Abstract
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. 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. 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. Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state. 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. 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. 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.
Highlights
Nursing homes have been centers for outbreaks and excess mortality from the COVID-19 pandemic, the federal government did not require nursing homes to report cases and deaths from COVID-19 until May 24, 2020, more than 3 months after the first reported nursing home outbreak at Life Care Center of Kirkland, Washington.[1,2] In addition, in the first submission to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN), facilities were given the option—but were not required—to retrospectively report cases and deaths from earlier in the pandemic.[3]
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
These findings suggest that federal NHSN data understated total cases and deaths in nursing homes
Summary
Nursing homes have been centers for outbreaks and excess mortality from the COVID-19 pandemic, the federal government did not require nursing homes to report cases and deaths from COVID-19 until May 24, 2020, more than 3 months after the first reported nursing home outbreak at Life Care Center of Kirkland, Washington.[1,2] In addition, in the first submission to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN), facilities were given the option—but were not required—to retrospectively report cases and deaths from earlier in the pandemic.[3]. These data are widely known to undercount total cases and deaths in nursing homes, the degree of nonreporting, and the true impact of COVID-19 on nursing homes, remains unknown.[6,7]. In light of the federal data limitations, significant efforts have been made to provide alternative estimates of COVID-19 cases and deaths in nursing homes.[8,9] these alternative estimates generally rely on a patchwork of state and local sources and have their own limitations. Data are not available for all states and include significant numbers of non–nursing home residences (eg, assisted living) in some states, and only nursing homes in others
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