Residents of US nursing homes with more than 40% non-white residents died of COVID-19 at 3.3 times the rate of those of those with higher proportions of white residents, a study today in JAMA Network Open shows.
Using the Nursing Home COVID-19 Public File from the Centers for Medicare & Medicaid Services, University of Chicago researchers found that nursing homes with the lowest shares of white residents reported a mean of 5.6 deaths, compared with 1.7 in those with the highest proportions, as of Sep 13, 2020.
Facilities with large percentages of non-white residents had, on average, 3.9 more deaths than mostly white facilities, for a 3.3-fold higher rate. After adjustment for number of certified beds, there was a difference of 2.2 deaths between the two types of homes, and adjustment for county-level factors further lowered the difference in death rates to 1.0.
The number of COVID-19 infections and deaths fell with higher percentages of white residents per home. Controlling for case mix and other facility characteristics did not affect the association.
Wide disparities in cases, too
A total of 344,844 COVID-19 infections and 51,606 related deaths were reported among the 13,312 nursing homes in the study, with an average of 3.9 deaths each. Of all nursing homes, 10,494 (78.8%) reported at least one coronavirus case, and 5,794 (43.5%) recorded at least one related death.
Mean resident age was 79.5 years. Among all facilities, the average proportion of white residents was 77.9%, ranging from 59.7% to 97.3%.
The mean number of coronavirus cases among facilities with the highest shares of white residents was 12.3, versus 37.1 in those with higher proportions of non-white residents. Likewise, the average number of COVID-19 deaths per 100 infections in each facility was 15.9 in homes with larger proportions of non-white nursing homes, twice as high as in mostly white facilities (8.0).
While these associations were mostly consistent among nursing homes with the same star rating, those with the lowest star rating had, on average, 2.3 more COVID-19 deaths than those with the highest ratings.
Compared with facilities with high percentages of non-white residents, nursing homes with mostly white residents tended to be located in counties with lower prevalence of COVID-19 infections (12.1 per 1,000 people vs 23.2) and were less likely to be for-profit (50.2% vs 83.8%), and had fewer mean certified beds (87.9 vs 127.8).
Homes with mostly white residents also had better resident health (mean acuity index score, 11.8 vs 12.6), less high blood pressure (75.7% vs 76.9%), higher proportions of Medicare residents (11.9% vs 11.2%), fewer Medicaid residents (53.5% vs 69.7%), more nursing hours per resident (4.0 vs 3.7), and higher star quality ratings (3.6 vs 2.7).
'Highly segregated' nursing homes
The authors noted that even before the coronavirus pandemic, racial disparities in both COVID-19 infections and deaths and nursing home quality were widely acknowledged.
Non-white residents are more likely than their white counterparts to be admitted to nursing homes in poorer health and to live in the largest and poorest-quality nursing homes, with their attendant greater risk of viral transmission, lower nurse-to-patient ratios, more severe regulatory issues, more Medicaid residents, and higher odds of termination from the Medicaid program.
"Disparities in care appear to be largely a function of where people go for care rather than differential treatment by staff members within the same facilities, as nursing homes are highly segregated," the authors wrote.
While the pandemic has adversely affected many nursing home residents because of the viral transmission risks inherent in congregate living, those residing in areas with greater community coronavirus spread and that struggle with a lack of personal protective equipment and staff shortages have fared particularly poorly.
"Consistent with historical racial disparities in long-term care and current pandemic-associated deaths, this study's results suggest that nursing homes with higher proportions of non-White residents are experiencing the worst COVID-19 outcomes," the researchers said. "Disparities in deaths by nursing home racial composition are associated with the disproportionately high spread of the disease in non-White communities and the characteristics of the nursing homes that serve those communities."