Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
JAMA Netw Open. 2021 Mar 1;4(3):e216315. doi: 10.1001/jamanetworkopen.2021.6315.
Nursing home residents account for approximately 40% of deaths from SARS-CoV-2.
To identify risk factors for SARS-CoV-2 incidence, hospitalization, and mortality among nursing home residents in the US.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective longitudinal cohort study was conducted in long-stay residents aged 65 years or older with fee-for-service Medicare residing in 15 038 US nursing homes from April 1, 2020, to September 30, 2020. Data were analyzed from November 22, 2020, to February 10, 2021.
The main outcome was risk of diagnosis with SARS-CoV-2 (per International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) by September 30 and hospitalization or death within 30 days after diagnosis. Three-level (resident, facility, and county) logistic regression models and competing risk models conditioned on nursing home facility were used to determine association of patient characteristics with outcomes.
Among 482 323 long-stay residents included, the mean (SD) age was 82.7 (9.2) years, with 326 861 (67.8%) women, and 383 838 residents (79.6%) identifying as White. Among 137 119 residents (28.4%) diagnosed with SARS-CoV-2 during follow up, 29 204 residents (21.3%) were hospitalized, and 26 384 residents (19.2%) died within 30 days. Nursing homes explained 37.2% of the variation in risk of infection, while county explained 23.4%. Risk of infection increased with increasing body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) (eg, BMI>45 vs BMI 18.5-25: adjusted hazard ratio [aHR], 1.19; 95% CI, 1.15-1.24) but varied little by other resident characteristics. Risk of hospitalization after SARS-CoV-2 increased with increasing BMI (eg, BMI>45 vs BMI 18.5-25: aHR, 1.40; 95% CI, 1.28-1.52); male sex (aHR, 1.32; 95% CI, 1.29-1.35); Black (aHR, 1.28; 95% CI, 1.24-1.32), Hispanic (aHR, 1.20; 95% CI, 1.15-1.26), or Asian (aHR, 1.46; 95% CI, 1.36-1.57) race/ethnicity; impaired functional status (eg, severely impaired vs not impaired: aHR, 1.15; 95% CI, 1.10-1.22); and increasing comorbidities, such as renal disease (aHR, 1.21; 95% CI, 1.18-1.24) and diabetes (aHR, 1.16; 95% CI, 1.13-1.18). Risk of mortality increased with age (eg, age >90 years vs 65-70 years: aHR, 2.55; 95% CI, 2.44-2.67), impaired cognition (eg, severely impaired vs not impaired: aHR, 1.79; 95% CI, 1.71-1.86), and functional impairment (eg, severely impaired vs not impaired: aHR, 1.94; 1.83-2.05).
These findings suggest that among long-stay nursing home residents, risk of SARS-CoV-2 infection was associated with county and facility of residence, while risk of hospitalization and death after SARS-CoV-2 infection was associated with facility and individual resident characteristics. For many resident characteristics, there were substantial differences in risk of hospitalization vs mortality. This may represent resident preferences, triaging decisions, or inadequate recognition of risk of death.
重要性：养老院居民约占 SARS-CoV-2 死亡人数的 40%。
目的：确定美国养老院居民中 SARS-CoV-2 发病率、住院率和死亡率的风险因素。
设计、地点和参与者：这是一项回顾性纵向队列研究，纳入了 2020 年 4 月 1 日至 2020 年 9 月 30 日期间美国 15038 家养老院中 65 岁或以上、采用收费服务的医疗保险的长期居民。数据于 2020 年 11 月 22 日至 2021 年 2 月 10 日进行分析。
主要结局和措施：主要结局是 2020 年 9 月 30 日之前通过国际疾病分类第十次修订临床修正版（ICD-10-CM）代码诊断为 SARS-CoV-2 的风险，以及诊断后 30 天内住院或死亡。使用三级（居民、设施和县）逻辑回归模型和基于养老院设施的竞争风险模型，确定患者特征与结局的关联。
结果：在纳入的 482323 名长期居民中，平均（SD）年龄为 82.7（9.2）岁，326861 名（67.8%）为女性，383838 名（79.6%）居民自认为是白人。在 137119 名在随访期间被诊断患有 SARS-CoV-2 的居民中，29204 名（21.3%）住院，26384 名（19.2%）在 30 天内死亡。养老院解释了感染风险变异的 37.2%，而县解释了 23.4%。感染风险随体重指数（BMI）增加而增加（例如，BMI>45 与 BMI 18.5-25：调整后的危险比[aHR]，1.19；95%CI，1.15-1.24），但随其他居民特征变化不大。SARS-CoV-2 后住院风险随 BMI 增加而增加（例如，BMI>45 与 BMI 18.5-25：aHR，1.40；95%CI，1.28-1.52）；男性（aHR，1.32；95%CI，1.29-1.35）；黑人（aHR，1.28；95%CI，1.24-1.32）、西班牙裔（aHR，1.20；95%CI，1.15-1.26）或亚裔（aHR，1.46；95%CI，1.36-1.57）种族/民族；功能状态受损（例如，严重受损与未受损：aHR，1.15；95%CI，1.10-1.22）；以及增加的合并症，如肾脏疾病（aHR，1.21；95%CI，1.18-1.24）和糖尿病（aHR，1.16；95%CI，1.13-1.18）。死亡率随年龄增加而增加（例如，年龄>90 岁与 65-70 岁：aHR，2.55；95%CI，2.44-2.67），认知障碍（例如，严重受损与未受损：aHR，1.79；95%CI，1.71-1.86），以及功能障碍（例如，严重受损与未受损：aHR，1.94；1.83-2.05）。
结论：这些发现表明，在长期居住的养老院居民中，SARS-CoV-2 感染风险与县和设施居住地相关，而 SARS-CoV-2 感染后住院和死亡风险与设施和个体居民特征相关。对于许多居民特征，住院风险与死亡率之间存在显著差异。这可能代表了居民的偏好、分诊决策，或对死亡风险的识别不足。
