Despite the federal government supplying every eligible nursing home in the country with COVID-19 rapid-testing equipment, only a small fraction of them were taking advantage of it, a team of researchers revealed Friday.

Even in “hot spot” counties where the Department of Health and Human Services had delivered point-of-care devices by mid-August, less than 17% of providers posted testing turnaround times of less than 24 hours as of late September. 

“Lots of facilities are not even using the test,” study lead Brian McGarry, Ph.D., of the Division of Geriatrics and Aging, Department of Medicine, at the University of Rochester, told McKnight’s. “They receive them and they’re just sitting on a shelf someplace. And then the ones who are using them, it appears that it’s not their primary means of testing. It’s kind of like an add-on.”

Brian McGarry, Ph.D.
Brian McGarry, Ph.D.

McGarry and three Harvard-affiliated researchers posted their findings in a research letter in JAMA Internal Medicine on Friday. 

Test turnaround was three days or longer for 55% of skilled nursing facilities for the first week of September. It decreased to 40% by Sept. 27. Epidemiologists consider a 24-hour or less turnaround “essential” to preventing or containing COVID-19 outbreaks.

The rapid tests can produce results in roughly 15 minutes, but feedback option used by federal regulators was “less than 24 hours,” researchers explained.

“It’s fairly obvious: They’re just not using these test kits,  in a major way,” researcher David Grabowski, Ph.D., a Harvard health policy professor, told McKnight’s on Friday. “This is a call to arms. [Adoption rates] will improve over time on their own, but there are some steps that providers and government can do to hasten that. Rapid testing has to be a part of the solution.”

McGarry said that the testing and turnaround is “a bottleneck” that must be overcome as quickly as possible. “We’ve seen other countries have more success with contact tracing and isolation and quarantine protocols, usually done on the back of a robust testing system that can turn around results rapidly.”

SOURCE: JAMA Internal Medicine, published online Oct. 30, 2020

There are several reasons why providers are either reluctant or unable to use the rapid tests. Some believe that the false-negative rate, which has been estimated at about 20%, is too high, while McGarry pointed out that such rapid antigen tests are “primarily good” at ruling COVID in or out when the test subject is symptomatic.

“There’s a lack of trust in these test kits to a certain extent,” he said, noting that one state (Nevada) went as far as briefly discontinuing their use before federal officials stepped in to compel otherwise. “There’s a disconnect where people are getting these test kits and saying this isn’t suited for the purpose we need them for right now.”

Cost-benefit considered

The researchers noted that despite the Centers for Medicare & Medicaid Services offering certain teaching resources on how and when to use the devices, providers are looking for more. Operators also note they need to have workers available to process results, and report them to authorities, as is required of all testers.

“Some feel they would have to pull nurses or aides to do some of this, but because they feel the tests aren’t perfect, they view it as another layer of time costs,” McGarry said. “It’s a tough situation. Each nursing home needs to decide individually.

“It looks like lots of facilities are sort of voting with their feet and not using these kits because they’re not finding them valuable, based on the costs they need to invest in getting them up and running,” he added.

David Grabowski, Ph.D.

Grabowski noted that 10.4% of providers in hot spot counties were getting less than one-day turnaround in early September and the number had risen to 16.4% near the end of the month. “That’s unacceptable,” he said, acknowledging the percentage has likely grown further during the past month.

He recommended CMS take to the field and make sure providers are better educated on the devices. He admitted to being wrong about thinking the integration of the tests would be “like flipping a switch.” 

“It wasn’t just about getting some of these rapid tests out but rather providing [operators] with guidance on how to use them, when to use them and basically how to report them across different levels,” he explained. “Some of this is owned by the facilities, but I also think [there has to be more than] a federal government perspective of, ‘We supplied these tests. Let’s check a box.’ Well, no, let’s make certain these tests actually fit with the broader efforts to protect staff and residents.”

He said that the research team’s analysis shows that providers are still relying on standard, slower lab testing too much and that it “confirms that [all] testing is still too slow.”

The beginning of what recently appears to be the “third wave” of COVID-19 infections and deaths is a possibly ominous sign, he warned.

“Unfortunately, with the coming spike in the fall here, we’ll start seeing hospitalizations go up and spread, and then deaths go up, and then it will all lead into the nursing homes,” he explained. “We’ve seen it twice already, first in the Northeast and then in the Sun Belt states. Without rapid testing like we’ve been talking about, without PPE, without other factors we’re talking about, we’re destined to see this again.”