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Death risk stratification in elderly patients with covid-19. A comparative cohort study in nursing homes outbreaks.

ABSTRACT: Elderly people are more severely affected by COVID-19. Nevertheless scarce information about specific prognostic scores for this population is available. The main objective was to compare the accuracy of recently developed COVID-19 prognostic scores to that of CURB-65, Charlson and PROFUND indices in a cohort of 272 elderly patients from four nursing homes, affected by COVID-19. Accuracy was measured by calibration (calibration curves and Hosmer-Lemeshov (H-L) test), and discriminative power (area under the receiver operation curve (AUC-ROC). Negative and positive predictive values (NPV and PPV) were also obtained. Overall mortality rate was 22.4 %. Only ACP and Shi et al. out of 10 specific COVID-19 indices could be assessed. All indices but CURB-65 showed a good calibration by H-L test, whilst PROFUND, ACP and CURB-65 showed best results in calibration curves. Only CURB-65 (AUC-ROC = 0.81 [0.75-0.87])) and PROFUND (AUC-ROC = 0.67 [0.6-0.75])) showed good discrimination power. The highest NPV was obtained by CURB-65 (95 % [90-98%]), PROFUND (93 % [77-98%]), and their combination (100 % [82-100%]); whereas CURB-65 (74 % [51-88%]), and its combination with PROFUND (80 % [50-94%]) showed highest PPV. PROFUND and CURB-65 indices showed the highest accuracy in predicting death-risk of elderly patients affected by COVID-19, whereas Charlson and recent developed COVID-19 specific tools lacked it, or were not available to assess. A comprehensive clinical stratification on two-level basis (basal death risk due to chronic conditions by PROFUND index, plus current death risk due to COVID-19 by CURB-65), could be an appropriate approach.

SUBMITTER: Bernabeu-Wittel M

PROVIDER: S-EPMC7446617 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ImportanceIt is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic.ObjectiveTo evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes.Design, setting, and participantsThis cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics.ExposureNursing home ownership status.Main outcomes and measuresSelf-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages.ResultsOf 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, -69.2 to -1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% (14.8 percentage points; 95% CI, 6.5 to 23.0 percentage points; P < .001), respectively, more likely to have at least a 1-week supply of N95 masks than PE-owned nursing homes. They were 24.3% (21.3 percentage points; 95% CI, 11.8 to 30.8 percentage points; P < .001), 30.7% (27.0 percentage points; 95% CI, 17.7 to 36.2 percentage points; P < .001), and 29.2% (25.7 percentage points; 95% CI, 16.1 to 35.3 percentage points; P < .001) more likely to have a 1-week supply of medical gowns than PE-owned nursing homes. Government nursing homes were more likely to have a shortage of nurses (6.9 percentage points; 95% CI, 0.0 to 13.9 percentage points; P = .049) than PE-owned nursing homes.Conclusions and relevanceIn this cross-sectional study, PE-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring.

Project description:Nursing homes are high-risk settings for outbreaks of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). During the COVID-19 pandemic, U.S. health departments worked to improve infection prevention and control (IPC) practices in nursing homes to prevent outbreaks and limit the spread of COVID-19 in affected facilities; however, limited resources have hampered health departments' ability to rapidly provide IPC support to all nursing homes within their jurisdictions. Since 2008, the Centers for Medicare & Medicaid Services (CMS) has published health inspection results and quality ratings based on their Five-Star Quality Rating System for all CMS-certified nursing homes (3); these ratings might be associated with facility-level risk factors for COVID-19 outbreaks. On April 17, 2020, West Virginia became the first state to mandate and conduct COVID-19 testing for all nursing home residents and staff members to identify and reduce transmission of SARS-CoV-2 in these settings (4). West Virginia's census of nursing home outbreaks was used to examine associations between CMS star ratings and COVID-19 outbreaks. Outbreaks, defined as two or more cases within 14 days (with at least one resident case), were identified in 14 (11%) of 123 nursing homes. Compared with 1-star-rated (lowest rated) nursing homes, the odds of a COVID-19 outbreak were 87% lower among 2- to 3-star-rated facilities (adjusted odds ratio [aOR] = 0.13, 95% confidence interval [CI] = 0.03-0.54) and 94% lower among 4- to 5-star-rated facilities (aOR = 0.06, 95% CI = 0.006-0.39). Health departments could use star ratings to help identify priority nursing homes in their jurisdictions to inform the allocation of IPC resources. Efforts to mitigate outbreaks in high-risk nursing homes are necessary to reduce overall COVID-19 mortality and associated disparities. Moreover, such efforts should incorporate activities to improve the overall quality of life and care of nursing home residents and staff members and address the social and health inequities that have been recognized as a prominent feature of the COVID-19 pandemic in the United States (5).

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Death risk stratification in elderly patients with covid-19. A comparative cohort study in nursing homes outbreaks.

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