COVID-19 Pandemic Increased Long-Term Nursing Home Stay or Death Across All Groups

Regardless of race and ethnicity, all individuals experienced an increased risk of long-term nursing home (NH) stay or death during the COVID-19 pandemic, according to a study published in JAMA Network Open.¹

NH residents were disproportionately affected by the COVID-19 pandemic, accounting for 22% of cases. In particular, NHs with the highest proportion of Black residents experienced 3 times as many COVID-19–related deaths.²

Consequently, the researchers emphasized the need to understand the pandemic’s impact on the aging population, particularly as it relates to long-term NH stay or death. They defined this as new long-term NH residence following hospitalization or postdischarge death among adults who were community dwelling before hospitalization. Although prior studies have examined the pandemic’s effect on postacute care, its association with long-term NH stay or death remains unreported.

Therefore, they investigated the association between the pandemic and long-term NH stay or death among community-dwelling individuals aged 65 and older who were hospitalized with sepsis; sepsis is a leading cause of death in the US and disproportionately affects minoritized groups. The study also examined whether individuals from racial and ethnic minoritized groups were more likely to experience long-term NH stay or death compared with White individuals during the pandemic.

Although long-term nursing home stay or death decreased before the COVID-19 pandemic, the trend slowed during the pandemic across all racial and ethnic groups. | Image Credit: New Africa - stock.adobe.com

The researchers considered patients discharged alive to have experienced long-term NH stay or death if they resided in an NH for 101 days post hospital discharge without spending more than 30 days at home, or if they died 30 or more days post discharge; the 101-day threshold was chosen because Medicare covers NH care for up to 100 days.

They conducted the study using patient-level data from the 100% Medicare Provider Analysis and Review (MEDPAR) File, the Master Beneficiary Summary (MBS) file, and the Minimum Data Set (MDS) between 2016 and 2021. The MEDPAR and MBSF files contain demographic measures; the International Statistical Classification of Diseases, 10th Revision (ICD-10) diagnosis and procedure codes; and admission and death dates. Additionally, the MDS includes assessment data for NH residents, covering admissions, discharges, and Medicare coverage for postacute care. These data were merged with the CMS Impact File, which provides hospital characteristic information.

The researchers initially identified 4,970,875 community-dwelling individuals hospitalized for sepsis between January 1, 2016, and December 31, 2021. However, based on their inclusion criteria, the study population consisted of 2,964,517 community-dwelling patients hospitalized for sepsis who were discharged alive. Patients were considered community dwelling if they had lived in the community for at least 30 days before their sepsis hospitalization. Sepsis was identified using relevant ICD-10 codes, while race and ethnicity were categorized using the Research Triangle Institute codes.

Of the study population, 49.5% (n = 1,468,754) were female, and the mean (SD), age was 76 (8.3) years. In terms of race and ethnicity, 3.2% (n = 95,308) of patients were American Indian or Alaska Native patients, 9.4% (n = 279,011) were Hispanic, 9.5% (n = 282,646) were Black, and 71.2% (n = 2,288,003) were White.

After controlling for age and sex, Black individuals were more likely to experience long-term NH stay or death (adjusted OR [aOR], 1.33; 95% CI, 1.30-1.37; P < .001) during the prepandemic period than White individuals. Conversely, American Indian or Alaska Native (aOR, 0.79; 95% CI, 0.72-0.87; P < .001), Asian or Pacific Islander (aOR, 0.79; 95% CI, 0.75-0.83; P < .001), and Hispanic (aOR, 0.72; 95% CI, 0.70-0.74; P < .001) individuals were less likely to experience long-term NH stay or death than White individuals during the prepandemic period.

Overall, long-term NH stay or death declined from 13.5% in the first quarter of 2016 to 6.9% in the first quarter of 2020. After adjusting for comorbidities, in-hospital complications, and hospital characteristics, the odds of long-term NH stay or death decreased by 4.2% each quarter before the pandemic (aOR, 0.958; 95% CI, 0.957-0.959; P < .001).

In particular, the pandemic was associated with an increase in the risk of long-term NH stay or death over time among non-Hispanic White individuals (aOR, 1.03; 95% CI, 1.02-1.04; P < .001 [each quarter]). Conversely, compared with White patients, the researchers did not find associations between the pandemic and differential changes in long-term NH stay or death for minoritized individuals.

The researchers acknowledged several limitations of their study, including it being restricted to older community-dwelling individuals hospitalized due to sepsis. Consequently, their findings may not be generalizable to individuals younger than 65, those hospitalized with other serious medical conditions, or those who lose independence without a prior hospitalization. Despite these limitations, the researchers expressed confidence in their findings and outlined actionable next steps.

“Among all individuals, regardless of race and ethnicity, decreases in long-term NH stay or death slowed during the pandemic,” the authors concluded. “The renewed focus on NHs during the pandemic presents an opportunity to strengthen NHs, which serve as the safety net for the most at-risk older individuals.”

References

1. Glance LG, Joynt Maddox KE, Stone PW, et al. COVID-19 Pandemic and racial and ethnic disparities in long-term nursing home stay or death following hospital discharge. JAMA Netw Open. 2025;8(1):e2456816. doi:10.1001/jamanetworkopen.2024.56816
2. Gorges RJ, Konetzka RT. Factors associated with racial differences in deaths among nursing home residents with COVID-19 infection in the US. JAMA Netw Open. 2021;4(2):e2037431. doi:10.1001/jamanetworkopen.2020.37431