BACKGROUND/OBJECTIVES: To determine racial/ethnic disparities in weekly counts of new COVID-19 cases and deaths among nursing home residents or staff. DESIGN: Cross-sectional analysis of national nursing home COVID-19 reports linked to other data. Multivariable twopart models modeled disparities in count of cases or deaths, and logistic regressions modeled disparities in self-reported shortages in staff and personal protective equipment (PPE), across nursing home groups with varying proportions of racial/ethnic minority residents, defined as low-, medium-, medium-high-, and high-proportion groups. SETTING: A total of 12,576 nursing homes nationally. PARTICIPANTS: None. INTERVENTION: None. MEASUREMENTS: Numbers of incident COVID-19 confirmed cases among residents and staff, and incident COVID-19 related deaths among residents (primary outcomes); and nursing home reported shortages in staff and PPE (secondary outcomes). All outcomes were reported for the week of May 25, 2020. RESULTS: The number of weekly new COVID-19 confirmed cases among residents ranged from an average of 0.4 cases per facility (standard deviation (SD) = 2.5) for the low-proportion group (93.0% had zero new cases) to 1.5 cases per facility (SD = 6.3) for the high-proportion group (78.9% had zero new cases). Multivariable regression estimated that compared with the low-proportion group, the likelihood of having at least one new resident case was 76% higher (odds ratio = 1.76; 95% confidence interval = 1.38-2.25; P = .000) for the high-proportion group. Similar across-facility disparities were found for the weekly count of new COVID-19 deaths among residents (ranging from 0.1 deaths per facility (SD = 1.1) for the low-proportion group to 0.4 deaths (SD = 2.0) for the high-proportion group) and in the weekly count of new COVID-19 confirmed cases among staff (ranging from 0.3 cases (SD = 1.4] to 1.3 cases (SD = 4.4) per facility). No substantial disparities in self-reported shortages of staff or PPE were found. CONCLUSION: Nursing homes caring for disproportionately more racial/ethnic minority residents reported more weekly new COVID-19 confirmed cases and/or deaths. Immediate actions are needed to address these system-level disparities.

Despite the increased use of nursing homes by minority residents, nursing home care remains highly segregated. Compared to whites, racial/ethnic minorities tend to be cared for in facilities with limited clinical and financial resources, low nurse staffing levels, and a relatively high number of care deficiency citations. We assessed the trends from 2006 to 2011 in those citations and in disparities across facilities with four different concentrations of racial/ethnic minority residents. We found that the number of health care–related deficiencies and the percentage of facilities with serious deficiencies decreased over time for all four facility groups. From 2006 to 2011, the average annual number of health care–related deficiencies declined from 7.4 to 6.8 for facilities with low minority concentrations (< 5 percent) and from 10.6 to 9.4 for facilities with high minority concentrations (≥ 35 percent). In multivariable analyses, across-site disparities in health care-related deficiencies and in life-safety deficiencies narrowed over time. We also found that increasing the Medicaid payment rate might help improve both overall quality and disparities, but state case-mix payment approaches might worsen both. These results suggest the need to reevaluate quality improvement and cost containment efforts to better foster quality and equity of nursing home care.

Background: The safety and quality of care provided to nursing home residents is a significant concern. Little is known whether fostering patient safety culture helps improve the safety and quality of nursing home care. Methods: This study determined the associations of nursing home patient safety culture performance, as reported by administrators, directors of nursing, and unit leaders in a large national sample of free-standing nursing homes, with several “Nursing Home Compare” performance indicators. We conducted the survey in 2017 using the Agency for Healthcare Research and Quality Survey on Patient Safety Culture for nursing homes to collect data on 12 core domains of safety culture scores. Survey data were linked to other nursing home files for multivariable regression analyses. Results: Overall, 818 of the 2254 sampled nursing homes had at least 1 completed survey returned for a response rate of 36%. After adjustment for nursing home, market, and state covariates, every 10 percentage points increase in overall positive response rate for safety culture was associated with 0.56 fewer health care deficiencies (P=0.001), 0.74 fewer substantiated complaints (P=0.004), reduced fines by $2285.20 (P=0.059), and 20% increased odds of being designated as 4-star or 5-star (vs. 1 to 3 star) facilities (odds ratio roughly=1.20, P<0.05). Conclusions: Efforts to improve nursing home performance in patient safety culture have the potential to improve broad safety and quality of care measures encapsulated in the Nursing Home Compare publication.

We compared racial disparities in thirty-day readmissions between traditional Medicare and Medicare Advantage beneficiaries who underwent one of six major surgeries in New York State in 2013. We found that Medicare Advantage was associated with greater racial disparity, compared to traditional Medicare. After controlling for patient, hospital, and geographic characteristics in a propensity score based approach, we found that in traditional Medicare, black patients were 33 percent more likely than white patients to be readmitted, whereas in Medicare Advantage, black patients were 64 percent more likely than white patients to be readmitted. Our findings suggest that the risk-reduction strategies adopted by Medicare Advantage plans have not been successful in lowering the markedly higher rate of readmission among black patients, compared to white patients.

Recent increases in state Medicaid payments to nursing homes have the potential to reduce disparities in nurse staffing between facilities with high and low concentrations of racial/ethnic minority residents. Analyses of nursing home and state policy survey data for the period 2001–11 suggest that registered nurse and licensed practical nurse staffing levels increased slightly during this period, regardless of racial/ethnic minority resident concentration. Adjusted disparities in registered nurse hours per resident day between nursing homes with high and low concentrations of racial/ethnic minority residents persisted, although they were reduced. Certified nursing assistant hours per patient day increased in nursing homes with low concentrations of racial/ethnic minorities but decreased in homes with high concentrations, creating a new disparity. Overall, increases in state Medicaid payment rates to nursing homes were associated with improvements in staffing and reduced staffing disparities across facilities, but the adoption of case-mix payments had the opposite effect. Further reforms in health care delivery and payment are needed to address persistent disparities in care between nursing homes serving higher proportions of minority residents and those serving lower proportions, and to prevent unintended exacerbations of such disparities.