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Risk Factors Associated With All-Cause 30-Day Mortality in Nursing Home Residents With COVID-19

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

Question  What patient characteristics are associated with 30-day all-cause mortality among symptomatic nursing home residents with coronavirus disease 2019 (COVID-19)?

Findings  In this cohort study of 5256 US nursing home residents with COVID-19, increased age, male sex, and impaired cognitive and physical function were independent risk factors for all-cause 30-day mortality.

Meaning  This cohort study of 5256 nursing home residents suggests that several characteristics, including sociodemographic characteristics, symptoms, comorbidities, and physical and cognitive functional impairments, can facilitate risk stratification among nursing home residents with COVID-19.

Abstract

Importance  The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing homes. Vulnerable nursing home residents are at high risk for adverse outcomes, but improved understanding is needed to identify risk factors for mortality among nursing home residents.

Objective  To identify risk factors for 30-day all-cause mortality among US nursing home residents with COVID-19.

Design, Setting, and Participants  This cohort study was conducted at 351 US nursing homes among 5256 nursing home residents with COVID-19–related symptoms who had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by polymerase chain reaction testing between March 16 and September 15, 2020.

Exposures  Resident-level characteristics, including age, sex, race/ethnicity, symptoms, chronic conditions, and physical and cognitive function.

Main Outcomes and Measures  Death due to any cause within 30 days of the first positive SARS-CoV-2 test result.

Results  The study included 5256 nursing home residents (3185 women [61%]; median age, 79 years [interquartile range, 69-88 years]; and 3741 White residents [71%], 909 Black residents [17%], and 586 individuals of other races/ethnicities [11%]) with COVID-19. Compared with residents aged 75 to 79 years, the odds of death were 1.46 (95% CI, 1.14-1.86) times higher for residents aged 80 to 84 years, 1.59 (95% CI, 1.25-2.03) times higher for residents aged 85 to 89 years, and 2.14 (95% CI, 1.70-2.69) times higher for residents aged 90 years or older. Women had lower risk for 30-day mortality than men (odds ratio [OR], 0.69 [95% CI, 0.60-0.80]). Two comorbidities were associated with mortality: diabetes (OR, 1.21 [95% CI, 1.05-1.40]) and chronic kidney disease (OR, 1.33 [95%, 1.11-1.61]). Fever (OR, 1.66 [95% CI, 1.41-1.96]), shortness of breath (OR, 2.52 [95% CI, 2.00-3.16]), tachycardia (OR, 1.31 [95% CI, 1.04-1.64]), and hypoxia (OR, 2.05 [95% CI, 1.68-2.50]) were also associated with increased risk of 30-day mortality. Compared with cognitively intact residents, the odds of death among residents with moderate cognitive impairment were 2.09 (95% CI, 1.68-2.59) times higher, and the odds of death among residents with severe cognitive impairment were 2.79 (95% CI, 2.14-3.66) times higher. Compared with residents with no or limited impairment in physical function, the odds of death among residents with moderate impairment were 1.49 (95% CI, 1.18-1.88) times higher, and the odds of death among residents with severe impairment were 1.64 (95% CI, 1.30-2.08) times higher.

Conclusions and Relevance  In this cohort study of US nursing home residents with COVID-19, increased age, male sex, and impaired cognitive and physical function were independently associated with mortality. Understanding these risk factors can aid in the development of clinical prediction models of mortality in this population.

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Article Information

Accepted for Publication: November 7, 2020.

Published Online: January 4, 2021. doi:10.1001/jamainternmed.2020.7968

Corresponding Author: Orestis A. Panagiotou, MD, PhD, Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 S Main St, PO Box G-6-121, Providence, RI 02912 (orestis_panagiotou@brown.edu).

Author Contributions: Drs Panagiotou and Mor 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. Dr Panagiotou and Mr Kosar contributed equally to this work.

Concept and design: Panagiotou, White, Feifer, Blackman, Gravenstein, Mor.

Acquisition, analysis, or interpretation of data: Panagiotou, Kosar, White, Bantis, Yang, Santostefano, Feifer, Rudolph, Gravenstein, Mor.

Drafting of the manuscript: Panagiotou, Kosar, White, Rudolph, Gravenstein.

Critical revision of the manuscript for important intellectual content: Kosar, White, Bantis, Yang, Santostefano, Feifer, Blackman, Rudolph, Gravenstein, Mor.

Statistical analysis: Panagiotou, Kosar, White, Bantis, Yang, Santostefano.

Obtained funding: Mor.

Administrative, technical, or material support: Kosar, Yang, Feifer, Blackman, Rudolph.

Supervision: Panagiotou, Feifer, Rudolph, Gravenstein, Mor.

Conflict of Interest Disclosures: Dr Panagiotou reported receiving grants from the National Institutes of Health and the Agency for Healthcare Research and Quality during the conduct of the study; and personal fees from International Consulting Associates Inc outside the submitted work. Mr Kosar reported receiving grants from the National Institute on Aging during the conduct of the study. Dr White reported receiving grants from the National Institute on Aging during the conduct of the study. Dr Bantis reported receiving grants from the National Institutes of Health Centers of Biomedical Research Excellence during the conduct of the study; and grants from the National Institutes of Health outside the submitted work. Dr Yang reported receiving grants from the National Institute on Aging during the conduct of the study. Dr Rudolph reported receiving grants from the the Department of Veterans Affairs and the National Institutes of Health during the conduct of the study. Dr Mor reported receiving grants from Brown University during the conduct of the study; and serving as Chair of the Scientific Advisory Committee at NaviHealth, Inc, serving as former Chair of the Independent Quality Committee at HCR ManorCare, and being the former Director of PointRight Inc, where he holds less than 1% equity; and receiving personal fees from naviHealth outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grant 3P01AG027296-11S1 from the National Institute on Aging. Dr Bantis was supported in part by grant P20GM130423 from the National Institutes of Health Centers of Biomedical Research Excellence.

Role of the Funder/Sponsor: The funding sources 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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