Improving Understanding of COVID-19–Associated Outcomes and Vaccination among Nursing Home Residents in the United States

Nursing home residents have experienced disproportionately high levels of infection and severe outcomes associated with COVID-19. In the first year of the pandemic, approximately 40% of all COVID-19 deaths in the U.S. were among nursing home residents. The tragedy of nursing homes during the COVID-19 pandemic requires attention and resources, and policymakers should advocate for greater investments to protect and meet the needs of our aging population during and outside of public health emergencies. This dissertation aims to improve the understanding of COVID-19-associated outcomes in U.S. nursing home residents and facility-level factors that may impact these outcomes. Specifically, this dissertation assesses: 1) the relationship between COVID-19 vaccination in healthcare personnel and the incidence of COVID-19 cases in nursing home residents; 2) if the ownership and operational management of a nursing home affects COVID-19 vaccination coverage and COVID-19–associated outcomes among residents; 3) and whether nursing home resident COVID-19 case data can predict community case incidence at the national and state levels. In the first paper, we found that facilities with higher percentages of HCP who were up to date with COVID-19 vaccines had lower incidence of COVID-19 cases among residents in U.S. nursing homes (odds ratio [OR] for facilities in the highest quartile of HCP vaccination vs. lowest = 0.84; 95% confidence interval [CI]: 0.79, 0.90). In the second paper, PE and REIT-invested nursing homes had significantly lower COVID-19 vaccination coverage among nursing home residents compared to residents in other for-profit, non-profit, and government-owned facilities by the end of the 2023-2024 respiratory virus season. Compared to REIT-invested nursing homes, incidence rate ratios (95% CI) of COVID-19–associated hospitalizations were lower in non-profit nursing homes (0.83, 0.73-0.94) and in government-owned nursing homes (0.82, 0.70-0.97). In the third paper, we estimated that the median weekly incidence of COVID-19 in the United States was 701.9 cases per 100,000 persons (95% CrI 701.2-702.6) from December 2020 – February 2022, and our estimates aligned closely with observed cases and accurately captured both the magnitude and trends in observed cases, including the timing of peaks in cases. Together, the papers included in this dissertation help to fill gaps in understanding of operational and nursing home-level factors that may influence COVID-19 vaccination and COVID-19–associated outcomes among residents. The results from this dissertation can be used to better understand the nursing home resident population in the US and to inform policy and prevention efforts. These studies also highlight the broad utility of the nursing home data collected in the CDC’s National Healthcare Safety Network by demonstrating their value for purposes beyond the traditional surveillance scope.