 to prevent COVID-19 infection in SNFs in the US.

Evidence Review

Two analyses were performed. First, an analysis of the federal COVID-19 SNF Database was conducted to describe time trends in COVID-19 incidence, deaths, testing, vaccination, and treatment among SNF residents and staff, as well as shortages in staff and personal protective equipment (PPE). Then, a comprehensive literature search was conducted from May 2023 to April 2024 to identify high-quality evidence on the use and effectiveness of modifiable preventive measures used among SNF residents. Both nonpharmacologic (facility characteristics, PPE, cohorting, and isolation, visitation, staffing, testing) and pharmacologic (vaccination, treatment) measures were reviewed.

Findings

Nationwide data indicated early shortages of PPE, infrequent testing, and persistent staff shortages in SNFs. Other nonpharmacologic measures, such as visitor restrictions or ventilation modifications, were widely adopted but there were no available national data to quantify their effectiveness. These nonpharmacologic measures lacked high-quality studies to verify effectiveness. In contrast, the effectiveness of vaccination and antiviral treatment was shown in multiple studies. Evidence also showed associations between COVID-19 outcomes in residents and crowding, staff size, hours per residents and networks, and surveillance testing of residents and staff. Despite high initial uptake, up-to-date vaccination status was suboptimal in residents and staff from 2022 to 2024. Only a minority of infected residents received antiviral treatment.

Conclusions and Relevance

This scoping review found that although many preventive measures were implemented in SNFs in the US throughout the COVID-19 pandemic, few were based on clear evidence of their effectiveness. Pharmacologic measures, such as vaccination and antiviral treatment, had more robust evidence supporting their efficacy than nonpharmacologic interventions. Using the scarce resources and staff of SNFs on measures of questionable effectiveness could distract from known effective ones such as vaccination and antiviral treatment. When possible, implementation efforts should be commensurate with the demonstrated effectiveness of available preventive measures.

All-cause nursing home mortality rates have remained above pre-pandemic levels after accounting for decline in occupancy

During the initial year of the COVID-19 pandemic, a disproportionate share of COVID-19-related deaths occurred among nursing home residents. Initial estimates of all-cause mortality rates also spiked in early and late 2020 before falling to near or below historical rates by early 2021. During the first 3 years of the pandemic, the US nursing home resident population also decreased by 18% (239 000 fewer residents) compared with pre-pandemic levels. After accounting for these population changes, the all-cause nursing home mortality rate has remained above pre-pandemic levels through the middle of 2023. The peak was in December 2020 at 5692 deaths per 100 000 residents, which was 19% higher than estimates not accounting for the population decrease.

Loneliness in Seriously Ill Nursing Home Residents During the COVID-19 Pandemic

Background: Loneliness and social isolation coexist, making it difficult to study each separately. The COVID-19 lockdown provided an unprecedented and ethically viable opportunity to study loneliness in seriously ill nursing home residents under uniformly imposed social isolation conditions. Objective: To understand the phenomenon of loneliness of the seriously ill nursing home patients under a uniform social isolation condition imposed by the COVID-19 pandemic lockdown. Design: Cross-sectional, semi-structured interviews were tape-recorded, transcribed verbatim, and analyzed qualitatively using an inductive thematic analysis. The University of California, Los Angeles (UCLA) Three-Item Loneliness Scale was used to measure loneliness and any relationships between self-reported loneliness and isolation were elucidated. Setting/Participants: Thirty seriously ill nursing home residents living in complete social isolation imposed by the COVID-19 pandemic lockdown. Results: Thematic analysis identified four key themes: (1) Diverse perceptions about the impact of the COVID-19 lockdown, (2) regret over the missed opportunities for spending time with friends and family, (3) using electronic communication to maintain connections with loved ones, and (4) the impact of nursing home staff. In total, 50% of the participants reported feeling socially isolated, 60% patients reported loneliness, and 70% reported being adversely impacted by the lockdown. Patients who felt socially isolated also reported experiencing loneliness (Kendall's Tau = 0.61, 95% confidence interval [CI] = 0.30, 0.89, p < 0.01, large effect size). Persons from communities of color had higher median loneliness scores compared to Non-Hispanic Whites. Participants in the last year of life also reported higher levels of loneliness. Conclusion: A study of loneliness under uniform social isolation conditions in seriously ill nursing home patients showed a high prevalence of loneliness and a strong correlation between self-reported loneliness and social isolation, especially in persons from minority communities and those in the last year of life. In-person support provided by nursing home staff and virtual support from family was helpful to patients.

Nursing Home Oversight Trends During COVID-19 and the Current Survey Backlog in the United States

Since the Nursing Home Reform Act of 1987, regular oversight of United States nursing home activities has been a key strategy to ensure minimum levels of care quality for residents. Oversight activities have included "standard" survey visits - that is, annual unannounced visits by state survey agencies (SSAs) that directly observe resident care and interview nursing home residents and staff. This study provides an overview of these activities, focusing on oversight delays arising from policy changes brought on by the pandemic. Data from the Centers for Medicare and Medicaid Service's (CMS) Quality, Certification and Oversight Reports, Survey Summary Files, and Provider Information Files were used to measure delays in survey completion across SSAs. Study findings reveal delays in inspection activities, which have resulted in a large backlog of uncompleted standard surveys far exceeding regulatory requirements. These delays exist across nursing homes with high and low levels of quality. As SSAs work through the backlog of surveys, they may prioritize the completion of surveys based on prior performance. This precedent may be expanded as CMS explores opportunities to produce processes that target the completion of surveys in the poorest performing nursing homes.

Model-based estimates of age-structured SARS-CoV-2 epidemiology in households

BACKGROUND

Understanding how infectious disease transmission varies from person to person, including associations with age and contact behavior, can help design effective control strategies. Within households, transmission may be highly variable because of differing transmission risks by age, household size, and individual contagiousness. Our aim was to disentangle those factors by fitting mathematical models to SARS-CoV-2 household survey and serologic data.

METHODS

We surveyed members of 3,381 Utah households from January-April 2021 and performed SARS-CoV-2 antibody testing on all available members. We paired these data with a probabilistic model of household importation and transmission composed of a novel combination of transmission variability and age- and size-structured heterogeneity. We calculated maximum likelihood estimates of mean and variability of household transmission probability between household members in different age groups and different household sizes, simultaneously with importation probability and probabilities of false negative and false positive test results.

RESULTS

12.8% of individual participants, residing in 17.4% of the participating households, showed serologic evidence of prior infection or reported a prior positive test on the survey. Serologically positive individuals in younger age groups were less likely than older adults to have tested positive during their infection according to our survey results. Our model results suggested that adolescents and young adults (ages 13-24) acquired SARS-CoV-2 infection outside the household at a rate substantially higher than younger children and older adults. Our estimate of the household secondary attack rate (HSAR) among adults aged 45 and older exceeded HSARs to and/or from younger age groups at a given household size. We found lower HSAR in households with more members, independent of age differences. The age-specific HSAR patterns we found could not be explained by age-dependent biological susceptibility and transmissibility alone, suggesting that age groups contacted each other at different rates within households.

CONCLUSIONS

We disentangled several factors contributing to age-specific infection risk, including non-household exposure, within-household exposure to specific age groups, and household size. Within-household contact rate differences played a significant role in driving household transmission epidemiology. These findings provide nuanced insights for understanding community outbreak patterns and mechanisms of differential infection risk.

Effects of essential caregiver policies on COVID-19 and non-COVID-19 deaths in nursing homes

Federal authorities banned nursing home visitation in the early days of the coronavirus disease 2019 (COVID-19) pandemic. However, there was growing concern that physical isolation may have unintended harms on nursing home residents. Thus, nursing homes and policymakers faced a tradeoff between minimizing COVID-19 outbreaks and limiting the unintended harms. Between June 2020 and January 2021, 17 states implemented Essential Caregiver policies (ECPs) allowing nursing home visitation by designated family members or friends under controlled circumstances. Using the Nursing Home COVID-19 Public File and other relevant data, we analyze the effects of ECPs on deaths among nursing home residents. We exploit variation in the existence of ECPs across states and over time, finding that these policies effectively reduce both non-COVID-19 and COVID-19 deaths, resulting in a decrease in total deaths. These effects are larger for states that implemented policies mandatorily or without restrictions, indicating a dose-response relationship. These policies reduce non-COVID-19 deaths in facilities with higher quality or staffing levels, while reducing COVID-19 deaths in facilities with lower quality or staffing levels. Our findings support the use and expansion of ECPs to balance resident safety and the need for social interaction and informal care during future pandemics.

Impacts of the COVID-19 pandemic on healthcare utilization among Home Care Aides in Washington, U.S

This study assesses the impacts of the COVID-19 pandemic on healthcare access for Washington State Home Care Aides (HCAs). Analyzing 62 months of medical claims data from over 35,000 HCAs, the research reveals significant healthcare disruptions during the early pandemic, especially in outpatient settings. However, healthcare utilization rebounded swiftly, surpassing pre-COVID levels as new variants emerged. Furthermore, the analysis indicated significant decreases in healthcare utilization for respiratory conditions in later stages of the pandemic, suggesting that the implementation of non-pharmaceutical and pharmaceutical interventions played a crucial role in preventing the transmission of respiratory diseases. Notably, behavioral health-related utilization among HCAs increased significantly throughout most pandemic phases, underscoring the importance of enhancing behavioral health support during public health crises. This research represents the first comprehensive study unveiling the effects of the COVID-19 pandemic on HCAs' healthcare access and opening avenues for further research and policy development to support this essential workforce.

Medical visits and mortality among dementia patients during the COVID-19 pandemic compared to rates predicted from 2019

BACKGROUND

During the COVID-19 pandemic, patients with Alzheimer's disease and related dementias (ADRD) were especially vulnerable, and modes of medical care delivery shifted rapidly. This study assessed the impact of the pandemic on care for people with ADRD, examining the use of primary, emergency, and long-term care, as well as deaths due to COVID and to other causes.

METHODS

Among 4.2 million beneficiaries aged 66 and older with ADRD in traditional Medicare, monthly deaths and claims for routine care (doctors' office and telehealth visits), inpatient/emergency department (ED) visits, and long-term care facility use from March or June 2020 through December 2022 are compared to monthly rates predicted from January-December 2019 using OLS and logistic/negative binomial regression. Correlation analyses examine the association between excess deaths - due to COVID and non-COVID causes - and changes in care use in the beneficiary's state of residence.

RESULTS

Increased telehealth visits more than offset reduced office visits, with primary care visits increasing overall (by 9 percent from June 2020 onward relative to the predicted rate from 2019, p < .001). Emergency/inpatient visits declined (by 9 percent, p < .001) and long-term care facility use declined, remaining 14% below the 2019 trend from June 2020 onward (p < .001). Both COVID and non-COVID deaths rose, with 231,000 excess deaths (16% above the prediction from 2019), over 80 percent of which were attributable to COVID. Excess deaths were higher among women, non-White patients, those in rural and isolated zip codes, and those with higher social deprivation index scores. States with the largest increases in primary care visits had the lowest excess deaths (correlation -0.49).

CONCLUSIONS

Older adults with ADRD had substantial deaths above pre-pandemic projections during the COVID-19 pandemic, 80 percent of which were attributed to COVID-19. Routine care increased overall due to a dramatic increase in telehealth visits, but this was uneven across states, and mortality rates were significantly lower in states with higher than pre-pandemic visits.

Changes in Physical Function and Physical Therapy Use in Older Veterans Not Infected by CoVID-19 Residing in Community Living Centers during the CoVID-19 Pandemic

OBJECTIVES

Examine physical function change and physical therapy (PT) use in short-stay and long-stay residents not infected by CoVID-19 within Veterans Affairs (VA) Community Living Centers (CLCs).

DESIGN

Retrospective cohort study using Minimum Data Set (MDS) 3.0 assessments.

SETTINGS AND PARTICIPANTS

12,606 Veterans in 133 VA CLCs between September 2019 and September 2020.

METHODS

Difference in physical function [MDS Activities of Daily Living Score (MDS-ADL)] and PT use (minutes in past 7 days) from admission to last assessment in a period were compared between the pre-CoVID-19 (September 2019 to February 2020) and early CoVID-19 (April 2020 to September 2020) period using mixed effects regression with multivariable adjustment. Assessments after a positive CoVID-19 test were excluded. Differences were examined in the sample and repeated after stratifying into short- and long-stay stratums.

RESULTS

Veterans admitted during early CoVID-19 had more comorbidities, worse MDS-ADL scores, and were more often long-stay residents compared with those admitted during pre-CoVID-19. In comparison to pre-CoVID-19, Veterans in VA CLCs during early CoVID-19 experienced greater improvements in their MDS-ADL (-0.49 points, 95% CI -0.27, -0.71) and received similar minutes of therapy (2.6 minutes, 95% CI -0.8, 6.0). Stratification revealed short-stay residents had relative improvements in their function (-0.69 points, 95% CI -0.44, -0.94) and higher minutes of PT (5.1 minutes, 95% CI 0.9, 9.2) during early CoVID-19 whereas long-stay residents did not see differences in functional change (0.08 points, 95% CI -0.36, 0.51) or PT use (-0.6 minutes, 95% CI -6.1, 4.9).

CONCLUSIONS AND IMPLICATIONS

During early CoVID-19, physical function improved while the amount of PT received was maintained compared with pre-CoVID-19 for Veterans in VA CLCs. Short-stay residents experienced greater improvements in physical function and increases in PT use. These findings may be partly due to selection bias relating to Veterans admitted to CLCs during early CoVID-19.

Variation in Excess Mortality Across Nursing Homes in the Netherlands During the COVID-19 Pandemic

OBJECTIVES

Nursing home residents constituted a vulnerable population during the COVID-19 pandemic, and half of all cause-attributed COVID-19 deaths occurred within nursing homes. Yet, given the low life expectancy of nursing home residents, it is unclear to what extent COVID-19 mortality increased overall mortality within this population. Moreover, there might have been differences between nursing homes in their ability to protect residents against excess mortality. This article estimates the number of excess deaths among Dutch nursing home residents during the pandemic, the variation in excess deaths across nursing homes, and its relationship with nursing home characteristics.

DESIGN

Retrospective, use of administrative register data.

SETTING AND PARTICIPANTS

All residents (N = 194,432) of Dutch nursing homes (n = 1463) in 2016-2021.

METHODS

We estimated the difference between actual and predicted mortality, pooled at the nursing home level, which provided an estimate of nursing home-specific excess mortality corrected for resident case-mix differences. We show the variation in excess mortality across nursing homes and relate this to nursing home characteristics.

RESULTS

In 2020 and 2021, the mortality probability among nursing home residents was 4.0 and 1.6 per 100 residents higher than expected. There was considerable variation in excess deaths across nursing homes, even after correcting for differences in resident case mix and regional factors. This variation was substantially larger than prepandemic mortality and was in 2020 related to prepandemic spending on external personnel and satisfaction with the building, and in 2021 to prepandemic staff absenteeism.

CONCLUSIONS AND IMPLICATIONS

The variation in excess mortality across nursing homes was considerable during the COVID-19 pandemic, and larger compared with prepandemic years. The association of excess mortality with the quality of the building and spending on external personnel indicates the importance of considering differences across nursing home providers when designing policies and guidelines related to pandemic preparedness.

COVID19 and the Follies of History: Forebodings that Forewarned is Not Forearmed

COVID-19 was the first pandemic of the internet age. Beginning at a time of great societal division in the United States (and globally), pandemic responses were further beleaguered by the viral proliferation of information, disinformation, and propaganda-collectively, an "infodemic." Polarized, blinkered views of the crisis precluded a balanced consideration of objectives, opportunities, and ineluctable trade-offs between the risks of actions and corresponding inactions. The results were lapses in both directions, greatly amplifying the pandemic toll. Persistence of this costly fractiousness is now spawning monocular critiques of the pandemic response, with neglect of essential nuance. There is a better pandemic that might have been, and the chance for far better responses to the next- but only if the follies of this history are lessons learned and applied. Failing that, the risk looms that having been amply forewarned of our liabilities, we will fail to be forearmed.

Describing Psychiatric Symptoms Experienced by Older Adults in a Skilled Nursing Facility During the COVID-19 Pandemic

There is limited investigation about psychiatric symptoms experienced by older adults with mental health conditions or neurocognitive ones residing in a skilled nursing facility during the COVID-19 pandemic. The objective of this descriptive-design study was to describe the psychiatric symptoms from the year before COVID-19 pandemic to the 1st year of the pandemic for older adults with a mental health condition or a neurocognitive one residing in a skilled nursing facility. A database (n = 84) was established from the extraction of already collected data on the assessment of older adults (n = 84) with mental health conditions or neurocognitive ones living in one skilled nursing facility. The timeframe was from March 1, 2019 to February 28, 2021, eight quarters of extracted data. Psychiatric symptoms were impaired decision making, altered level of consciousness, disorganized thinking, understanding or comprehension, disruptive behaviors, delirium, delusions, hallucinations, inattentiveness, impaired cognition, and depression. Data were analyzed with descriptive statistics. Participants had a mean age of 74.2 ± 10.8. A description of the psychiatric symptoms over the 2 years was a decrease in the level of understanding along with an increase in delusions, disruptive behaviors (physical and verbal), impaired decision making, cognitive impairment, and inattentiveness. The findings focus on the description of the psychiatric symptoms associated with the COVID-19 pandemic. These findings relate to the first step to address a gap in the literature about psychiatric symptoms and COVID-19 for nursing home residents. Future longitudinal and multisite studies are warranted to expound on these findings and the described psychiatric symptoms over time.

Implementation of COVID-19 infection control best practices in nursing homes amid the pandemic

BACKGROUND

The COVID-19 pandemic has claimed around 170,000 lives among nursing home residents and staff in the United States through April 2023. In a cluster randomized controlled trial (RCT) with 136 nursing homes, we delivered training to improve COVID-19 infection control best practices. We sought to assess the implementation of infection control practices in participating nursing homes.

METHODS

Concurrent with the delivery of the RCT (January-November 2021), we surveyed nursing home administrators (NHAs, n = 38) at baseline and 6-month follow-up. Using validated items from the Centers for Disease Control and Prevention (CDC), the surveys inquired about 80 infection control best-practice activities (yes/no). The survey also asked seven scales corresponding to inner setting factors that may have impacted implementation. We assessed changes in infection control practices and inner setting factors between baseline and 6-month follow-up.

RESULTS

Overall, the implementation of 11 best practices changed over time. NHAs reported an increase in the availability of informational materials for residents and families (84% vs. 100%, p = 0.031), the use of alcohol-based hand sanitizer over soap (76% vs. 97%, p = 0.008), and the development of contingency plans for increased postmortem care (53% vs. 82%, p = 0.013). The implementation of four best-practice visitation policies and three communal restrictions decreased between baseline and 6-month follow-up (all p < 0.05). Regarding inner setting factors, only culture stress (perceived strain, stress, and role overload) increased between surveys (mean scores: 3.14 vs. 3.58, p = 0.004).

CONCLUSION

This study was among the first to report changes in implementing COVID-19 infection control best practices in nursing homes amid the pandemic. Culture stress was an important inner setting factor that may have impacted implementation activities.

TRIAL REGISTRATION

NCT04499391 DATE OF REGISTRATION: August 3rd, 2020.

Cause of Death by Race and Ethnicity in Minnesota Before and During the COVID-19 Pandemic, 2019-2020

OBJECTIVES

To measure changes in cause of death dynamics in 2019 and 2020 and the relationship between the concurrent occurrence of the COVID-19 pandemic and mortality outcome by race and ethnicity.

PATIENTS AND METHODS

We used resident mortality data from the Minnesota Department of Health (MDH) to conduct a retrospective statistical analysis of deaths in Minnesota in 2019 relative to 2020 to assess changes in mortality in a pre-pandemic and pandemic period.

RESULTS

COVID-19 strongly contributed to ethnicity-related mortality disparities in Minnesota. Not only was there a greater proportion of COVID-19 decedents within Black and Hispanic populations, but their average decedent age was markedly lower relative to the White population. The Black population experienced a disproportionate increase in decedents with a 34% increase during 2020 compared to 2019.

CONCLUSIONS

This retrospective analysis of death dynamics and mortality outcomes in Minnesota from 2019 to 2020 demonstrated an increase in adverse mortality outcomes relative to the pre-pandemic period that disproportionately impacted Black and Hispanic minority populations.

US State Restrictions and Excess COVID-19 Pandemic Deaths

Importance

Despite considerable prior research, it remains unclear whether and by how much state COVID-19-related restrictions affected the number of pandemic deaths in the US.

Objective

To determine how state restrictions were associated with excess COVID-19 deaths over a 2-year analysis period.

Design, Setting, and Participants

This was a cross-sectional study using state-level mortality and population data from the US Centers for Disease Control and Prevention for 2020 to 2022 compared with baseline data for 2017 to 2019. Data included the total US population, with separate estimates for younger than 45 years, 45 to 64 years, 65 to 84 years, and 85 years or older used to construct age-standardized measures. Age-standardized excess mortality rates and ratios for July 2020 to June 2022 were calculated and compared with prepandemic baseline rates. Excess death rates and ratios were then regressed on single or multiple restrictions, while controlling for excess death rates or ratios, from March 2020 to June 2020. Estimated values of the dependent variables were calculated for packages of weak vs strong state restrictions. Behavioral changes were investigated as a potential mechanism for the overall effects. Data analyses were performed from October 1, 2023, to June 13, 2024.

Exposures

Age and cause of death.

Main Outcomes

Excess deaths, age-standardized excess death rates per 100 000, and excess death ratios.

Results

Mask requirements and vaccine mandates were negatively associated with excess deaths, prohibitions on vaccine or mask mandates were positively associated with death rates, and activity limitations were mostly not associated with death rates. If all states had imposed restrictions similar to those used in the 10 most restrictive states, excess deaths would have been an estimated 10% to 21% lower than the 1.18 million that actually occurred during the 2-year analysis period; conversely, the estimates suggest counterfactual increases of 13% to 17% if all states had restrictions similar to those in the 10 least-restrictive states. The estimated strong vs weak state restriction difference was 271 000 to 447 000 deaths, with behavior changes associated with 49% to 79% of the overall disparity.

Conclusions and Relevance

This cross-sectional study indicates that stringent COVID-19 restrictions, as a group, were associated with substantial decreases in pandemic mortality, with behavior changes plausibly serving as an important explanatory mechanism. These findings do not support the views that COVID-19 restrictions were ineffective. However, not all restrictions were equally effective; some, such as school closings, likely provided minimal benefit while imposing substantial cost.

Chronic Obstructive Pulmonary Disease and the Omicron Variant of COVID-19 Prognosis: A Retrospective Cohort Study

BACKGROUND AND AIM

This retrospective cohort study aimed to investigate the association between chronic obstructive pulmonary disease (COPD) and the prognosis of COVID-19 patients infected with the Omicron variant. The primary objective was to determine if COVID-19 patients with COPD had higher mortality rates compared to those without COPD. Secondary objectives included assessing the risk of respiratory failure, hospital stay length, intensive care unit (ICU) admission, and oxygen requirements in COPD patients with COVID-19.

MATERIALS AND METHODS

The study included 2761 COVID-19 patients admitted to the Princess Margaret Hospital, Hong Kong, between January 1 and June 30, 2022. Among them, 7.4% (n = 205) had COPD. Demographic and clinical data, including vaccination status and comorbidities, were collected. The primary outcome was 30-day mortality, and secondary outcomes included respiratory support requirement, hospital stay length, and ICU admission. Logistic regression analyses were conducted, adjusting for potential confounders.

RESULTS

COPD did not independently increase the risk of COVID-19 mortality after adjusting for confounders. Instead, older age, male sex, incomplete vaccination, long-term oxygen therapy use, and specific comorbidities were identified as significant predictors of 30-day mortality. COPD patients were more likely to require oxygen and noninvasive ventilation, but there were no significant differences in other secondary outcomes compared to non-COPD patients.

CONCLUSION

COPD itself was not an independent risk factor for COVID-19 mortality. Age, sex, vaccination status, comorbidities, and long-term oxygen therapy use were important predictors of mortality. These findings underscore the importance of considering multiple factors when assessing the impact of COPD on COVID-19 prognosis, particularly with the Omicron variant.

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

OBJECTIVES

Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study was to assess excess mortality among AL and NH residents with and without dementia or significant cognitive impairment in Alberta, Canada, during the first 2 years of the COVID-19 pandemic, relative to the 3 years before.

DESIGN

Population-based, retrospective cohort study.

SETTING AND PARTICIPANTS

Residents who lived in an AL or NH facility operated or contracted by the Provincial health care system to provide publicly funded care in Alberta between January 1, 2017, and December 31, 2021.

METHODS

We used administrative health care data, including Resident Assessment Instrument - Home Care (RAI-HC, AL) and Minimum Data Set 2.0 (RAI-MDS 2.0, NHs) records, linked with data on residents' vital statistics, COVID-19 testing, emergency room registrations, and hospital stays. The outcome was excess deaths during COVID-19 (ie, the number of deaths beyond that expected based on pre-pandemic data), estimated, using overdispersed Poisson generalized linear models.

RESULTS

Overall, the risk of excess mortality [adjusted incidence rate ratio (95% confidence interval)] was higher in ALs than in NHs [1.20 (1.14-1.26) vs 1.10 (1.07-1.13)]. Weekly peaks in excess deaths coincided with COVID-19 pandemic waves and were higher among those with diagnosed dementia or significant cognitive impairment in both, AL and NHs.

CONCLUSIONS AND IMPLICATIONS

Finding excess mortality within both AL and NH facilities should lead to greater focus on infection prevention and control measures across all forms of congregate housing for vulnerable older adults. The specific needs of residents with dementia in particular will have to be addressed.

Comparing multiple infection control measures in a nursing home setting: a simulation study

OBJECTIVE

Compare the effectiveness of multiple mitigation measures designed to protect nursing home residents from infectious disease outbreaks.

DESIGN

Agent-based simulation study.

SETTING

Simulation environment of a small nursing home.

METHODS

We collected temporally detailed and spatially fine-grained location information from nursing home healthcare workers (HCWs) using sensor motes. We used these data to power an agent-based simulation of a COVID-19 outbreak using realistic time-varying estimates of infectivity and diagnostic sensitivity. Under varying community prevalence and transmissibility, we compared the mitigating effects of (i) regular screening and isolation, (ii) inter-resident contact restrictions, (iii) reduced HCW presenteeism, and (iv) modified HCW scheduling.

RESULTS

Across all configurations tested, screening every other day and isolating positive cases decreased the attack rate by an average of 27% to 0.501 on average, while contact restrictions decreased the attack rate by an average of 35%, resulting in an attack rate of only 0.240, approximately half that of screening/isolation. Combining both interventions impressively produced an attack rate of only 0.029. Halving the observed presenteeism rate led to an 18% decrease in the attack rate, but if combined with screening every 6 days, the effect of reducing presenteeism was negligible. Altering work schedules had negligible effects on the attack rate.

CONCLUSIONS

Universal contact restrictions are highly effective for protecting vulnerable nursing home residents, yet adversely affect physical and mental health. In high transmission and/or high community prevalence situations, restricting inter-resident contact to groups of 4 was effective and made highly effective when paired with weekly testing.

Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities

Importance

During the COVID-19 pandemic, stabilized COVID-19-positive patients were discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges generated controversy due to fears of seeding outbreaks, but there is little empirical evidence to inform policy.

Objective

To assess the association between the admission to SNFs of COVID-19-positive patients and subsequent COVID-19 cases and death rates among residents.

Design, Setting, and Participants

This cohort study analyzed survey data from the National Healthcare Safety Network of the Centers for Disease Control and Prevention. The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities (ie, with initial admission of COVID-19-positive patients) were matched to control facilities (ie, without initial admission of COVID-19-positive patients) in the same county and with similar preadmission case counts. Data were analyzed from June 2023 to February 2024.

Exposure

The week of the first observable admission of COVID-19-positive patients (defined as those previously diagnosed with COVID-19 and continued to require transmission-based precautions) during the study period.

Main Outcomes and Measures

Weekly counts of new cases of COVID-19, COVID-19-related deaths, and all-cause deaths per 100 residents in the week prior to the initial admission. A stacked difference-in-differences approach was used to compare outcomes for 10 weeks before and 15 weeks after the first admission. Additional analyses examined whether outcomes differed in facilities with staff or personal protective equipment (PPE) shortages.

Results

A matched group of 264 exposed facilities and 518 control facilities was identified. Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI, 2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19-related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI, 2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared with those without such shortages.

Conclusion

This cohort study suggests that admission of COVID-19-positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection-control best practices as they continue to face COVID-19 strains and other respiratory diseases.

Strengths, challenges, and strategies for implementing pragmatic multicenter randomized controlled trials (RCTs): example of the Personalized Citizen Assistance for Social Participation (APIC) trial

BACKGROUND

Randomized controlled trials (RCTs) are rigorous scientific research designs for evaluating intervention effectiveness. However, implementing RCTs in a real-world context is challenging. To develop strategies to improve its application, it is essential to understand the strengths and challenges of this design. This study thus aimed to explore the strengths, challenges, and strategies for improving the implementation of a pragmatic multicenter, prospective, two-arm RCT evaluating the effects of the Personalized Citizen Assistance for Social Participation (Accompagnement-citoyen Personnalisé d'Intégration Communautaire: APIC; weekly 3-h personalized stimulation sessions given by a trained volunteer over a 12-month period) on older adults' health, social participation, and life satisfaction.

METHODS

A multiple case study was conducted with 14 participants, comprising one research assistant, seven coordinators, and six managers of six community organizations serving older adults, who implemented the APIC in the context of a RCT. Between 2017 and 2023, qualitative data were extracted from 24 group meetings, seven semi-directed interviews, emails exchanged with the research team, and one follow-up document.

RESULTS

Aged between 30 and 60 (median ± SIQR: 44.0 ± 6.3), most participants were women from organizations already offering social participation interventions for older adults and working with the public sector. Reported strengths of this RCT were its relevance in assessing an innovative intervention to support healthy aging, and the sharing of common goals, expertise, and strategies with community organizations. Challenges included difficulties recruiting older adults, resistance to potential control group assignments, design complexity, and efforts to mobilize and engage volunteers. The COVID-19 pandemic lockdown and health measures exacerbated challenges related to recruiting older adults and mobilizing volunteers and complicated delivery of the intervention. The strategies that mostly overcame difficulties in recruiting older adults were reducing sample size, simplifying recruitment procedures, emphasizing the health follow-up, extending partnerships, and recognizing and supporting volunteers better. Because of the lockdown and physical distancing measures, the intervention was also adapted for remote delivery, including via telephone or videoconferencing.

CONCLUSION

Knowledge of the strengths and challenges of pragmatic RCTs can contribute to the development of strategies to facilitate implementation studies and better evaluate health and social participation interventions delivered under real-life conditions.

TRIAL REGISTRATION

NCT03161860; Pre-results. Registered on May 22, 2017.

Association of institutional masking policies with healthcare-associated SARS-CoV-2 infections in Swiss acute care hospitals during the BA.4/5 wave (CH-SUR study): a retrospective observational study

BACKGROUND

In the initial phase of the SARS-CoV-2 pandemic, masking has been widely accepted in healthcare institutions to mitigate the risk of healthcare-associated infection. Evidence, however, is still scant and the role of masks in preventing healthcare-associated SARS-CoV-2 acquisition remains unclear.We investigated the association of variation in institutional mask policies with healthcare-associated SARS-CoV-2 infections in acute care hospitals in Switzerland during the BA.4/5 2022 wave.

METHODS

SARS-CoV-2 infections in hospitalized patients between June 1 and September 5, 2022, were obtained from the "Hospital-based surveillance of COVID-19 in Switzerland"-database and classified as healthcare- or community-associated based on time of disease onset. Institutions provided information regarding institutional masking policies for healthcare workers and other prevention policies. The percentage of healthcare-associated SARS-CoV-2 infections was calculated per institution and per type of mask policy. The association of healthcare-associated SARS-CoV-2 infections with mask policies was tested using a negative binominal mixed-effect model.

RESULTS

We included 2'980 SARS-CoV-2 infections from 13 institutions, 444 (15%) were classified as healthcare-associated. Between June 20 and June 30, 2022, six (46%) institutions switched to a more stringent mask policy. The percentage of healthcare-associated infections subsequently declined in institutions with policy switch but not in the others. In particular, the switch from situative masking (standard precautions) to general masking of HCW in contact with patients was followed by a strong reduction of healthcare-associated infections (rate ratio 0.39, 95% CI 0.30-0.49). In contrast, when compared across hospitals, the percentage of health-care associated infections was not related to mask policies.

CONCLUSIONS

Our findings suggest switching to a more stringent mask policy may be beneficial during increases of healthcare-associated SARS-CoV-2 infections at an institutional level.

Geospatial patterns of excess mortality in Belgium: Insights from the first year of the COVID-19 pandemic

OBJECTIVES

Belgium experienced multiple COVID-19 waves that hit various groups in the population, which changed the mortality pattern compared to periods before the pandemic. In this study, we investigated the geographical excess mortality trend in Belgium during the first year of the COVID-19 pandemic.

METHODS

We retrieved the number of deaths and population data in 2020 based on gender, age, and municipality of residence, and we made a comparison with the mortality data in 2017-2019 using a spatially discrete model.

RESULTS

Excess mortality was significantly associated with age, gender, and COVID-19 incidence, with larger effects in the second half of 2020. Most municipalities had higher risks of mortality with a number of exceptions in the northeastern part of Belgium. Some discrepancies in excess mortality were observed between the north and south regions.

CONCLUSIONS

This study offers useful insight into excess mortality and will aid local and regional authorities in monitoring mortality trends.

Drivers of COVID-19 Outcomes in Long-Term Care Facilities Using Multi-Level Analysis: A Systematic Review

This study aimed to identify the individual, organizational, and environmental factors which contributed to COVID-19-related outcomes in long-term care facilities (LTCFs). A systematic review was conducted to summarize and synthesize empirical studies using a multi-level analysis approach to address the identified influential factors. Five databases were searched on 23 May 2023. To be included in the review, studies had to be published in peer-reviewed journals or as grey literature containing relevant statistical data. The Joanna Briggs Institute critical appraisal tool was employed to assess the methodological quality of each article included in this study. Of 2137 citations identified after exclusions, 99 records met the inclusion criteria. The predominant individual, organizational, and environmental factors that were most frequently found associated with the COVID-19 outbreak comprised older age, higher dependency level; lower staffing levels and lower star and subset domain ratings for the facility; and occupancy metrics and co-occurrences of outbreaks in counties and communities where the LTCFs were located, respectively. The primary individual, organizational, and environmental factors frequently linked to COVID-19-related deaths comprised age, and male sex; higher percentages of racial and ethnic minorities in LTCFs, as well as ownership types (including private, for-profit, and chain membership); and higher occupancy metrics and LTCF's size and bed capacity, respectively. Unfolding the risk factors collectively may mitigate the risk of outbreaks and pandemic-related mortality in LTCFs during future endemic and pandemics through developing and improving interventions that address those significant factors.

Revealing the divide: Contrasting COVID-19 outcomes in Green Houses and traditional nursing homes in the United States

INTRODUCTION

This study compares COVID-19 case and mortality rates in Green Houses (GHs) and traditional nursing homes (NHs) during the COVID-19 pandemic.

METHODS

CMS data from 10 states (June 2020 to September 2022) were analyzed for GHs (n = 19), small NHs (n = 266), and large NHs (n = 2,932). Multivariate Poisson regressions with GEE were used.

RESULTS

Participants (mean age 73.4) were predominantly female (57.8 %) and White (78.2 %). Small and large NHs had a significantly higher COVID-19 case risk (RR = 1.61; 95 % CI 1.25-2.08 and RR = 1.75; 95 % CI 1.36-2.24, respectively) compared to GHs. Large NHs also had an increased mortality risk (RR = 1.67; 95 % CI 1.01-2.77) compared to GHs, with no difference found between GHs and small NHs.

CONCLUSION

After adjusting for age, gender, and ADL disability, GHs demonstrated lower COVID-19 case and mortality rates than traditional NHs, likely due to their unique features, including person-centered care, size, and physical structure.

Timing of Goals of Care Discussions in Nursing Homes: A Systematic Review

OBJECTIVES

Discussions between health professionals and nursing home (NH) residents or their families about the current or future goals of health care may be associated with better outcomes at the end of life (EOL), such as avoidance of unwanted interventions or death in hospital. The timing of these discussions varies, and it is possible that their influence on EOL outcomes depends on their timing. This study synthesized current evidence concerning the timing of goals of care (GOC) discussions in NHs and its impact on EOL outcomes.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Adult populations in NH settings.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Embase, and Cumulative Index of Nursing and Allied Health from January 2000 to September 2022. We included studies that examined timing of GOC discussions in NHs, were peer-reviewed, and published in English. Quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Screening of 1930 abstracts yielded 149 papers that were evaluated for eligibility. Of the 18 articles, representing 16 distinct studies that met review criteria, 12 evaluated the timing of advance directives. There was variation in the timing of GOC discussions and compared with discussions that occurred within a month of death, earlier discussions (eg, at the time of facility admission) were associated with lower rates of hospitalization at the EOL and lower health care costs.

CONCLUSIONS AND IMPLICATIONS

The timing of GOC discussions in NHs varies and evidence suggests that late discussions are associated with poorer EOL outcomes. The benefits of goal-concordant care may be enhanced by earlier and more frequent discussions. Future studies should examine the optimal timing for GOC discussions in the NH population.

The Evolution of Excess Deaths in the United States During the First 2 Years of the COVID-19 Pandemic

Understanding consequences of the COVID-19 pandemic requires information on the excess mortality resulting from it. Multiple studies have examined excess deaths during the pandemic's initial stages, but how these have changed over time is unclear. National- and state-level death counts and population data from 2009 to 2022 were used in this analysis to evaluate excess fatalities from March 2020 to February 2021 and March 2021 to February 2022, with deaths from earlier years used to project baseline counts. The outcomes were total, group-specific, cause-specific, and age-by-cause excess fatalities, and numbers and percentages directly involving COVID-19. Excess deaths declined from 655,735 (95% confidence interval: 619,028, 691,980) during the first pandemic year to 586,505 (95% confidence interval: 532,823, 639,205) in the second. The reductions were particularly large for Hispanics, Blacks, Asians, seniors, and residents of states with high vaccination rates. Excess deaths increased from the first to second year for persons younger than 65 years and in low-vaccination states. Excess mortality from some diseases declined, but those from alcohol, drug, vehicle, and homicide causes likely increased between the first and second pandemic year, especially for prime-age and younger individuals. The share of excess fatalities involving COVID-19 decreased modestly over time, with little change in its role as an underlying versus contributing cause of death.

Exploring the impact of population ageing on the spread of emerging respiratory infections and the associated burden of mortality

BACKGROUND

Increasing life expectancy and persistently low fertility levels have led to old population age structures in most high-income countries, and population ageing is expected to continue or even accelerate in the coming decades. While older adults on average have few interactions that potentially could lead to disease transmission, their morbidity and mortality due to infectious diseases, respiratory infections in particular, remain substantial. We aim to explore how population ageing affects the future transmission dynamics and mortality burden of emerging respiratory infections.

METHODS

Using longitudinal individual-level data from population registers, we model the Belgian population with evolving age and household structures, and explicitly consider long-term care facilities (LTCFs). Three scenarios are presented for the future proportion of older adults living in LTCFs. For each demographic scenario, we simulate outbreaks of SARS-CoV-2 and a novel influenza A virus in 2020, 2030, 2040 and 2050 and distinguish between household and community transmission. We estimate attack rates by age and household size/type, as well as disease-related deaths and the associated quality-adjusted life-years (QALYs) lost.

RESULTS

As the population is ageing, small households and LTCFs become more prevalent. Additionally, families with children become smaller (i.e. low fertility, single-parent families). The overall attack rate slightly decreases as the population is ageing, but to a larger degree for influenza than for SARS-CoV-2 due to differential age-specific attack rates. Nevertheless, the number of deaths and QALY losses per 1,000 people is increasing for both infections and at a speed influenced by the share living in LTCFs.

CONCLUSION

Population ageing is associated with smaller outbreaks of COVID-19 and influenza, but at the same time it is causing a substantially larger burden of mortality, even if the proportion of LTCF residents were to decrease. These relationships are influenced by age patterns in epidemiological parameters. Not only the shift in the age distribution, but also the induced changes in the household structures are important to consider when assessing the potential impact of population ageing on the transmission and burden of emerging respiratory infections.

The impact of protective measures against COVID-19 on the wellbeing of residents in nursing homes and their relatives: a rapid review

During the COVID-19 pandemic and compared to other population groups, older people were at a heightened risk of developing lethal disease symptoms. Thus, many countries put in place protective measures to protect this "at-risk" population, especially in nursing homes, to limit the number of infections. These measures consisted mostly in the absence of social gatherings, the impossibility for relatives to enter the nursing homes, limitations in group activities, and the ban of group-eating. Although these measures were helpful to mitigate the spread of the disease, they also induced long periods of social isolation for the residents of nursing homes. This could have impacted the wellbeing and quality of life of residents and their relatives, with a possible impact on the overall health of residents. We designed this rapid review to investigate the literature on the impact of COVID-19 protective measures in nursing homes on the quality of life, wellbeing and physical health of residents and their relatives. Our results showed that most of the articles included in the review, either using qualitative or quantitative methods, evidenced a detrimental impact of protective measures on resident's and their relatives' wellbeing. We argue that, in the event of a new pandemic similar to the COVID-19, protective measures should also take into account their psychological impact, and not only their physical impact.

Perceived Work Environment, Educational Status, Staffing Levels, and Work Outcomes in Long-Term Care Settings During COVID-19

OBJECTIVES

Coronavirus disease (COVID-19) has severely affected older residents in long-term care (LTC) settings. However, care workers' perceptions of their work environment and potential impact on their work outcomes during the pandemic is not well known. This study examined associations between care staff's perceived work environment, educational status, and facility staffing levels and work outcomes of care staff in LTC settings during the COVID-19 pandemic.

DESIGN

This study employed a cross-sectional, observational, correlational design.

SETTING AND PARTICIPANTS

A total of 207 care staff were conveniently recruited from 30 LTC settings in South Korea.

METHODS

The perceived work environment, educational status of care staff, and facility staffing levels (ie, beds-to-registered nurse [RN] and beds-to-nursing assistant [NA] or care worker ratios), as well as their work outcomes (ie, general and COVID-19 specific outcomes) were collected using questionnaires. Multivariable binary logistic regressions were conducted, controlling for the characteristics of care staff (ie, age, sex, occupation, and career length) and facilities (ie, location, bed size, ownership, and residents' disease and care profiles).

RESULTS

Approximately 45% of the participants were either NAs or care workers, and 38% were RNs. More than half (53.14%) perceived their work environment to be good. LTC staff who perceived their work environment to be poor were more likely to be dissatisfied with their work [odds ratio (OR) 20.88), experience high burnout (OR 8.63), intend to leave the facility within a year (OR 5.00), and experience increased overtime work (OR 3.58) and work-life imbalance (OR 1.93) due to COVID-19.

CONCLUSIONS AND IMPLICATIONS

LTC work environments should be improved and government-led initiatives for ensuring such improvements should be implemented to enable a better response to future public health crises and maintain the quality of care for and safety of residents in LTC settings.

Epidemic-Prevention Measures and Health Management in a Nursing Home during the Coronavirus Disease 2019 Pandemic

This study aimed to investigate the impact of epidemic prevention and isolation policies on residents' health and well-being and assess the effectiveness of implementing intervention measures to maintain their quality of life. This mixed-methods research study involved a retrospective record review of residents' daily life diaries and descriptive statistical analysis. Data were collected between March 2021 and June 2022, and epidemic-prevention measures were implemented using Taiwan's Centers for Disease Control guidelines. Three interventions were developed to address residents' health, social, and rehabilitation needs. Despite an overall infection rate of 10% at various times between 2021 and 2022, there were no reported outbreaks of nosocomial infections. The concept of reablement proved effective in helping residents maintain their independence and physical function, with a maintenance rate of 66.6%, thereby improving their quality of life. By implementing epidemic-prevention measures, we found that proper hand washing and the use of surgical masks were effective in controlling infections. Furthermore, the decline in physical function is a continuous and gradual process for older adults. Even under the restriction of social interaction, it is essential to incorporate rehabilitation plans into residents' daily activities and encourage their active participation, as this promotes improved physical function and enhances their overall quality of life.

Excess mortality among older adults institutionalized in long-term care facilities during the COVID-19 pandemic: a population-based analysis in Catalonia

Objectives

To assess excess mortality among older adults institutionalized in nursing homes within the successive waves of the COVID-19 pandemic in Catalonia (north-east Spain).

Design

Observational, retrospective analysis of population-based central healthcare registries.

Setting and participants

Individuals aged >65 years admitted in any nursing home in Catalonia between January 1, 2015, and April 1, 2022.

Methods

Deaths reported during the pre-pandemic period (2015-2019) were used to build a reference model for mortality trends (a Poisson model, due to the event counting nature of the variable "mortality"), adjusted by age, sex, and clinical complexity, defined according to the adjusted morbidity groups. Excess mortality was estimated by comparing the observed and model-based expected mortality during the pandemic period (2020-2022). Besides the crude excess mortality, we estimated the standardized mortality rate (SMR) as the ratio of weekly deaths' number observed to the expected deaths' number over the same period.

Results

The analysis included 175,497 older adults institutionalized (mean 262 days, SD 132), yielding a total of 394,134 person-years: 288,948 person-years within the reference period (2015-2019) and 105,186 within the COVID-19 period (2020-2022). Excess number of deaths in this population was 5,403 in the first wave and 1,313, 111, -182, 498, and 329 in the successive waves. The first wave on March 2020 showed the highest SMR (2.50; 95% CI 2.45-2.56). The corresponding SMR for the 2nd to 6th waves were 1.31 (1.27-1.34), 1.03 (1.00-1.07), 0.93 (0.89-0.97), 1.13 (1.10-1.17), and 1.07 (1.04-1.09). The number of excess deaths following the first wave ranged from 1,313 (2nd wave) to -182 (4th wave). Excess mortality showed similar trends for men and women. Older adults and those with higher comorbidity burden account for higher number of deaths, albeit lower SMRs.

Conclusion

Excess mortality analysis suggest a higher death toll of the COVID-19 crisis in nursing homes than in other settings. Although crude mortality rates were far higher among older adults and those at higher health risk, younger individuals showed persistently higher SMR, indicating an important death toll of the COVID-19 in these groups of people.

Individual and contextual risk factors for mortality in nursing home residents during the first wave of COVID-19 in France: a multilevel analysis of a nationwide cohort study

BACKGROUND

Mortality amongst nursing home (NH) residents increased by 43% during the first wave of coronavirus disease 2019 (COVID-19). We estimated the 'contextual effect' on mortality, tried to explain it by NH characteristics and identified resident- and NH-level risk factors for mortality.

METHODS

The contextual effect was measured for two cohorts of NH residents managed by the general scheme in metropolitan France (RESIDESMS data from 03/01/2020 to 05/31/2020 and 03/01/2019 to 05/31/2019) by the intraclass correlation coefficient (ICC) estimated from mixed-effects logistic regression.

RESULTS

Amongst 385,300 residents (5,339 NHs) included in 2020 (median age 89 years, 25% men), 9.1% died, versus 6.7% of 379,926 residents (5,270 NHs) in 2019. In the empty model, the ICC was 9.3% in 2020 and 1.5% in 2019. Only the geographic location partially explained the heterogeneity observed in 2020 (ICC: 6.5% after adjustment). Associations with mortality were stronger in 2020 than in 2019 for male sex and diabetes and weaker for heart disease, chronic respiratory disease and residence <6 months. Mortality was higher in 2020 (15.1%) than 2019 (6.3%) in NHs with at least one death with a mention of COVID-19 and more heterogeneous (ICC: 8.0%) than in the others (mortality: 6.7% in both years; ICC: 1.1%).

CONCLUSION

Our results suggest that the COVID-19 crisis had a heterogeneous impact on mortality in NH residents and that geographic location explain a part of the contextual effect, which appears to have had little influence on mortality in NHs not being affected by the virus.

Excess Mortality at Veterans Health Administration Facilities During the COVID-19 Pandemic

IMPORTANCE

The COVID-19 pandemic resulted in excess mortality among the general US population and at Veterans Health Administration (VHA) facilities. It is critical to understand the characteristics of facilities that experienced the highest and lowest pandemic-related mortality to inform future mitigation efforts.

OBJECTIVE

To identify facility-level excess mortality during the pandemic and to correlate these estimates with facility characteristics and community-wide rates of COVID-19 burden.

DESIGN

We used pre-pandemic data to estimate mortality risk prediction models using 5-fold cross-validation and Poisson quasi-likelihood regression. We then estimated excess mortality and observed versus expected (O/E) mortality ratios by the VHA facility from March to December 2020. We examined facility-level characteristics by excess mortality quartile.

PARTICIPANTS

Overall, there were 11.4 million VHA enrollees during 2016 and 2020.

MAIN MEASURES

Facility-level O/E mortality ratios and excess all-cause mortality.

RESULT

VHA-enrolled veterans experienced 52,038 excess deaths from March to December 2020, equating to 16.8% excess mortality. Facility-specific rates ranged from -5.5% to +63.7%. Facilities in the lowest quartile for excess mortality experienced fewer COVID-19 deaths (0.7-1.51, P <0.001) and cases (52.0-63.0, P =0.002) per 1,000 population compared with the highest quartile. The highest quartile facilities had more hospital beds (276.7-187.6, P =0.024) and a higher percent change in the share of visits conducted via telehealth from 2019 to 2020 (183%-133%, P <0.008).

CONCLUSIONS

There was a large variation in mortality across VHA facilities during the pandemic, which was only partially explained by the local COVID-19 burden. Our work provides a framework for large health care systems to identify changes in facility-level mortality during a public health emergency.

Evolution of rehabilitation services in response to a global pandemic: reflection on opportunities and challenges ahead

The rapidly evolving COVID-19 public health emergency has disrupted and challenged traditional healthcare, rehabilitation services, and treatment delivery worldwide. This perspective paper aimed to unite experiences and perspectives from an international group of rehabilitation providers while reflecting on the lessons learned from the challenges and opportunities raised during the COVID-19 pandemic. We discuss the global appreciation for rehabilitation services and changes in access to healthcare, including virtual, home-based rehabilitation, and long-term care rehabilitation. We illustrate lessons learned by highlighting successful rehabilitation approaches from the US, Belgium, and Japan.

Staffing Shortages, Staffing Hours, and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic

OBJECTIVES

Staffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents' care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.

DESIGN

This study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths.

SETTING AND PARTICIPANTS

15,212 nursing homes.

MEASURES

The primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents.

RESULTS

Between May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%.

CONCLUSION AND IMPLICATIONS

Our results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.

Intergenerational coresidence and the Covid-19 pandemic in the United States

This paper investigates the relation between intergenerational coresidence and mortality from Covid-19 in 2020. Using a cross-section of U.S. counties, we show that this association is positive, sizeable, significant, and robust to the inclusion of several demographic and socio-economic controls. Furthermore, using evidence from past, pre-pandemic years, we argue that this positive, sizeable and significant association is somewhat specific to the Covid-19 pandemic.

Cause of Death by Race and Ethnicity in Minnesota Before and During the COVID-19 Pandemic, 2019-2020

Objectives

To measure changes in cause of death dynamics in 2019 and 2020 and the relationship between concurrent occurrence of the COVID-19 pandemic and mortality outcome by race and ethnicity.

Patients and Methods

We used resident mortality data from the Minnesota Department of Health (MDH) to conduct retrospective statistical analysis of deaths in Minnesota in 2019 relative to 2020 to assess changes in mortality in a pre-pandemic and pandemic period.

Results

COVID-19 strongly contributed to ethnicity-related mortality disparities in Minnesota. Not only was there a greater proportion of COVID-19 decedents within the Black and Hispanic populations, but their average decedent age was markedly lower relative to the White population. The Black population experienced a disproportionate increase in decedents with a 34% increase during 2020 compared to 2019.

Conclusions

This retrospective analysis of death dynamics and mortality outcomes in Minnesota from 2019 to 2020 demonstrated an increase in adverse mortality outcomes relative to the pre-pandemic period that disproportionately impacted Black and Hispanic minority populations. Access to non-pharmaceutical interventions combating COVID-19 infection in Black and Hispanic communities should be expanded in Minnesota.

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.

Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities

BACKGROUND

Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics.

METHODS

We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics.

RESULTS

PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding.

CONCLUSIONS

SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.

Nursing homes and mortality in Europe: Uncertain causality

The current health crisis has particularly affected the elderly population. Nursing homes have unfortunately experienced a relatively large number of deaths. On the basis of this observation and working with European data (from SHARE), we want to check whether nursing homes were lending themselves to excess mortality even before the pandemic. Controlling for a number of important characteristics of the elderly population in and outside nursing homes, we conjecture that the difference in mortality between those two samples is to be attributed to the way nursing homes are designed and organized. Using matching methods, we observe excess mortality in Sweden, Belgium, Germany, Switzerland, Czech Republic and Estonia but not in the Netherlands, Denmark, Austria, France, Luxembourg, Italy and Spain. This raises the question of the organization and management of these nursing homes, but also of their design and financing.

Strengthening a One Health approach to emerging zoonoses

Given the enormous global impact of the COVID-19 pandemic, outbreaks of highly pathogenic avian influenza in Canada, and manifold other zoonotic pathogen activity, there is a pressing need for a deeper understanding of the human-animal-environment interface and the intersecting biological, ecological, and societal factors contributing to the emergence, spread, and impact of zoonotic diseases. We aim to apply a One Health approach to pressing issues related to emerging zoonoses, and propose a functional framework of interconnected but distinct groups of recommendations around strategy and governance, technical leadership (operations), equity, education and research for a One Health approach and Action Plan for Canada. Change is desperately needed, beginning by reorienting our approach to health and recalibrating our perspectives to restore balance with the natural world in a rapid and sustainable fashion. In Canada, a major paradigm shift in how we think about health is required. All of society must recognize the intrinsic value of all living species and the importance of the health of humans, other animals, and ecosystems to health for all.

The implications of the COVID-19 pandemic for long term care facilities

PURPOSE OF REVIEW

Despite advances in infection prevention and control and breakthroughs in vaccination development, challenges remain for long-term care facilities (LTCFs) as they face a likely future of emerging infectious diseases. To ensure the safety of LTCF residents from the current and future pandemics, we identify lessons learned from the coronavirus disease 2019 (COVID-19) experience for improving future prevention and response efforts.

RECENT FINDINGS

In addition to high disease susceptibility among LTCF residents, LTCF vulnerabilities include a lack of pandemic preparedness, a lack of surge capacity in human, material and testing resources, and poorly designed buildings. External sources of vulnerability include staff working in multiple LTCFs and high COVID-19 rates in surrounding communities. Other challenges include poor cooperation between LTCFs and the other components of health systems, inadequately enforced regulations, and the sometimes contradictory interests for-profit LTCFs face between protecting their residents and turning a profit.

SUMMARY

These challenges can be addressed in the post-COVID-19 period through systemic reforms. Governments should establish comprehensive health networks that normalize mechanisms for prediction/preparedness and response/recovery from disruptive events including pandemics. In addition, governments should facilitate cooperation among public and private sector health systems and institutions while utilizing advanced digital communication technologies. These steps will greatly reduce the threat to LTCFs posed by emerging infectious diseases in future.