A national study of long-stay skilled nursing facilities may shed new light on where residents’ greatest risks lie for COVID-19-related infections, hospitalization and death. And new risk factors, including impaired cognition and physical functioning, also were identified, investigators said. 

The retrospective cohort study is the first of its kind, according to the researchers. Investigators followed COVID-19 transmission rates and clinical outcomes between April 1 and Sept. 30, 2020 among more than 480,000 facility residents aged 65 years or older with fee-for-service Medicare. Participants represented 15,000 U.S. facilities.

Infections were associated with geographic area and specific facility, whereas resident characteristics played a large role in the risk of hospitalization and death, reported James S. Goodwin, M.D., of Johns Hopkins University.

There was a large divergence between how much individual characteristics — such as age, race/ethnicity, cognitive status, and functional status — were linked to hospitalization versus the magnitude of their link to mortality, Goodwin and colleagues found. When they considered race/ethnicity and body mass index, for example, residents’ likelihood of hospitalization was considerably higher than the magnitude of risk for mortality. 

Residents who were Black, Hispanic, or Asian had substantially higher risk of hospitalization after SARS-CoV-2 diagnosis, but the risk for mortality was very close to that of white residents. 

With other characteristics, meanwhile, the risk of death was substantially higher than the odds of hospitalization. 

Severe cognitive or functional impairment or having a feeding tube, intravenous line, or catheter, were associated with an increased risk of infection. These characteristics may indicate the need for more care and staff contact, which could contribute to risk, the authors wrote.

The risk of hospitalization with increasing age was inconsistent, in contrast with flu and other illnesses, where hospitalization risk tends to increase with age, the authors wrote. The reasons for this finding are complex, but may include resident preferences, triaging decisions or inadequate assessment of mortality risk, they said.

The study was published Wednesday in JAMA Network Open.