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Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data

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

Question  How many COVID-19 cases and deaths at nursing homes were missed in the federal National Healthcare Safety Network (NHSN) reporting system owing to the delayed start in required reporting?

Findings  In this cross-sectional study of 15 307 US nursing homes, approximately 44% of COVID-19 cases and 40% of COVID-19 deaths that occurred before the start of reporting were not reported in the first NHSN submission in sample states, suggesting there were more than 68 000 unreported cases and 16 000 unreported deaths nationally.

Meaning  These findings suggest that federal NHSN data understate total COVID-19 cases and deaths in nursing homes and that using these data without accounting for this issue may result in misleading conclusions about the determinants of nursing home outbreaks.

Abstract

Importance  Federal data underestimate the impact of COVID-19 on US nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020.

Objective  To assess the magnitude of unreported cases and deaths in the National Healthcare Safety Network (NHSN) and provide national estimates of cases and deaths adjusted for nonreporting.

Design, Setting, and Participants  This is a cross-sectional study comparing COVID-19 cases and deaths reported by US nursing homes to the NHSN with those reported to state departments of health in late May 2020. The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021.

Exposures  Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state.

Main Outcomes and Measures  The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN.

Results  Among 15 415 US nursing homes, including 4599 with state case data and 7405 with state death data, a mean (SE) of 43.7% (1.4%) of COVID-19 cases and 40.0% (1.1%) of COVID-19 deaths prior to May 24 were not reported in the first NHSN submission in sample states, suggesting that 68 613 cases and 16 623 deaths were omitted nationwide, representing 11.6% of COVID-19 cases and 14.0% of COVID-19 deaths among nursing home residents in 2020.

Conclusions and Relevance  These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.

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Article Information

Accepted for Publication: June 24, 2021.

Published: September 9, 2021. doi:10.1001/jamanetworkopen.2021.22885

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Shen K et al. JAMA Network Open.

Corresponding Author: Karen Shen, PhD, Department of Economics, Harvard University, 1805 Cambridge St, Cambridge, MA 02138 (karenshen@g.harvard.edu).

Author Contributions: Dr Shen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

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

Drafting of the manuscript: Shen, Loomer, Gandhi.

Critical revision of the manuscript for important intellectual content: Abrams, Grabowski.

Supervision: Gandhi.

Conflict of Interest Disclosures: Dr Loomer reported receiving personal fees from the American Health Care Association outside the submitted work. Dr Grabowski reported receiving personal fees from naviHealth, Medicare Payment Advisory Commission, RTI International, Abt Associates, Analysis Group, and Compass Lexecon and grants from the National Institutes on Aging (NIA), Agency for Healthcare Research and Quality, the Arnold Foundation, and the Warren Alpert Foundation outside the submitted work. Dr Gandhi reported receiving grants from the NIA through the National Bureau of Economic Research, National Institute for Health Care Management, University of California, Los Angeles (UCLA), Ziman Center for Real Estate, UCLA Fink Center for Finance & Investment, UCLA Price Center for Entrepreneurship, the UCLA Morrison Center for Marketing and Data Analytics, Harvard Institute for Quantitative Social Sciences, and Harvard University Lab for Economic Applications Policy outside the submitted work. No other disclosures were reported.

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