An Ecological Analysis of Quality Ratings and Inspections Associated with COVID-19 Outbreaks in Skilled Nursing Homes

Objectives: As COVID-19 spread across the United States, and most rapidly in skilled nursing homes, public health departments developed policies to mitigate the spread. Concerns grew over whether this spread linked to nursing home quality. Design: We collected data on nursing home quality, staffing, and COVID-19 cases from the Centers of Medicare and Medicaid Services. Demographic data was sourced from Long Term Care Focus. Settings and Participants: The analysis used cross-sectional data from 1,025 California skilled nursing homes including quality ratings and confirmed COVID-19 cases between May 17, 2020 and August 23, 2020. Methods: The dependent variable was confirmed COVID-19 cases among residents. The primary independent variables were Overall Rating and Health Inspection Rating, while also including nursing home beds, patient race composition, ownership and geographic classification. Results: 5-Star Overall Rating, 5-Star Health Inspection Rating, and a lower count of health inspection deficiencies each predicted a lower likelihood of having a confirmed COVID resident case (p<.05). Conclusions and Implications: Skilled nursing homes with higher quality ratings and fewer health inspection deficiencies were less likely to have a confirmed case of COVID-19 among residents.

Intensity of Care, Expenditure, and Place of Death in French Women in the Year Before Their Death From Breast Cancer: A Population-Based Study

Health care utilization of women with breast cancer (BC) during the last year of life, together with the causes and place of death and associated expenditure have been poorly described. Women treated for BC (2014-2015) with BC as a cause of death in 2015 and covered by the national health insurance general scheme (77% of the population) were identified in the French health data system (n = 6,696, mean age: 68.7 years, SD ± 15). Almost 70% died in short-stay hospitals (SSH), 4% in hospital-at-home (HaH), 9% in Rehab, 5% in skilled nursing homes (SNH) and 12% at home. One-third presented cardiovascular comorbidity. During the last year, 90% were hospitalized at least once in SSH, 25% in Rehab, 13% in HaH and 71% received hospital palliative care (HPC), but only 5% prior to their end-of-life stay. During the last month, 85% of women were admitted at least once to a SSH, 42% via the emergency department, 10% to an ICU, 24% received inpatient chemotherapy and 18% received outpatient chemotherapy. Among the 83% of women who died in hospital, independent factors for HPC use were cardiovascular comorbidity (adjusted odds ratio, aOR: 0.83; 95%CI: 0.72–0.95) and, in the 30 days before death, at least one SNH stay (aOR: 0.52; 95%CI: 0.36-0.76), ICU stay (aOR: 0.36; 95%CI: 0.30-0.43), inpatient chemotherapy (aOR: 0.55; 95%CI: 0.48-0.63), outpatient chemotherapy (aOR: 0.60; 95%CI: 0.51-0.70), death in Rehab (aOR: 1.4; 95%CI: 1.05-1.86) or HAH (aOR: 4.5; 95%CI: 2.47-8.1) vs SSH. Overall mean expenditure reimbursed per woman was €38,734 and €42,209 for those with PC. Women with inpatient or outpatient chemotherapy during the last month had lower rates of HPC, suggesting declining use of HPC before death. This study also indicates SSH-centered management with increased use of HPC in HaH and Rehab units and decreased access to HPC in SNH.

STATE VARIATION IN NURSING HOME CIVIL MONEY PENALTY ENFORCEMENT ACTIONS FOR QUALITY DEFICIENCIES

States vary in their overall rates of nursing home deficiency citations as well as deficiencies for actual harm or jeopardy (Harrington et al., 2018). Civil Money Penalty (CMP) fines collected by the Centers for Medicare and Medicaid Services (CMS) are one enforcement action imposed to promote nursing home compliance with regulations. Collected CMP funds are redistributed to states for the sole purpose of improving nursing home resident care and quality of life through reinvestment in quality improvement projects. Using CASPER data available for US skilled nursing homes in 2015 and 2016 through the CMS QCOR database we examined the distribution of quality of care (QOC) and quality of life (QOL) deficiencies and CMP enforcement action across states. Guided by the systems framework for evaluating nursing home quality (Unruh & Wan, 2004) we further explored how contextual factors such as state spending for nursing home care, structural characteristics of facilities in states, and inadequate care processes indicated by deficiencies contribute to CMP enforcement actions and fines. Findings indicate that 27% of enforcement actions resulting in a CMP between 2015 and 2016 were imposed for a QOL deficiency while 61.7% represented QOC deficiencies. QOL deficiencies represented only 8% of the highest severity deficiency category but 81.7% of enforcement actions for QOC were for those causing immediate harm or jeopardy. QOC deficiencies are a focus of enforcement actions as they represent critical care processes influencing resident basic needs for hydration, ambulation, skin integrity and care for other special physical and behavioral needs.