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Changes in Health and Quality of Life in US Skilled Nursing Facilities by COVID-19 Exposure Status in 2020

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

Question  How did health and quality of life in US skilled nursing facilities (SNFs) change during the COVID-19 pandemic?

Findings  In this retrospective observational study that included data from 2 985 864 long-term care resident-years in 15 477 SNFs in 2018-2020, SNFs with active COVID-19 cases experienced significant increases in mortality and functional decline during the first year of the pandemic compared with the prepandemic period, while significant increases in weight loss and depressive symptoms occurred in SNFs with active COVID-19 and SNFs with no known COVID-19 cases.

Meaning  Among skilled nursing facilities in the US from January to November 2020, adverse changes occurred in some health and quality of life measures during the first year of the pandemic and prior to the availability of COVID-19 vaccination, compared with the prepandemic period of January to November 2018 and 2019, even among facilities that did not have known COVID-19 cases.

Abstract

Importance  During the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects.

Objective  To assess health outcomes among SNFs with and without known COVID-19 cases.

Design, Setting, and Participants  This retrospective observational study used US Medicare claims and Minimum Data Set 3.0 for January through November in each year beginning in 2018 and ending in 2020 including 15 477 US SNFs with 2 985 864 resident-years.

Exposures  January through November of calendar years 2018, 2019, and 2020. COVID-19 diagnoses were used to assign SNFs into 2 mutually exclusive groups with varying membership by month in 2020: active COVID-19 (≥1 COVID-19 diagnosis in the current or past month) or no-known COVID-19 (no observed diagnosis by that month).

Main Outcomes and Measures  Monthly rates of mortality, hospitalization, emergency department (ED) visits, and monthly changes in activities of daily living (ADLs), body weight, and depressive symptoms. Each SNF in 2018 and 2019 served as its own control for 2020.

Results  In 2018-2019, mean monthly mortality was 2.2%, hospitalization 3.0%, and ED visit rate 2.9% overall. In 2020, among active COVID-19 SNFs compared with their own 2018-2019 baseline, mortality increased by 1.60% (95% CI, 1.58% to 1.62%), hospitalizations decreased by 0.10% (95% CI, −0.12% to −0.09%), and ED visit rates decreased by 0.57% (95% CI, −0.59% to −0.55%). Among no-known COVID-19 SNFs, mortality decreased by 0.15% (95% CI, −0.16% to −0.13%), hospitalizations by 0.83% (95% CI, −0.85% to −0.81%), and ED visits by 0.79% (95% CI, −0.81% to −0.77%). All changes were statistically significant. In 2018-2019, across all SNFs, residents required assistance with an additional 0.89 ADLs between January and November, and lost 1.9 lb; 27.1% had worsened depressive symptoms. In 2020, residents in active COVID-19 SNFs required assistance with an additional 0.36 ADLs (95% CI, 0.34 to 0.38), lost 3.1 lb (95% CI, −3.2 to −3.0 lb) more weight, and were 4.4% (95% CI, 4.1% to 4.7%) more likely to have worsened depressive symptoms, all statistically significant changes. In 2020, residents in no-known COVID-19 SNFs had no significant change in ADLs (−0.06 [95% CI, 0.12 to 0.01]), but lost 1.8 lb (95% CI, −2.1 to −1.5 lb) more weight and were 3.2% more likely (95% CI, 2.3% to 4.1%) to have worsened depressive symptoms, both statistically significant changes.

Conclusions and Relevance  Among skilled nursing facilities in the US during the first year of the COVID-19 pandemic and prior to the availability of COVID-19 vaccination, mortality and functional decline significantly increased at facilities with active COVID-19 cases compared with the prepandemic period, while a modest statistically significant decrease in mortality was observed at facilities that had never had a known COVID-19 case. Weight loss and depressive symptoms significantly increased in skilled nursing facilities in the first year of the pandemic, regardless of COVID-19 status.

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Article Information

Corresponding Author: Michael L. Barnett, MD, MS, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 411, Boston, MA 02115 (mbarnett@hsph.harvard.edu).

Accepted for Publication: August 10, 2022.

Published Online: August 29, 2022. doi:10.1001/jama.2022.15071

Author Contributions: Dr Barnett 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: Barnett, Epstein, Joynt Maddox.

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

Drafting of the manuscript: Barnett, Joynt Maddox.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Barnett, Waken, Zheng, Orav.

Obtained funding: Barnett, Epstein, Joynt Maddox.

Administrative, technical, or material support: Epstein, Joynt Maddox.

Supervision: Barnett, Joynt Maddox.

Conflict of Interest Disclosures: Dr Barnett reported receiving support from the National Institute on Aging, the Agency for Healthcare Research and Quality, and the Retirement Research Foundation. Dr Grabowski reported receiving personal fees from AARP, the Analysis Group, GRAIL LLC, Health Care Lawyers PLC, the Medicare Payment Advisory Commission, and RTI International outside the submitted work. Dr Joynt Maddox reported receiving grants from the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the National Institute of Nursing Research; research support from Humana Inc; and personal fees for serving on the health policy advisory council of Centene Corp. No other disclosures were reported.

Funding/Support: This work was supported by grants K23 AG058806 and R01 AG060935 from the National Institute on Aging of the National Institutes of Health (Drs Barnett, Epstein, Grabowski, Orav, and Joynt Maddox).

Role of the Funder/Sponsor: The National Institute on Aging 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.

Disclaimer: Dr Joynt Maddox is an Associate Editor of JAMA, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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