Abstract
Background:
While many healthcare settings have since returned to pre-pandemic levels of operation, long term care facilities have experienced extended and significant changes to operations, including unprecedented levels of short staffing and facility closures, that may have a detrimental effect on resident outcomes. This study assessed the pandemic’s extended effect on outcomes for LTC residents, comparing outcomes one and two years after the start of the pandemic to pre-pandemic times, with special focus on residents with frailty and dually enrolled in Medicare and Medicaid.
Methods:
Using Medicare claims data from January 1, 2018, through December 31, 2022, we ran over-dispersed Poisson models to compare the monthly adjusted rates of emergency department use, hospitalization, and mortality among LTC residents, comparing residents with and without frailty and dually enrolled and non-dually enrolled residents.
Results:
Two years after the start of the pandemic, adjusted ED and hospitalization rates were lower and adjusted mortality rates were higher compared to pre-pandemic years for all examined subgroups. For example, compared to 2018–19, 2022 ED visit rates for dually enrolled residents were 0.89 times lower, hospitalization rates were 0.87 times lower, and mortality rates were 1.17 higher; and 2022 ED visit rates for frail residents were 0.85 times lower, hospitalization rates were 0.83 times lower, and mortality rates were 1.21 higher.
Conclusions:
In 2022, emergency department and hospital utilization rates among long term residents were lower than pre-pandemic levels and mortality rates were higher than pre-pandemic levels. These findings suggest that the pandemic has had an extended impact on outcomes for long term care residents.
Keywords: Long-term care, Frail Elderly, dual Medicaid Medicare eligibility, COVID-19, pandemics
INTRODUCTION
The COVID-19 pandemic had a disproportionate impact on long-term care (LTC) residents, defined as people who live in residential care facilities such as nursing homes. Not only were LTC residents more physically vulnerable to serious manifestations of COVID-19 due to a high burden of comorbidities, but they also spend much of their time in communal settings where COVID-19 is more likely to spread. Further, from March 2020 to November 2021 many skilled nursing facilities closed their premises to all visitors to control disease spread. This may have been effective in reducing the spread of infection, but it also imposed isolation and caused stress that may have worsened functional and clinical outcomes among this vulnerable group.1 Unprecedented levels of nursing home staff shortages at many facilities brought on by the pandemic may have compromised care quality in LTC settings; the nursing home workforce is the only healthcare workforce that had still not returned to pre-pandemic levels as of 2023.2
Although all LTC residents were at higher risk of adverse outcomes, certain subgroups may have been at even greater risk such as those with frailty and those that are dually enrolled in both Medicaid and Medicare. Frail nursing home residents can be characterized by a loss of muscle mass and strength, leading to worse functional impairment.2 Dual eligible individuals have their long-stay nursing home care covered by Medicaid if they meet both income and asset eligibility tests.3 These groups are especially likely to be impacted by these changes due to their high levels of medical and social complexity. Even before the pandemic, people with frailty were at markedly increased risk of poor outcomes compared to those without frailty,4 and significant disparities in quality of care for dually enrolled residents have been documented since the early 2000s.4,5 Decrements in staffing or other substandard quality practices might be expected to harm these groups disproportionately.
Several previous studies have examined changes in health care utilization and outcomes associated with the pandemic.6 However, we are unaware of previous studies that have examined the extended effect (through 2022) of the pandemic on outcomes for LTC residents, and most specifically, on vulnerable subgroups that are most at risk for adverse outcomes. In this study, we focused on two vulnerable subgroups—those who are frail and those who are dually eligible for Medicare and Medicaid. We used national data to assess long-term care residents’ ED visit, hospitalization, and mortality rates to determine whether and how outcomes among these vulnerable groups have changed compared to pre-pandemic levels.
METHODS
Data Source and Measures.
We used Medicare inpatient, outpatient, skilled nursing, carrier, and hospice claims data for 100% of fee-for-service Medicare beneficiaries from January 1, 2018 through December 31, 2022. We identified LTC residents residing in care facilities (as opposed to short stay patients who come to skilled nursing facilities for post-acute care and are there only temporarily) using a previously validated algorithm,7 altering the algorithm to allow beneficiaries to enter and exit the cohort on a monthly rather than annual basis. Designation of frailty was based on a validated claims-based frailty index that incorporated information from ICD-10 codes.8–10 Residents were considered frail if they scored at or above 0.45 on the frailty index, as has been previously recommended. Dual-Medicaid enrollment and original reason for Medicare entitlement were obtained from the enrollment file. Additional variables of interest included age, sex, race, and comorbidities. Resident race was determined using the RTI imputed race variable; this variable draws from the Social Security database which groups people into mutually exclusive categories of American Indian/Alaska Native, Asian/Pacific Islander, Black, Hispanic, other (including multiracial), and non-Hispanic white, and augments it with surname and address information to increase sensitivity for non-Hispanic white racial and ethnic groups. Due to cell size limitations, American Indian/Alaska Native, Asian/Pacific Islander, other, and missing/unknown were grouped together for the purposes of reporting LTC resident characteristics. Comorbidities were identified by chronic conditions warehouse (CCW) flags.
Our primary outcomes were the monthly counts of visits to the emergency department without subsequent hospitalization, hospitalization, and mortality. Outcome measures were calculated as the average number of events among residents in each population per month. In our results, we present outcomes standardized as rates per 100 resident-months.
Analyses.
Characteristics of long-term care residents and skilled nursing facilities were compared across years 2018 – 2022. Descriptive figures showing monthly, unadjusted population-level emergency department (ED) visit rates, hospitalization rates, and mortality rates were created by summing across all LTC residents for each month. To examine the balance in resident characteristics by frail and dual status, we calculated standardized mean differences (SMD). The SMD describes the difference between two groups, standardized by the pooled standard deviation of both groups and allows for a more meaningful comparison across groups with large sample sizes.5 Following prior work, we considered an SMD greater than 0.1 to be a very small difference, 0.2 a small difference, 0.5 a medium difference, 0.8 a large difference, and 1.2 a very large difference.6–9
To adjust for changes over time in resident characteristics, average monthly outcome rates were estimated by linear regression using indicator variables for time periods as the primary predictors, and resident age, sex, race, dementia, frailty, CCW comorbidities, and dual eligibility as adjustment covariates. To formally compare outcomes between time periods and between LTC resident subgroups, we used over-dispersed Poisson models with the resident-month as the unit of analysis. Poisson models were chosen in order present more interpretable rate ratios. All models were adjusted for quarterly fixed effects and resident age, sex, race, dementia, and comorbidities to account for changes in LTC resident composition over time. To compare across time periods, we included fixed effects for 2018/19 as our pre-COVID period, 2020 for the start of the pandemic, and 2021 and 2022 for one and two years after the start of the pandemic, respectively. Differences between time periods were estimated as the ratios of rates between each time period and our pre-pandemic period. A ratio greater than one suggests that the rates increased between years, while a ratio less than one suggests that the rates decreased.
Differences between LTC resident subgroups were estimated as ratios or rates between subgroups in each time period (e.g., frail vs non-frail in the 2018/2019 pre-pandemic period). Finally, we calculated ratios of ratios to compare how differences between LTC resident subgroups changed over time. For example, the ratio of ratios for frail compared to non-frail residents between 2020 and 2018/19 can be interpreted as how much the gap between frail and non-frail residents have widened or narrowed between 2020 and 2018/19. A ratio greater than one suggests that the gap widened while a ratio less than one suggests that the gap narrowed. Results are presented as adjusted rates for each time period, followed by adjusted rate ratios, with 95% confidence intervals.
A two-tailed p-value less than 0.05 was considered statistically significant, though secondary outcomes should be considered exploratory given the large number of outcomes assessed. All analyses were performed using SAS statistical software on the Medicare Virtual Research Data Center.
RESULTS
LTC Resident Characteristics.
Our dataset contained a total of 73,794,726 beneficiary-month observations. Pre-COVID (2018/19), LTC residents were more likely to be older, frail, have dementia, and have more chronic conditions than long-term care residents 2 years after the start of the pandemic (2022) (Supplementary Table S1 in Supplemental Material). Residents with frailty were more likely to be dually enrolled, older, female, not have qualified for Medicare due to a disability, have dementia, and have more chronic conditions than residents without frailty (Table 1). Dually enrolled residents were more likely to be frail, and were much younger, more often male, more likely to have qualified for Medicare due to a disability, to have dementia, to have more chronic conditions, and to be Black, Hispanic, or Asian-PI/AI-AN/unknown/other race than residents who were not dually enrolled (Table 1).
Table 1.
Long-Term Care (LTC) Resident Characteristics by Frailty and Dual-Eligibility Status
| LTC Resident Characteristics | By Frail Status | By Dual Status | ||||
|---|---|---|---|---|---|---|
| Frail | Non-Frail | SMD1 | Dual | Non-Dual | SMD1 | |
| N of unique LTC Residents | 4,637,396 | 4,777,902 | 5,404,310 | 4,010,988 | ||
| Frail | 100.00% | 0.00% | 54.5% | 47.8% | 0.134 | |
| Medicaid Dual Eligible | 66.3% | 60.1% | 0.130 | 100.0% | 0.0% | |
| Age | ||||||
| Age 64 and under | 10.2% | 13.8% | 0.113 | 17.4% | 2.5% | 0.472 |
| Age 65–79 | 33.2% | 31.5% | 0.036 | 36.4% | 25.6% | 0.232 |
| Age 80+ | 56.6% | 54.6% | 0.040 | 46.2% | 71.9% | 0.534 |
| Female | 66.9% | 61.2% | 0.118 | 63.7% | 65.0% | 0.029 |
| Qualified for Medicare based on a disability, without ESRD | 9.9% | 13.7% | 0.119 | 17.1% | 2.4% | 0.468 |
| Dementia | 68.0% | 33.9% | 0.727 | 53.9% | 47.8% | 0.122 |
| Number of Chronic Conditions | 10.59 | 5.71 | 1.496 | 8.47 | 7.87 | 0.148 |
| Race | ||||||
| White | 78.9% | 78.2% | 0.017 | 71.6% | 90.6% | 0.476 |
| Black | 12.2% | 12.5% | 0.008 | 16.7% | 4.9% | 0.363 |
| Hispanic | 5.8% | 5.6% | 0.012 | 7.8% | 2.1% | 0.243 |
| Unknown or Other | 3.1% | 3.8% | 0.039 | 4.0% | 2.3% | 0.093 |
SMD = Standardized Mean Difference
Unadjusted Rates
Monthly all-cause unadjusted ED visit, hospitalization, and mortality rates per year are illustrated in Figure 1 and 2. As expected, monthly trends show a drop in hospitalization and ED visits and a spike in mortality rates among all subgroups in April 2020. In 2021–22, for most months, ED visit and hospitalization rates were lower and mortality rates were higher than pre-pandemic levels for both frail and non-frail residents. (Figure 1). Similar trends were observed for dually enrolled and non-dually enrolled residents. In 2021–22, for most months, ED visit and hospitalization rates were lower and mortality rates were higher than pre-pandemic levels for both dually enrolled and non-dually enrolled residents. (Figure 2).
Figure 1. Monthly Unadjusted Emergency Department (ED) Visit, Hospitalization and Mortality Rates for Non-Frail and Frail Long Term Care Residents.
Unadjusted rates presented are the average monthly incidence rate per resident-month.
Figure 2. Monthly Unadjusted Emergency Department (ED) Visit, Hospitalization and Mortality Rates for Non-Dually Enrolled and Dually Enrolled Long Term Care Residents.
Unadjusted rates presented are the average monthly incidence rate per resident-month.
Adjusted Rates
Adjusted monthly rates by year are shown in Figure 3 and Supplementary Table S2 in Supplemental Material. Compared to pre-pandemic years, adjusted monthly ED visit rates were lower for all subgroups in 2020–2022. In 2022, adjusted monthly ED visit rates were 0.85–0.90 times lower than pre-pandemic years. For example, among frail residents, adjusted monthly ED visit rates were 7.51% in 2018–19, 5.27% in 2020, 6.30% in 2021, and 6.61% in 2022. (Figure 3, Supplementary Table S2 in Supplemental Material) Compared to pre-pandemic years, adjusted monthly hospitalization rates were lower for all subgroups in 2020–2022. In 2022, adjusted monthly hospitalization rates were 0.83–0.87 times lower than pre-pandemic years in 2022. For example, among frail residents, adjusted monthly hospitalization rates were 7.67% in 2018–19, 6.46% in 2020, 6.46% in 2021, and 6.49% in 2022. Compared to pre-pandemic years, adjusted monthly mortality rates were higher for all subgroups in 2020–2022. At the end of the study period, adjusted monthly mortality rates were 1.10–1.21 times higher than pre-pandemic years in 2022. For example, among frail residents, adjusted monthly mortality rates were 2.94% in 2018–19, 4.02% in 2020, 3.17% in 2021, and 3.22% in 2022.
Figure 3. Average Monthly Adjusted All-Cause Emergency Department (ED) Visit, Hospitalization, and Mortality Rates by Frailty and Dual-Eligibility.
Adjusted rates presented are yearly averages of the monthly incidence rate per resident-month.
Subgroup Differences in Adjusted Rates
Pre-pandemic differences existed between frail and non-frail LTC residents, with higher adjusted monthly ED visit, hospitalization, and mortality rates among the frail. During and after the pandemic, the direction of these differences persisted, but the magnitudes changed. For example, compared to non-frail residents, frail residents were 1.25 times more likely to die in 2020, 1.23 times more likely to die in 2021, and 1.14 times more likely to die in 2022. (Table 2) Compared to non-frail residents, frail residents had a greater increase in the risk of ED visits and hospitalizations in 2022 vs pre-pandemic (ratio of ratios 1.05 and 1.05, respectively) but a smaller increase in mortality (ratio of ratios 0.91).
Table 2.
Differences in Adjusted All-Cause Emergency Department (ED) Visit, Hospitalization, and Mortality Rates by Frailty and Dual-Eligibility
| Subgroup | Pre-Pandemic (2018–19) | Start of Pandemic (2020) | 2020 vs. 2018–19 | 1 Year After (2021) | 2021 vs. 2018–19 | 2 Years After (2022) | 2022 vs. 2018–19 |
|---|---|---|---|---|---|---|---|
| Ratio between Groups (95% CI) | Ratio between Groups (95% CI) | Ratio of Ratios (95% CI) | Ratio between Groups (95% CI) | Ratio of Ratios (95% CI) | Ratio between Groups (95% CI) | Ratio of Ratios (95% CI) | |
| ED Visits | |||||||
| Frail vs Non-Frail | 1.21 (1.20, 1.21) |
1.15 (1.15, 1.16) |
0.96 (0.95, 0.96) |
1.19 (1.18, 1.19) |
0.98 (0.98, 0.99) |
1.27 (1.26, 1.28) |
1.05 (1.05, 1.06) |
| Dual vs Non-Dual | 0.78 (0.78, 0.78) |
0.80 (0.79, 0.8) |
1.03 (1.02, 1.03) |
0.72 (0.72, 0.72) |
0.93 (0.92, 0.93) |
0.75 (0.75, 0.76) |
0.97 (0.96, 0.97) |
| Hospitalization | |||||||
| Frail vs Non-Frail | 1.11 (1.11, 1.11) |
1.05 (1.05, 1.06) |
0.95 (0.94, 0.95) |
1.08 (1.07, 1.08) |
0.97 (0.97, 0.98) |
1.16 (1.16, 1.17) |
1.05 (1.04, 1.05) |
| Dual vs Non-Dual | 0.73 (0.72, 0.73) |
0.79 (0.79, 0.8) |
1.09 (1.09, 1.1) |
0.67 (0.67, 0.68) |
0.93 (0.92, 0.93) |
0.71 (0.71, 0.71) |
0.98 (0.97, 0.98) |
| Mortality | |||||||
| Frail vs Non-Frail | 1.25 (1.24, 1.26) |
1.25 (1.24, 1.26) |
1.00 (0.99, 1.01) |
1.23 (1.22, 1.24) |
0.98 (0.98, 0.99) |
1.14 (1.13, 1.14) |
0.91 (0.90, 0.92) |
| Dual vs Non-Dual | 0.81 (0.81, 0.82) |
1.08 (1.07, 1.09) |
1.33 (1.32, 1.34) |
0.82 (0.81, 0.82) |
1.01 (1.00, 1.02) |
0.78 (0.77, 0.78) |
0.96 (0.95, 0.97) |
Note: Ratios presented are ratios of the average monthly adjusted incidence rate per resident-month such that ratios > 1.0 suggest that the rates are larger for frail/dual residents compared to non-frail non-dual residents, respectively. Ratio of ratios represent the change over time, such that ratio of ratios > 1.0 suggest that the gap between frail/non-frail or dual/non-dual is wider between years.
For dually enrolled compared to non- dually enrolled LTC residents, we found different patterns. Compared to non-dually enrolled residents, dually enrolled residents had lower adjusted monthly ED visit and hospitalization rates in 2018–19 (0.78 and 0.73, respectively), higher adjusted monthly ED visit and hospitalization rates in 2020 (1.03 and 1.09, respectively), and lower monthly adjusted ED visit and hospitalization rates in 2021 and 2022 (0.72 and 0.67, and 0.75 and 0.71 respectively). Dually enrolled residents were 0.81 (95% CI: 0.81, 0.82) times less likely to die than non-dually enrolled residents in 2018–19. During the pandemic, dually enrolled residents were 1.08 (95% CI: 1.07, 1.09) times more likely to die than non-dually enrolled residents. In 2021 and 2022, this difference decreased back to baseline (0.82 and 0.78, respectively). 2022 vs pre-pandemic differences in adjusted monthly ED visits, hospitalizations, and mortality rates were similar between dually enrolled and non-dually enrolled LTC residents (ratio of ratios 0.97, 0.98, and 0.96, respectively). (Table 2)
DISCUSSION
In this study, we found surprisingly lower rates of emergency department use and hospitalization and higher rates of mortality in 2022 compared with pre-pandemic across all subgroups examined (i.e., frail, non-frail, dual, and non-dual). Lower rates of ED and hospitalizations may indicate that LTC facilities have made meaningful COVID-related shifts in their capacity to care for residents in place, such as through on-site assessment, telehealth, or clinician visits, and/or that patient preferences to seek emergency department care and inpatient care have changed. The waiver of the three-day hospital rule early in the pandemic may have also incentivized SNFs to avoid transfers.10 However, given both ongoing and widespread issues with staffing and the observed higher rates of mortality, the explanation that LTC residents increased in their capacity to care for LTC residents onsite is not likely the whole story. It is possible that the decrease in ED visit and hospitalization rates were driven by a shortage of hospital beds caused by high ED/hospital occupancy, or by a decrease in medical acuity among LTC residents caused by a healthy survivor effect. Another possible explanation is that LTC facilities have been selecting healthier patients. In addition, it is possible that the long-term effects of COVID, including chronic inflammation and other sequelae, among LTC residents lowered overall health, increasing mortality rates. Understanding the causes and consequences of this change in utilization patterns and mortality rates is important and will require additional research, likely site-based and qualitative in nature.
Our study suggests that LTC residents with frailty are at a higher risk of adverse clinical outcomes than those without frailty two years after the pandemic. Interestingly, the difference in ED visit and hospitalization rates between frail and non-frail LTC residents was wider in 2022 than pre-pandemic, but narrower for mortality. Although ED and hospital use decreased for both groups after the pandemic, utilization dropped further for non-frail residents in the year immediately after the pandemic and recovered faster in 2022. Frailty is a well-established risk factor for adverse clinical outcomes,11–13 and overlaps with multiple conditions that would make beneficiaries particularly susceptible to COVID, as well as to any decreases in staffing related to its aftermath. It is unclear why ED visit and hospitalization rates would have improved less for frail than non-frail residents. It may be that interventions driving the observed decreases in ED visits and hospitalizations may have disproportionately benefited less-frail residents, however the concomitant mortality findings are harder to explain. It is feasible that there is a healthy survivor effect that remains through 2022, such that LTC residents in general are at lower risk of mortality than their pre-pandemic counterparts, in ways that are not reflected in the frailty index or CCW comorbidities.
We did not find any evidence of a lasting disproportionate impact of pandemic-related changes to clinical outcomes among LTC residents who were dually enrolled in Medicare and Medicaid. Indeed, we found that at baseline and for the most part throughout the study period (with the notable exception of 2020), dually enrolled residents had better outcomes than those who were not dually enrolled. It may be that that dually enrolled LTC residents tend to be of a much lower age, although measures of frailty and comorbidity were more similar between the two groups. Prior studies have also shown lower levels of dual/non-dual inequities within SNFs than in other care settings,14 perhaps because facilities provide food, shelter, access to medications, social support, and a host of other resources that may level the ground between people living in poverty and those not living in poverty. Our finding that residents who were dually enrolled in 2020 had significantly higher mortality rates in 2020 than non-dually enrolled residents suggests that the pandemic disproportionately impacted residents with lower means who may have been more susceptible to pandemic-related harms either because of outsized exposure to the disease, residence in facilities with fewer resources, and/or accumulated stressors over the life course.
Results from our study must be interpreted with several limitations in mind. First, our study is limited to Medicare beneficiaries living in long-term care facilities and does not provide insight into outcomes for individuals in need of but unable to access long-term care due to COVID-related nursing home closures or decreased capacity due to staffing shortages. Second, our study is associational and not casual. Although we hypothesize that COVID-related disruptions led to poorer outcomes among long-term care residents, more research is necessary to understand the potential multitude of mechanisms that caused these changes, including how the pandemic impacted long-term care facility staffing, quality, and supply. Third, we describe differences in outcomes by patient subgroups, but are not able to provide insight into the potential causes of those differences. Additional research is needed to understand how the “new normal” of nursing home care delivery has changed for frail and dual-eligible adults, especially in light of differential underlying causes of ED use and hospitalization that may be driven by broader societal inequities and upstream determinants of health (e.g., healthcare access, differences in wealth and education, smoking, obesity). Furthermore, more work is necessary to understand how pandemic-related changes in the receipt of ED and inpatient care impacted mortality rates, especially for marginalized populations. Finally, our study sample is limited to fee-for-service Medicare beneficiaries and results may not generalize to non-fee-for-service Medicare long-term care populations, including Medicare Advantage beneficiaries and residents too young to qualify for Medicare, both of which are likely to be disproportionately made up of people of color.
In conclusion, we found that the COVID-19 pandemic was associated with extended changes in outcomes among Medicare beneficiaries in long-term care settings, including significant and sustained decreases in monthly rates of emergency department and hospital utilization and significant and sustained increases in monthly mortality rates. The gap in ED and hospital utilization between frail and non-frail LTC residents, but not the gap in mortality, widened after the pandemic. Further research is needed to understand the changes in care delivery that underlie these patterns.
Supplementary Material
Supplementary Table S1. Long-term Care (LTC) Resident Characteristics
Supplementary Table S2. Adjusted All-Cause Emergency Department (ED) Visit, Hospitalization, and Mortality Rates by Frailty and Dual-Eligibility
Key points:
Two years after the start of the COVID-19 pandemic devastated long term care communities, ED visit and hospitalization rates have dropped below pre-pandemic levels while mortality rates remain elevated.
Monthly mortality rates for frail residents in 2022 were 1.21 times (0.27 percentage points) higher than in 2018–19 (3.22% compared to 2.94%), and monthly mortality rates for dual-Medicaid enrollees in 2022 were 1.17 times (0.28 percentage points) higher than in 2018–19 (2.73% compared to 2.45%).
Differences between residents with versus without frailty in ED visit, hospitalization, and mortality rates have decreased since the start of the pandemic, though frail residents were still at a higher risk of experiencing an ED visit or hospitalization than non-frail residents in 2022.
Why does this paper matter?
The COVID-19 pandemic continues to have an effect on outcomes for long-term care residents, including significant decreases in emergency department and hospital utilization and increases in mortality rates.
Funding:
National Institute on Aging of the National Institutes of Health (R01 AG060935–01).
Conflict of Interest Statement:
Dr. Joynt Maddox previously served on the Health Policy Advisory Council for the Centene Corporation (St. Louis, MO) and received research funding from Humana. The remaining authors declare no conflicts.
Sponsor’s Role:
This research was supported by the National Institutes of Health’s National Institute on Aging, grant R01 AG060935-01. This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Institute on Aging.
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Associated Data
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Supplementary Materials
Supplementary Table S1. Long-term Care (LTC) Resident Characteristics
Supplementary Table S2. Adjusted All-Cause Emergency Department (ED) Visit, Hospitalization, and Mortality Rates by Frailty and Dual-Eligibility