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Comparative Performance of Private Equity–Owned US Nursing Homes During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
Key Points

Question  Compared with other nursing homes, are private equity (PE)–owned nursing homes associated with better or worse coronavirus disease 2019 (COVID-19) outcomes?

Findings  In this cross-sectional study of 11 470 US nursing homes, there were no statistically significant differences in staffing levels, COVID-19 cases or deaths, or deaths from any cause between PE nursing homes and facilities with other ownership types. Compared with PE, all other ownership types were more likely to have at least a 1-week supply of N95 masks and medical gowns.

Meaning  In this study, PE-owned nursing homes performed comparably with for-profit and nonprofit nursing homes based on COVID-19 cases and deaths and deaths by any cause but had less personal protective equipment than other nursing homes.


Importance  It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic.

Objective  To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes.

Design, Setting, and Participants  This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics.

Exposure  Nursing home ownership status.

Main Outcomes and Measures  Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages.

Results  Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, −69.2 to −1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% (14.8 percentage points; 95% CI, 6.5 to 23.0 percentage points; P < .001), respectively, more likely to have at least a 1-week supply of N95 masks than PE-owned nursing homes. They were 24.3% (21.3 percentage points; 95% CI, 11.8 to 30.8 percentage points; P < .001), 30.7% (27.0 percentage points; 95% CI, 17.7 to 36.2 percentage points; P < .001), and 29.2% (25.7 percentage points; 95% CI, 16.1 to 35.3 percentage points; P < .001) more likely to have a 1-week supply of medical gowns than PE-owned nursing homes. Government nursing homes were more likely to have a shortage of nurses (6.9 percentage points; 95% CI, 0.0 to 13.9 percentage points; P = .049) than PE-owned nursing homes.

Conclusions and Relevance  In this cross-sectional study, PE-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring.

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Article Information

Accepted for Publication: September 25, 2020.

Published: October 28, 2020. doi:10.1001/jamanetworkopen.2020.26702

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Braun RT et al. JAMA Network Open.

Corresponding Author: Mark Aaron Unruh, PhD, Department of Population Health Sciences, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065 (mau2006@med.cornell.edu).

Author Contributions: Dr Braun and Ms Yun had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Braun, Myslinski, Jung, Unruh.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Braun, Myslinski, Kuwonza, Jung, Unruh.

Critical revision of the manuscript for important intellectual content: Braun, Yun, Casalino, Jung, Unruh.

Statistical analysis: Braun, Yun, Jung, Unruh.

Obtained funding: Casalino, Unruh.

Administrative, technical, or material support: Myslinski, Kuwonza.

Supervision: Braun, Casalino, Jung, Unruh.

Conflict of Interest Disclosures: Dr Casalino reported receiving research funding from Arnold Ventures, the Agency for Healthcare Research and Quality, the American Medical Association, and the Physicians Foundation outside the submitted work. Dr Jung reported receiving research funding from the National Institute and Aging and the Robert Wood Johnson Foundation outside the submitted work. Dr Unruh reported receiving research funding from the New York eHealth Collaborative, the Robert Wood Johnson Foundation, and the National Instituting on Aging outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded by grant 5327069701 Arnold Ventures to Drs Casalino and Unruh.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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