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Ryskina KL, Tu E, Liang J, Kim S, Werner RM. Nursing Home Compare star ratings before versus after a change in nursing home ownership. J Am Geriatr Soc 2024; 72:3078-3088. [PMID: 39074916 DOI: 10.1111/jgs.19104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/29/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Efforts to increase transparency and accountability of nursing homes, and thus improve quality, now include information about changes in nursing home ownership. However, little is known about how change in ownership affects nursing home quality. METHODS We conducted a retrospective cohort study of 15,471 U.S. nursing homes between January 2016 and December 2022, identifying all changes in ownership during that period. We used logistic regression to measure the association between nursing home characteristics and the odds of a change in ownership. A difference-in-differences model with multiple time periods was used to examine the impact of a change in ownership on the Medicare Nursing Home Compare 5-star ratings. RESULTS One in five (23%) facilities changed ownership between 2016 and 2022. Nursing homes that were urban, for-profit, part of a chain, located in the South, had >50 beds, lower occupancy, higher percentage of stays covered by Medicaid, higher percentage of residents with non-white race, or a 1-star (poor) rating were more likely to undergo a change in ownership. There was a small statistically significant decrease in 5-star ratings after a change in ownership (-0.09 points on a 5-point scale; 95% CI -0.13 to -0.04; p < 0.001), driven primarily by a decrease in staffing ratings (-0.19 points; 95% CI -0.24 to -0.14; p < 0.001), and health inspections ratings (-0.07 points; 95% CI -0.11 to -0.03; p = 0.001). This was mitigated by an increase in quality measure ratings (0.15 points; 95% CI 0.10-0.20; p < 0.001). CONCLUSION Nursing Home Compare ratings decreased slightly after a change in facility ownership, driven by lower staffing and health inspection ratings and mitigated somewhat by higher quality measure ratings. These conflicting trends underscore the need for transparency around changes in facility ownership and a better understanding of consequences of changes in ownership that are salient to patients and families.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Tu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Junning Liang
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seiyoun Kim
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel M Werner
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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Escribà-Salvans A, Jerez-Roig J, Farrés-Godayol P, Bezerra de Souza DL, Skelton DA, Minobes-Molina E. Health and sociodemographic determinants of excess mortality in Spanish nursing homes during the COVID-19 pandemic: a 2-year prospective longitudinal study. Z Gerontol Geriatr 2024; 57:459-466. [PMID: 38625391 PMCID: PMC11422266 DOI: 10.1007/s00391-024-02294-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/06/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Age, multimorbidity, immunodeficiency and frailty of older people living in nursing homes make them vulnerable to COVID-19 and overall mortality. OBJECTIVE To estimate overall and COVID-19 mortality parameters and analyse their predictive factors in older people living in nursing homes over a 2-year period. METHOD Design: A 2-year prospective longitudinal multicentre study was conducted between 2020 and 2022. SETTING This study involved five nursing homes in Central Catalonia (Spain). PARTICIPANTS Residents aged 65 years or older who lived in the nursing homes on a permanent basis. MEASUREMENTS Date and causes of deaths were recorded. In addition, sociodemographic and health data were collected. For the effect on mortality, survival curves were performed using the Kaplan-Meier method and multivariate analysis using Cox regression. RESULTS The total sample of 125 subjects had a mean age of 85.10 years (standard deviation = 7.3 years). There were 59 (47.2%) deaths at 24 months (95% confidence interval, CI, 38.6-55.9) and 25 (20.0%) were due to COVID-19, mostly in the first 3 months. In multivariate analysis, functional impairment (hazard ratio, HR 2.40; 95% CI 1.33-4.32) was a significant risk factor for mortality independent of age (HR 1.17; 95% CI 0.69-2.00) and risk of sarcopenia (HR 1.40; 95% CI 0.63-3.12). CONCLUSION Almost half of this sample of nursing home residents died in the 2‑year period, and one fifth were attributed to COVID-19. Functional impairment was a risk factor for overall mortality and COVID-19 mortality, independent of age and risk of sarcopenia.
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Affiliation(s)
- Anna Escribà-Salvans
- Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O). Faculty of Health Sciences and Welfare. Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVic-UCC), C. Sagrada Família 7, 08500, Vic, Spain
- Institute for Research and Innovation in Life Sciences and Health in Central Catalonia (IRIS-CC), Vic, Spain
| | - Javier Jerez-Roig
- Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O). Faculty of Health Sciences and Welfare. Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVic-UCC), C. Sagrada Família 7, 08500, Vic, Spain.
- Institute for Research and Innovation in Life Sciences and Health in Central Catalonia (IRIS-CC), Vic, Spain.
- Department of Health Promotion and Rehabilitation, Institute of Sport Science and Innovations, Lithuanian Sports University, Kaunas, Lithuania.
| | - Pau Farrés-Godayol
- Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O). Faculty of Health Sciences and Welfare. Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVic-UCC), C. Sagrada Família 7, 08500, Vic, Spain
- Institute for Research and Innovation in Life Sciences and Health in Central Catalonia (IRIS-CC), Vic, Spain
| | | | - Dawn A Skelton
- Research Centre for Health (ReaCH), School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Eduard Minobes-Molina
- Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O). Faculty of Health Sciences and Welfare. Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVic-UCC), C. Sagrada Família 7, 08500, Vic, Spain
- Institute for Research and Innovation in Life Sciences and Health in Central Catalonia (IRIS-CC), Vic, Spain
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Richards MR, Whaley CM. Hospital behavior over the private equity life cycle. JOURNAL OF HEALTH ECONOMICS 2024; 97:102902. [PMID: 38861907 PMCID: PMC11392649 DOI: 10.1016/j.jhealeco.2024.102902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 05/10/2024] [Accepted: 05/28/2024] [Indexed: 06/13/2024]
Abstract
Private equity is an increasing presence in US healthcare, with unclear consequences. Leveraging unique data sources and difference-in-differences designs, we examine the largest private equity hospital takeover in history. The affected hospital chain sharply shifts its advertising strategy and pursues joint ventures with ambulatory surgery centers. Inpatient throughput is increased by allowing more patient transfers, and crucially, capturing more patients through the emergency department. The hospitals also manage shorter, less treatment-intensive stays for admitted patients. Outpatient surgical care volume declines, but remaining cases focus on higher complexity procedures. Importantly, behavior changes persist even after private equity divests.
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Affiliation(s)
- Michael R Richards
- Jeb E. Brooks School of Public Policy, Cornell University, 3301 MVR Hall, Ithaca NY 14853 and NBER.
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4
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Tchouaket EN, Kruglova K, Létourneau J, Bélanger E, Robins S, Jubinville M, El-Mousawi F, Shen S, Beogo I, Sia D. Factors influencing long-term care facility performance during the COVID-19 pandemic: a scoping review. BMC Health Serv Res 2024; 24:901. [PMID: 39113065 PMCID: PMC11304669 DOI: 10.1186/s12913-024-11331-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 07/19/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic wreaked havoc on long-term care facilities (LTCFs). Some LTCFs performed better than others at slowing COVID-19 transmission. Emerging literature has mostly described infection prevention and control strategies implemented by LTCFs during the pandemic. However, there is a need for a comprehensive review of factors that influenced the performance of LTCFs in containing COVID-19 spread to inform public health policy. OBJECTIVE To build on the existing literature, we conducted a scoping review of factors that influenced LTCF performance during the COVID-19 pandemic using a multidimensional conceptual framework of performance. METHODS We followed the Joanna Briggs Institute's methodology for scoping reviews. We queried CINAHL, MEDLINE (Ovid), CAIRN, Science Direct, Scopus, and Web of Science for peer-reviewed literature in English or French published between January 1st, 2020 and December 31st, 2021. Retrieved records were screened for context (COVID-19 pandemic), population (LTCFs), interest (internal and external factors that influenced LTCF performance), and outcomes (dimensions of performance: equity, accessibility, reactivity, safety, continuity, efficacy, viability, efficiency). Descriptive characteristics of included articles were summarized. Dimensions of performance as well as internal (e.g., facility characteristics) and external (e.g., visitors) factors identified to have influenced LTCF performance were presented. RESULTS We retained 140 articles of which 68% were classified as research articles, 47% originated in North America, and most covered a period between March and July 2020. The most frequent dimensions of performance were "efficacy" (75.7%) and "safety" (75.7%). The most common internal factors were "organizational context" (72.9%) and "human resources" (62.1%), and the most common external factors were "visitors" (27.1%) and "public health guidelines" (25.7%). CONCLUSIONS Our review contributes to a global interest in understanding the impact of the COVID-19 pandemic on vulnerable populations residing and working in LTCFs. Though a myriad of factors were reported, a lack of randomized controlled trials makes it impossible to establish causality between the identified factors and LTCF performance. The use of a multidimensional framework can be recommended to evaluate healthcare system performance not merely in terms of efficacy and safety, but alongside other critical dimensions such as efficiency and equity. TRIAL REGISTRATION Research Registry ID: researchregistry7026.
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Affiliation(s)
- Eric Nguemeleu Tchouaket
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada.
| | - Katya Kruglova
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
| | - Josiane Létourneau
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
| | - Emilie Bélanger
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
| | - Stephanie Robins
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
| | - Maripier Jubinville
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
| | - Fatima El-Mousawi
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
| | - Shiyang Shen
- Faculty of Medicine and Health Sciences, McGill University, 3605 Rue de la Montagne, Montréal, QC, H3G 2M1, Canada
| | - Idrissa Beogo
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 200 Lees Avenue, Ottawa, ON, K1N 6N5, Canada
| | - Drissa Sia
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, QC, J7Z 0B7, Canada
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5
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Williams D, Fernandez R, Stevenson D, Unruh M, Braun RT. Nursing home finances associated with real estate investment trust and private equity investments. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae037. [PMID: 38756179 PMCID: PMC11034530 DOI: 10.1093/haschl/qxae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/04/2024] [Accepted: 04/03/2024] [Indexed: 05/18/2024]
Abstract
In 2021, real estate investment trusts (REITs) and private equity (PE) held investments in 1915 (16%) and 1569 (13%) US nursing homes (NHs), respectively. We created a database of REIT and PE investments in NHs, merged it with Medicare Cost Report data (2011-2019), and used a difference-in-differences approach within an event-study framework to compare NH spending and financial performance before and after REIT or PE investment to NHs that did not receive REIT or PE investment. REIT investments were associated with higher total wages (3%), total nursing wages (3%; both logged, per resident day [PRD]), and current ratio (81%). PE investments were associated with lower net patient service revenue (7%), total expenses (7%), and total wages (8%; all logged, PRD). The impact of REIT and PE investments in NHs may vary in different market conditions, as may occur in the current environment of low, falling NH profits, potentially higher minimum staffing requirements, and rising interest rates. Therefore, it is important for stakeholders to understand the impact of these large, growing investments on the financial performance of NHs.
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Affiliation(s)
- Dunc Williams
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425-9620, United States
- Center for Telehealth—Telehealth Center of Excellence, Medical University of South Carolina, Charleston, SC 29425-9620, United States
| | - Rahul Fernandez
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
| | - David Stevenson
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN 37232, United States
- The Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN 37212-2637, United States
| | - Mark Unruh
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
| | - Robert Tyler Braun
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
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6
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Singh Y, Reddy M, Zhu JM. Life cycle of private equity investments in physician practices: an overview of private equity exits. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae047. [PMID: 38756171 PMCID: PMC11044962 DOI: 10.1093/haschl/qxae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/04/2024] [Accepted: 04/09/2024] [Indexed: 05/18/2024]
Abstract
Private equity (PE) firms acquire and grow physician practices through add-on consolidation, generating outsized returns on the sale of the acquisition in 3-8 years ("exit"). Private equity's abbreviated investment timeline and exit incentives may deter long-term investments in care delivery and workforce needed for high-quality care. To our knowledge, there has been no published analyses of the nature or duration of PE exits from physician practices. We address this knowledge gap by using novel data to characterize PE exits from dermatology, ophthalmology, and gastroenterology, physician specialties with the largest number of acquisitions between 2016 and 2020. Of 807 acquisitions, over half (51.6%) of PE-acquired practices underwent an exit within 3 years of initial investment. In nearly all instances (97.8%), PE firms exited investments through secondary buyouts, where physician practices were resold to other PE firms with larger investment funds. Between investment and exit, PE firms increased the number of physician practices affiliated with the PE firm by an average of 595% in 3 years. Findings highlight the rapid scale of ownership change and consolidation under PE ownership and motivate evaluations by policymakers on the effects of PE ownership over the life cycle of PE investments.
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Affiliation(s)
- Yashaswini Singh
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02903, United States
| | - Megha Reddy
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02903, United States
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health and Science University, Portland, OR 97201, United States
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7
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Chen AC, Skinner RJ, Braun RT, Konetzka RT, Stevenson DG, Grabowski DC. New CMS Nursing Home Ownership Data: Major Gaps And Discrepancies. Health Aff (Millwood) 2024; 43:318-326. [PMID: 38437601 DOI: 10.1377/hlthaff.2023.01110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
Nursing home ownership has become increasingly complicated, partly because of the growth of facilities owned by institutional investors such as private equity (PE) firms and real estate investment trusts (REITs). Although the ownership transparency and accountability of nursing homes have historically been poor, the Biden administration's nursing home reform plans released in 2022 included a series of data releases on ownership. However, our evaluation of the newly released data identified several gaps: One-third of PE and fewer than one-fifth of REIT investments identified in the proprietary Irving Levin Associates and S&P Capital IQ investment data were present in Centers for Medicare and Medicaid Services (CMS) publicly available ownership data. Similarly, we obtained different results when searching for the ten top common owners of nursing homes using CMS data and facility survey reports of chain ownership. Finally, ownership percentages were missing in the CMS data for 82.40 percent of owners in the top ten chains and 55.21 percent of owners across all US facilities. Although the new data represent an important step forward, we highlight additional steps to ensure that the data are timely, accurate, and responsive. Transparent ownership data are fundamental to understanding the adequacy of public payments to provide patient care, enable policy makers to make timely decisions, and evaluate nursing home quality.
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Affiliation(s)
- Amanda C Chen
- Amanda C. Chen, Harvard University, Cambridge, Massachusetts
| | | | | | | | - David G Stevenson
- David G. Stevenson, Vanderbilt University and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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8
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Yin C, Mpofu E, Brock K, Ingman S. Nursing Home Residents' COVID-19 Infections in the United States: A Systematic Review of Personal and Contextual Factors. Gerontol Geriatr Med 2024; 10:23337214241229824. [PMID: 38370579 PMCID: PMC10870703 DOI: 10.1177/23337214241229824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/22/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Background: This mixed methods systemic review synthesizes the evidence about nursing home risks for COVID-19 infections. Methods: Four electronic databases (PubMed, Web of Science, Scopus, and Sage Journals Online) were searched between January 2020 and October 2022. Inclusion criteria were studies reported on nursing home COVID-19 infection risks by geography, demography, type of nursing home, staffing and resident's health, and COVID-19 vaccination status. The Mixed Methods Appraisal Tool (MMAT) was used to assess the levels of evidence for quality, and a narrative synthesis for reporting the findings by theme. Results: Of 579 initial articles, 48 were included in the review. Findings suggest that highly populated counties and urban locations had a higher likelihood of COVID-19 infections. Larger nursing homes with a low percentage of fully vaccinated residents also had increased risks for COVID-19 infections than smaller nursing homes. Residents with advanced age, of racial minority, and those with chronic illnesses were at higher risk for COVID-19 infections. Discussion and implications: Findings suggest that along with known risk factors for COVID-19 infections, geographic and resident demographics are also important preventive care considerations. Access to COVID-19 vaccinations for vulnerable residents should be a priority.
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Affiliation(s)
- Cheng Yin
- University of North Texas, Denton, USA
| | - Elias Mpofu
- University of North Texas, Denton, USA
- University of Sydney, Australia
- University of Johannesburg, South Africa
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9
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Matthews S, Roxas R. Private equity and its effect on patients: a window into the future. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:673-684. [PMID: 35604628 PMCID: PMC9125965 DOI: 10.1007/s10754-022-09331-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/08/2022] [Indexed: 05/17/2023]
Affiliation(s)
- Sajith Matthews
- Department of Internal Medicine, Wayne State University School of Medicine, 4201 St. Antoine St, UHC 5A, 48201 Detroit, MI United States
| | - Renato Roxas
- Department of Internal Medicine, Wayne State University School of Medicine, 4201 St. Antoine St, UHC 5A, 48201 Detroit, MI United States
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10
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Evers J, Geraedts M. COVID-19 risks in private equity nursing homes in Hesse, Germany - a retrospective cohort study. BMC Geriatr 2023; 23:648. [PMID: 37821816 PMCID: PMC10568849 DOI: 10.1186/s12877-023-04361-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/27/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Private-equity-owned nursing homes (PENH) represent the strongest form of profit orientation in the nursing care market. Private equity firms aim to increase the profitability of nursing care facilities, which often leads to cost-cutting measures and the use of less qualified staff. Our study aims to fill the existing knowledge gap by examining the association between private equity ownership and COVID-19 related infections and deaths among residents and staff during the COVID-19 pandemic. METHODS We analyzed outbreak and mortality data for the period from 20/03/2020 to 05/01/2022 from 32 long-term care facilities in the Federal State of Hesse, Germany, which included 16 PENH that were propensity score matched on regional population density and number of beds with 16 non-PENH. We used logistic regression to determine the odds ratios (OR) for above-median values for the independent variables of PENH-status, number of beds, proportion of single rooms, registered nurses' ratio, and copayments. RESULTS PENH had substantially fewer outbreaks in number, but longer and larger outbreaks among nursing home residents, as well as a markedly increased proportion of deceased residents. The odds of the outcome "infections & deaths" were 5.38 (p <. 05) times higher among PENH compared to non-PENH. CONCLUSIONS The study indicates a need for further research into the quality of care in PENH to inform evidence-based policy decisions, given the higher infection and death rates. Improved documentation and public visibility of PENH is also recommended, in line with existing practices for for-profit and non-profit nursing homes in Germany. Given our findings, regulatory bodies should closely observe PENH operational practices.
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Affiliation(s)
- Janis Evers
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Marburg, Germany.
| | - Max Geraedts
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Marburg, Germany
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11
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Lin H, Munnich EL, Richards MR, Whaley CM, Zhao X. Private equity and healthcare firm behavior: Evidence from ambulatory surgery centers. JOURNAL OF HEALTH ECONOMICS 2023; 91:102801. [PMID: 37657144 PMCID: PMC10528209 DOI: 10.1016/j.jhealeco.2023.102801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 05/26/2023] [Accepted: 08/04/2023] [Indexed: 09/03/2023]
Abstract
Healthcare firms regularly seek outside capital; yet, we have an incomplete understanding of external investor influence on provider behavior. We investigate the effects of private equity investment, divestment, and an initial public offering (IPO) on ambulatory surgery centers (ASCs). Throughput is unchanged while charges grow by up to 50% for the same service mix. Affected ASCs witness declines in privately insured cases and rely more on Medicare business. Private equity increases physician ASC ownership stakes, and both simultaneously divest when the ASC is sold. Our findings appear more consistent with private equity influencing the financing of ASCs, rather than treatment approaches.
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Affiliation(s)
- Haizhen Lin
- Department of Business Economics and Public Policy, Kelley School of Business, Indiana University, 1309 E Tenth St, Bloomington, IN 47405 USA
| | - Elizabeth L Munnich
- Department of Economics, College of Business, University of Louisville, Louisville, KY 40292 USA
| | - Michael R Richards
- Jeb E. Brooks School of Public Policy, Cornell University, 3300 MVR Hall, Ithaca, NY 14853 USA.
| | - Christopher M Whaley
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401 USA; Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Xiaoxi Zhao
- RAND Corporation, 1776 Main St, Santa Monica, CA 90401 USA
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12
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Borsa A, Bejarano G, Ellen M, Bruch JD. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review. BMJ 2023; 382:e075244. [PMID: 37468157 DOI: 10.1136/bmj-2023-075244] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To review the evidence on trends and impacts of private equity (PE) ownership of healthcare operators. DESIGN Systematic review. DATA SOURCES PubMed, Web of Science, Embase, Scopus, and SSRN. ELIGIBILITY CRITERIA FOR STUDY SELECTION Empirical research studies of any design that evaluated PE owned healthcare operators. MAIN OUTCOME MEASURES The main outcome measures were impact of PE ownership on health outcomes, costs to patients or payers, costs to operators, and quality. The secondary outcome measures were trends and prevalence of PE ownership of healthcare operators. DATA SYNTHESIS Studies were classified as finding either beneficial, harmful, mixed, or neutral impacts of PE ownership on main outcome measures. Results across studies were narratively synthesized and reported. Risk of bias was evaluated using ROBINS-I (Risk Of Bias In Non-randomised Studies of Interventions). RESULTS The electronic search identified 1778 studies, with 55 meeting the inclusion criteria. Studies spanned eight countries, with most (n=47) analyzing PE ownership of healthcare operators in the US. Nursing homes were the most commonly studied healthcare setting (n=17), followed by hospitals and dermatology settings (n=9 each); ophthalmology (n=7); multiple specialties or general physician groups (n=5); urology (n=4); gastroenterology and orthopedics (n=3 each); surgical centers, fertility, and obstetrics and gynecology (n=2 each); and anesthesia, hospice care, oral or maxillofacial surgery, otolaryngology, and plastics (n=1 each). Across the outcome measures, PE ownership was most consistently associated with increases in costs to patients or payers. Additionally, PE ownership was associated with mixed to harmful impacts on quality. These outcomes held in sensitivity analyses in which only studies with moderate risk of bias were included. Health outcomes showed both beneficial and harmful results, as did costs to operators, but the volume of studies for these outcomes was too low for conclusive interpretation. In some instances, PE ownership was associated with reduced nurse staffing levels or a shift towards lower nursing skill mix. No consistently beneficial impacts of PE ownership were identified. CONCLUSIONS Trends in PE ownership rapidly increased across almost all healthcare settings studied. Such ownership is often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality. Owing to risk of bias and frequent geographic focus on the US, conclusions might not be generalizable internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022329857.
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Affiliation(s)
- Alexander Borsa
- Department of Sociomedical Sciences, Columbia University, New York, NY, USA
| | - Geronimo Bejarano
- Department of Epidemiology, University of Texas School of Public Health (UTHealth), Austin, TX, USA
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Health Policy Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph Dov Bruch
- Department of Public Health Sciences, University of Chicago, Chicago, IL 60637, USA
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13
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Freeman T, Baum F, Musolino C, Flavel J, McKee M, Chi C, Giugliani C, Falcão MZ, De Ceukelaire W, Howden-Chapman P, Nguyen TH, Serag H, Kim S, Carlos AD, Gesesew HA, London L, Popay J, Paremoer L, Tangcharoensathien V, Sundararaman T, Nandi S, Villar E. Illustrating the impact of commercial determinants of health on the global COVID-19 pandemic: Thematic analysis of 16 country case studies. Health Policy 2023; 134:104860. [PMID: 37385156 DOI: 10.1016/j.healthpol.2023.104860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.
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Affiliation(s)
- Toby Freeman
- Stretton Health Equity, University of Adelaide, Adelaide, SA, 5005 Australia.
| | - Fran Baum
- Stretton Health Equity, University of Adelaide, Adelaide, SA, 5005 Australia
| | - Connie Musolino
- Stretton Health Equity, University of Adelaide, Adelaide, SA, 5005 Australia
| | - Joanne Flavel
- Stretton Health Equity, University of Adelaide, Adelaide, SA, 5005 Australia
| | - Martin McKee
- London School of Hygiene & Tropical Medicine, London WC1H 9SH, United Kingdom
| | - Chunhuei Chi
- Center for Global Health, Oregon State University, Corvallis, OR 7331, USA
| | - Camila Giugliani
- Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcellos, 2400 CEP 90035-003, Porto Alegre, Brazil
| | - Matheus Zuliane Falcão
- University of São Paulo, Brazil, Av. Dr. Arnaldo, 715 - 211 - Cerqueira César, São Paulo - SP, 01246-904, Brazil
| | | | | | - Thanh Huong Nguyen
- Faculty of Social Science and Behavior, Hanoi University of Public Health, 1A Duc Thang Road, Duc Thang Ward, North Tu Liem District, Hanoi, Vietnam
| | - Hani Serag
- University of Texas Medical Branch (UTMB), 301 University Blvd., Galveston, Texas, 77555, USA
| | - Sun Kim
- People's Health Institute, 36 Sadang-ro 13-gil, Dongjak-gu, Seoul 07004, South Korea
| | - Alvarez Dardet Carlos
- CIBERESP, Center for Research in Epidemiology and Public Health, University of Alicante, 03560 Spain
| | - Hailay Abrha Gesesew
- Research Centre for Public Health, Equity and Human Flourishing, Torrens University Australia, Adelaide, SA, 5000 AUSTRALIA & College of Health Sciences, Mekelle University, Mekelle, 231 Ethiopia
| | - Leslie London
- School of Public Health, University of Cape Town, South Africa
| | - Jennie Popay
- Division of Health Research, Faculty of Health & Medicine, Lancaster University, Bailrigg, Lancaster LA1 4YW, United Kingdom
| | - Lauren Paremoer
- Political Studies, University of Cape Town, Cape Town, South Africa
| | | | | | | | - Eugenio Villar
- Universidad Peruana Cayetano Heredio, San Martín de Porres 15102, Peru
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14
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Braun RT, Williams D, Stevenson DG, Casalino LP, Jung HY, Fernandez R, Unruh MA. The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes. Health Aff (Millwood) 2023; 42:207-216. [PMID: 36696597 DOI: 10.1377/hlthaff.2022.00278] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25 percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.
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Affiliation(s)
| | - Dunc Williams
- Dunc Williams, Medical University of South Carolina, Charleston, South Carolina
| | - David G Stevenson
- David G. Stevenson, Vanderbilt University and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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15
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Kang Y, David SV, Bowblis JR, Intrator O, Downer B, Li CY, Goodwin JS, Xu H. Financial Performance is Associated With PPE Shortages in Chain-Affiliated Nursing Homes During the COVID-19 Pandemic: A Longitudinal Study. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231219443. [PMID: 38102846 PMCID: PMC10725134 DOI: 10.1177/00469580231219443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/02/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Abstract
Many nursing homes operated at thin profit margins prior to the COVID-19 pandemic. This study examines the role of nursing homes' financial performance and chain affiliation in shortages of personal protection equipment (PPE) during the first year of the COVID-19 pandemic. We constructed a longitudinal file of 79 868 nursing home-week observations from 10 872 unique facilities. We found that a positive profit margin was associated with a 21.0% lower probability of reporting PPE shortages in chain-affiliated nursing homes, but not in non-chain nursing homes. Having adequate financial resources may help nursing homes address future emergencies, especially those affiliated with a multi-facility chain.
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Affiliation(s)
- Yejin Kang
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Orna Intrator
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Brian Downer
- University of Texas Medical Branch, Galveston, TX, USA
| | - Chih-Ying Li
- University of Texas Medical Branch, Galveston, TX, USA
| | | | - Huiwen Xu
- University of Texas Medical Branch, Galveston, TX, USA
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16
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Haslam-Larmer L, Grigorovich A, Quirt H, Engel K, Stewart S, Rodrigues K, Kontos P, Astell A, McMurray J, Levy A, Bingham KS, Flint AJ, Maxwell C, Iaboni A. Prevalence, causes, and consequences of moral distress in healthcare providers caring for people living with dementia in long-term care during a pandemic. DEMENTIA 2023; 22:5-27. [PMID: 36240074 PMCID: PMC9574526 DOI: 10.1177/14713012221124995] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Healthcare providers caring for people living with dementia may experience moral distress when faced with ethically challenging situations, such as the inability to provide care that is consistent with their values. The COVID-19 pandemic produced conditions in long-term care homes (hereafter referred to as 'care homes') that could potentially contribute to moral distress. We conducted an online survey to examine changes in moral distress during the pandemic, its contributing factors and correlates, and its impact on the well-being of care home staff. Survey participants (n = 227) working in care homes across Ontario, Canada were recruited through provincial care home organizations. Using a Bayesian approach, we examined the association between moral distress and staff demographics and roles, and characteristics of the long-term care home. We performed a qualitative analysis of the survey's free-text responses. More than 80% of care home healthcare providers working with people with dementia reported an increase in moral distress since the start of the pandemic. There was no difference in the severity of distress by age, sex, role, or years of experience. The most common factors associated with moral distress were lack of activities and family visits, insufficient staffing and high turnover, and having to follow policies and procedures that were perceived to harm residents with dementia. At least two-thirds of respondents reported feelings of physical exhaustion, sadness/anxiety, frustration, powerlessness, and guilt due to the moral distress experienced during the pandemic. Respondents working in not-for-profit or municipal homes reported less sadness/anxiety and feelings of not wanting to go to work than those in for-profit homes. Front-line staff were more likely to report not wanting to work than those in management or administrative positions. Overall, we found that increases in moral distress during the pandemic negatively affected the well-being of healthcare providers in care homes, with preliminary evidence suggesting that individual and systemic factors may intensify the negative effect.
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Affiliation(s)
| | - Alisa Grigorovich
- KITE Research Institute, University Health Network, 7961Toronto.,Recreation and Leisure Studies, 104266Brock University, St. Catherines, ON, Canada
| | - Hannah Quirt
- KITE Research Institute, University Health Network, 7961Toronto
| | - Katia Engel
- KITE Research Institute, University Health Network, 7961Toronto
| | - Steven Stewart
- KITE Research Institute, University Health Network, 7961Toronto
| | - Kevin Rodrigues
- KITE Research Institute, University Health Network, 7961Toronto
| | - Pia Kontos
- KITE Research Institute, University Health Network, 7961Toronto.,Dalla Lana School of Public Health, 7961University of Toronto, Toronto, ON, Canada
| | - Arlene Astell
- KITE Research Institute, University Health Network, 7961Toronto.,Departments of Occupational Sciences & Occupational Therapy and Psychiatry, 7938University of Toronto, Toronto, ON, Canada.,School of Psychology & Clinical Language Sciences, University of Reading, UK
| | - Josephine McMurray
- 8431Lazaridis School of Business & Economics Wilfrid Laurier University, Brantford, ON, Canada
| | - AnneMarie Levy
- 8431Lazaridis School of Business & Economics Wilfrid Laurier University, Brantford, ON, Canada
| | - Kathleen S Bingham
- Department of Psychiatry, Center of Mental Health, Temerty Faculty of Medicine, 7938University of Toronto, Toronto, ON, Canada
| | - Alastair J Flint
- Department of Psychiatry, Center of Mental Health, Temerty Faculty of Medicine, 7938University of Toronto, Toronto, ON, Canada
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health Sciences, 8430University of Waterloo, Waterloo, ON, Canada
| | - Andrea Iaboni
- KITE Research Institute, University Health Network, 7961Toronto.,Department of Psychiatry, Temerty Faculty of Medicine, 7938University of Toronto, Toronto, ON, Canada
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17
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Bruch JD, Foot C, Singh Y, Song Z, Polsky D, Zhu JM. Workforce Composition In Private Equity-Acquired Versus Non-Private Equity-Acquired Physician Practices. Health Aff (Millwood) 2023; 42:121-129. [PMID: 36623222 DOI: 10.1377/hlthaff.2022.00308] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Despite growth in private equity (PE) acquisitions of physician practices in the US, little is known about how changes in ownership influence workforce composition. Using clinician-level data linked to practice acquisition information, we estimated changes in clinician workforce composition in PE-acquired practice sites relative to non-PE-acquired independent practice sites for dermatology, ophthalmology, and gastroenterology specialties. We calculated a clinician replacement ratio (cumulative number of entering clinicians during 2014-19 divided by the cumulative number of exiting clinicians) across 213 PE-acquired practices and 995 matched non-PE-acquired practices. Using a difference-in-differences approach, we also examined practice-level changes in yearly clinician counts at PE-acquired practices before and after acquisition compared with non-PE-acquired controls. In aggregate and across the study period, the clinician replacement ratio was higher for PE-acquired practices compared with non-PE-acquired controls (1.75 versus 1.37), as well as within each specialty and clinician type (physician versus advanced practice provider). Relative to non-PE-acquired control practices, we also found significant yearly increases in the number of advanced practice providers at PE-acquired practices after acquisition. Taken together, these findings suggest differential changes in workforce composition at PE-acquired practices, especially a shift toward advanced practice providers for care delivery.
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Affiliation(s)
| | - Canyon Foot
- Canyon Foot, Oregon Health & Science University, Portland, Oregon
| | | | - Zirui Song
- Zirui Song, Harvard University, Boston, Massachusetts
| | | | - Jane M Zhu
- Jane M. Zhu , Oregon Health & Science University
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18
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Patwardhan S, Sutton M, Morciano M. Effects of chain ownership and private equity financing on quality in the English care home sector: retrospective observational study. Age Ageing 2022; 51:6936404. [PMID: 36571782 PMCID: PMC9792077 DOI: 10.1093/ageing/afac222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/21/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND the structure of care homes markets in England is changing with the emergence of for-profit homes organised in chains and financed by private equity. Previous literature shows for-profit homes were rated lower quality than not-for-profit homes when inspected by the national regulator, but has not considered new forms of financing. OBJECTIVES to examine whether financing and organisation of care homes is associated with regulator assessments of quality. METHODS retrospective observational study of the Care Quality Commission's ratings of 10,803 care homes providing services to older people as of January 2020. We used generalised ordered logistic models to assess whether ratings differed between not-for-profit and for-profit homes categorised into three groups: (i) chained ownership, financed by private equity; (ii) chained ownership, not financed by private equity and (iii) independent ownership. We compared Overall and domain (caring, effective, responsive, safe, well-led) ratings adjusted for care home size, age and location. RESULTS all three for-profit ownership types had lower average overall ratings than not-for-profit homes, especially independent (6.8% points (p.p.) more likely rated as 'Requires Improvement/Inadequate', 95% CI: 4.7-8.9) and private equity chains (6.6 p.p. more likely rated as 'Requires Improvement/Inadequate', 95% CI: 2.9-10.2). Independent homes scored better than private equity chains in the safe, effective and responsive domains but worst in the well-led domain. DISCUSSION private equity financing and independent for-profit ownership are associated with lower quality. The consequences of the changing care homes market structure for quality of services should be monitored.
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Affiliation(s)
- Sharvari Patwardhan
- Health Organization, Policy and Economics (HOPE) research group, School of Health Science, Oxford Road, M13 9PL, Manchester, UK
| | - Matthew Sutton
- Health Organization, Policy and Economics (HOPE) research group, School of Health Science, Oxford Road, M13 9PL, Manchester, UK
| | - Marcello Morciano
- Address correspondence to: Morciano Marcello, The University of Manchester, UK.
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19
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Franzosa E, Wyte-Lake T, Tsui EK, Reckrey JM, Sterling MR. Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies. J Am Med Dir Assoc 2022; 23:1990-1996. [PMID: 36343702 PMCID: PMC9634621 DOI: 10.1016/j.jamda.2022.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Geriatric Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, USA,Address correspondence to Emily Franzosa DrPH, Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY
| | - Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Emma K. Tsui
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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20
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NEWTON HELEN, HUMENSKY JENNIFER, GOLDMAN HOWARD, BUSCH SUSANH. What Explains Changes in Availability of Specialty Mental Health Services in Organized Settings? Milbank Q 2022; 100:1166-1191. [PMID: 36575952 PMCID: PMC9836237 DOI: 10.1111/1468-0009.12592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/10/2022] [Accepted: 07/18/2022] [Indexed: 12/29/2022] Open
Abstract
Policy Points Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. Facilities were no more likely to offer six of seven services studied in 2019 compared with 2010 in both Medicaid expansion and nonexpansion states. For-profit facilities generally experienced the largest declines in service availability, while public facilities experienced the smallest declines with small increases in availability of select services. New payment models that incentivize the offer of specialty support services may be needed to encourage adoption of clinical and support services by specialty mental health organizations. CONTEXT Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. This creates equity issues, particularly when low-income and minority communities have access to fewer facilities. Medicaid expansion might encourage facilities to offer these services. However, this decision may also be affected by facility ownership type or mediated by service cost structure, particularly in the absence of innovative payment mechanisms. In this study, we determine whether and how Medicaid expansion and facility ownership are associated with changes in specialty mental health service availability in organized settings over time. METHODS We estimated two-way fixed effects models using six cross-sections of the National Mental Health Services Survey and compared changes in facility-reported offering of seven services from 2010 to 2019 (54,885 facility years): psychotropic medication, case management, family psychoeducation, psychiatric emergency walk-in services, supported employment, assertive community treatment, illness management, and recovery services. We tested whether Medicaid expansion and facility ownership (private for-profit, private not-for-profit, public) were associated with differential changes in service availability from 2010 to 2019. FINDINGS Overall, facilities were no more likely to offer nearly all services in 2019 than 2010. We found smaller declines for psychotropic medication and psychiatric emergency walk-in services among facilities in Medicaid expansion states compared to declines in non-Medicaid expansion states (6.3 (95% CI 95% CI = 1.8-10.7) and 5.5 (95% CI = 0.2-10.8) percentage points respectively). For-profit facilities experienced the largest declines in availability from 2010 to 2019, while public facilities experienced the smallest declines and some increases in availability of select services. CONCLUSIONS Specialty mental health services are still not widely offered in community outpatient settings despite significant investments in Medicaid, although Medicaid expansion was associated with slower declines in availability. New payment models that incentivize outpatient facilities to offer clinical and support services may be needed.
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21
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Létourneau J, Bélanger E, Sia D, Beogo I, Robins S, Kruglova K, Jubinville M, Tchouaket EN. Identifying performance factors of long-term care facilities in the context of the COVID-19 pandemic: a scoping review protocol. Syst Rev 2022; 11:203. [PMID: 36151556 PMCID: PMC9502645 DOI: 10.1186/s13643-022-02069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) have been severely affected by the COVID-19 pandemic with serious consequences for the residents. Some LTCFs performed better than others, experiencing lower case and death rates due to COVID-19. A comprehensive understanding of the factors that have affected the transmission of COVID-19 in LTCFs is lacking, as no published studies have applied a multidimensional conceptual framework to evaluate the performance of LTCFs during the pandemic. Much research has focused on infection prevention and control strategies or specific disease outcomes (e.g., death rates). To address these gaps, our scoping review will identify and analyze the performance factors that have influenced the management of COVID-19 in LTCFs by adopting a multidimensional conceptual framework. METHODS We will query the CINAHL, MEDLINE (Ovid), CAIRN, Science Direct, and Web of Science databases for peer-reviewed articles written in English or French and published between January 1, 2020 and December 31, 2021. We will include articles that focus on the specified context (COVID-19), population (LTCFs), interest (facilitators and barriers to performance of LTCFs), and outcomes (dimensions of performance according to a modified version of the Ministère de la santé et des services sociaux du Québec conceptual framework). Each article will be screened by at least two co-authors independently followed by data extraction of the included articles by one co-author and a review by the principal investigator. RESULTS We will present the results both narratively and with visual aids (e.g., flowcharts, tables, conceptual maps). DISCUSSION Our scoping review will provide a comprehensive understanding of the factors that have affected the performance of LTCFs during the COVID-19 pandemic. This knowledge can help inform the development of more effective infection prevention and control measures for future pandemics and outbreaks. The results of our review may lead to improvements in the care and safety of LTCF residents and staff. SCOPING REVIEW REGISTRATION: Research Registry researchregistry7026.
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Affiliation(s)
- Josiane Létourneau
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
| | - Emilie Bélanger
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
| | - Drissa Sia
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
| | - Idrissa Beogo
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario Canada
| | - Stephanie Robins
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
| | - Katya Kruglova
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
| | - Maripier Jubinville
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
| | - Eric Nguemeleu Tchouaket
- Department of Nursing, Université du Québec en Outaouais, St-Jérôme Campus, 5, rue Saint-Joseph, Office J-2204, Saint-Jérôme, Québec, Canada
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22
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Berridge C, Grigorovich A. Algorithmic harms and digital ageism in the use of surveillance technologies in nursing homes. FRONTIERS IN SOCIOLOGY 2022; 7:957246. [PMID: 36189442 PMCID: PMC9525107 DOI: 10.3389/fsoc.2022.957246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/26/2022] [Indexed: 05/10/2023]
Abstract
Ageism has not been centered in scholarship on AI or algorithmic harms despite the ways in which older adults are both digitally marginalized and positioned as targets for surveillance technology and risk mitigation. In this translation paper, we put gerontology into conversation with scholarship on information and data technologies within critical disability, race, and feminist studies and explore algorithmic harms of surveillance technologies on older adults and care workers within nursing homes in the United States and Canada. We start by identifying the limitations of emerging scholarship and public discourse on "digital ageism" that is occupied with the inclusion and representation of older adults in AI or machine learning at the expense of more pressing questions. Focusing on the investment in these technologies in the context of COVID-19 in nursing homes, we draw from critical scholarship on information and data technologies to deeply understand how ageism is implicated in the systemic harms experienced by residents and workers when surveillance technologies are positioned as solutions. We then suggest generative pathways and point to various possible research agendas that could illuminate emergent algorithmic harms and their animating force within nursing homes. In the tradition of critical gerontology, ours is a project of bringing insights from gerontology and age studies to bear on broader work on automation and algorithmic decision-making systems for marginalized groups, and to bring that work to bear on gerontology. This paper illustrates specific ways in which important insights from critical race, disability and feminist studies helps us draw out the power of ageism as a rhetorical and analytical tool. We demonstrate why such engagement is necessary to realize gerontology's capacity to contribute to timely discourse on algorithmic harms and to elevate the issue of ageism for serious engagement across fields concerned with social and economic justice. We begin with nursing homes because they are an understudied, yet socially significant and timely setting in which to understand algorithmic harms. We hope this will contribute to broader efforts to understand and redress harms across sectors and marginalized collectives.
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Affiliation(s)
- Clara Berridge
- School of Social Work, University of Washington, Seattle, WA, United States
| | - Alisa Grigorovich
- Recreation and Leisure Studies, Brock University, St. Catharines, ON, Canada
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Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization. JAMA HEALTH FORUM 2022; 3:e222886. [PMID: 36218927 PMCID: PMC9440392 DOI: 10.1001/jamahealthforum.2022.2886] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Settings, and Participants Exposures Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Yashaswini Singh
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Daniel Polsky
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Carey Business School, Johns Hopkins University, Baltimore, Maryland
| | - Joseph D. Bruch
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jane M. Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland
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Heger D, Herr A, Mensen A. Paying for the view? How nursing home prices affect certified staffing ratios. HEALTH ECONOMICS 2022; 31:1618-1632. [PMID: 35581684 DOI: 10.1002/hec.4532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
Many countries limit public and private reimbursement for nursing care costs for social or financial reasons. Still, quality varies across nursing homes. We explore the causal link between case-mix adjusted nurse staffing ratios as an indicator of care quality and different price components in Swiss nursing homes. The Swiss reimbursement system limits and subsidizes the care price at the cantonal level, which implicitly limits staffing ratios, while the residents cover the nursing home-specific lodging price privately. To estimate causal effects, we exploit (i) the exogeneity of the Swiss care price regulation, (ii) nursing-home fixed effects estimations and (iii) instrumental variables for the lodging price. Our estimates show a positive impact of prices on certified staffing ratios. We find that a 10% increase in care prices increases certified staffing ratios by 3-4%. A comparable 10% increase in lodging prices raises certified staffing ratios by 1.5-10% (depending on the model). Our findings highlight that price limits for nursing care impose a limit on staffing ratios. Furthermore, our results indicate that providers circumvent price limits by increasing lodging prices that are privately covered. Thus, this cost shifting implicitly shifts the financial burden to the residents.
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Affiliation(s)
- Dörte Heger
- RWI - Leibniz Institute for Economic Research, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
| | - Annika Herr
- Institute of Health Economics and CHERH, Leibniz University Hannover, Hannover, Germany
- CINCH - Health Economics Research Center, Essen, Germany
| | - Anne Mensen
- RWI - Leibniz Institute for Economic Research, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
- Ruhr-University Bochum, Bochum, Germany
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Crowley R, Atiq O, Hilden D. Long-Term Services and Supports for Older Adults: A Position Paper From the American College of Physicians. Ann Intern Med 2022; 175:1172-1174. [PMID: 35816710 DOI: 10.7326/m22-0864] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The number of Americans aged 65 years or older is expected to increase in the coming decades. Because the risk for disability increases with age, more persons will need long-term services and supports (LTSS) to help with bathing, eating, dressing, and other everyday tasks. Long-term services and supports are delivered in nursing homes, assisted living facilities, the person's home, and other settings. However, the LTSS sector faces several challenges, including keeping patients and staff safe during the COVID-19 pandemic, workforce shortages, quality problems, and fragmented coverage options. In this position paper, the American College of Physicians offers policy recommendations on LTSS coverage, financing, workforce, safety and quality, and emergency preparedness and calls on policymakers and other stakeholders to reform and improve the LTSS sector so that care is high quality, accessible, equitable, and affordable.
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Affiliation(s)
- Ryan Crowley
- American College of Physicians, Washington, DC (R.C.)
| | - Omar Atiq
- University of Arkansas for Medical Sciences, Little Rock, Arkansas (O.A.)
| | - David Hilden
- Hennepin Healthcare, Minneapolis, Minnesota (D.H.)
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Verbiest MEA, Stoop A, Scheffelaar A, Janssen MM, van Boekel LC, Luijkx KG. Health impact of the first and second wave of COVID-19 and related restrictive measures among nursing home residents: a scoping review. BMC Health Serv Res 2022; 22:921. [PMID: 35841028 PMCID: PMC9286708 DOI: 10.1186/s12913-022-08186-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 06/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background and objectives COVID-19 disproportionally affects older adults living in nursing homes. The purpose of this review was to explore and map the scientific literature on the health impact of COVID-19 and related restrictive measures during the first and second wave among nursing home residents. A specific focus was placed on health data collected among nursing home residents themselves. Research design and methods In this study, best practices for scoping reviews were followed. Five databases were systematically searched for peer-reviewed empirical studies published up until December 2020 in which data were collected among nursing home residents. Articles were categorized according to the type of health impact (physical, social and/or psychological) and study focus (impact of COVID-19 virus or related restrictive measures). Findings were presented using a narrative style. Results Of 60 included studies, 57 examined the physical impact of COVID-19. All of these focused on the direct impact of the COVID-19 virus. These studies often used an observational design and quantitative data collection methods, such as swab testing or reviewing health records. Only three studies examined the psychological impact of COVID-19 of which one study focused on the impact of COVID-19-related restrictive measures. Findings were contradictory; both decreased and improved psychological wellbeing was found during the pandemic compared with before. No studies were found that examined the impact on social wellbeing and one study examined other health-related outcomes, including preference changes of nursing home residents in Advanced Care planning following the pandemic. Discussion and implications Studies into the impact of the first and second wave of the COVID-19 pandemic among nursing home residents predominantly focused on the physical impact. Future studies into the psychological and social impact that collect data among residents themselves will provide more insight into their perspectives, such as lived experiences, wishes, needs and possibilities during later phases of the pandemic. These insights can inform policy makers and healthcare professionals in providing person-centered care during the remaining COVID-19 pandemic and in future crisis periods.
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Affiliation(s)
- Marjolein E A Verbiest
- Academic Collaborative Centre Older Adults, Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands.
| | - Annerieke Stoop
- Academic Collaborative Centre Older Adults, Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
| | - Aukelien Scheffelaar
- Academic Collaborative Centre Older Adults, Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
| | - Meriam M Janssen
- Academic Collaborative Centre Older Adults, Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
| | - Leonieke C van Boekel
- Academic Collaborative Centre Older Adults, Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
| | - Katrien G Luijkx
- Academic Collaborative Centre Older Adults, Tranzo Scientific Centre for Care and Wellbeing, Tilburg School of Social and Behavioral Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, the Netherlands
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Torres ML, Palma Díaz D, Oliver-Parra A, Millet JP, Cosialls D, Guillaumes M, Rius C, Vásquez-Vera H. Inequities in the incidence and mortality due to COVID-19 in nursing homes in Barcelona by characteristics of the nursing homes. PLoS One 2022; 17:e0269639. [PMID: 35696404 PMCID: PMC9191699 DOI: 10.1371/journal.pone.0269639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/24/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Residents of Nursing Homes (NHs) have suffered greater impacts from the COVID-19 pandemic. However, the rates of COVID-19 in these institutions are heterogeneously distributed. Describing and understanding the structural, functional, and socioeconomic differences between NHs is extremely important to avoid new outbreaks. OBJECTIVES Analyze inequalities in the cumulative incidences (CIs) and in the mortality rates (MRs) due to COVID-19 in the NHs of Barcelona based on the characteristics of the NHs. METHODS Exploratory ecological study of 232 NHs. The dependent variables were the cumulative incidence and mortality rate due to COVID-19 in NHs between March and June 2020. Structural variables of the NHs were evaluated such as neighborhood socioeconomic position (SEP), isolation and sectorization capacity, occupancy, overcrowding and ownership. RESULTS The cumulative incidence and mortality rate were higher in the low SEP neighborhoods and lower in those of high SEP neighborhoods. Regarding the isolation and sectorization capacity, Type B NHs had a higher risk of becoming infected and dying, while Type C had a lower risk of dying than Type A. Greater overcrowding was associated with greater morbidity and mortality, and higher occupancy was associated with higher incidence. The risk of becoming infected and dying in public NHs was significantly higher than for-profit NH. CONCLUSIONS The social components together with the functional and infrastructure characteristics of the NHs influence the cumulative incidence and the mortality rate by COVID-19. It is necessary to redefine the care model in the NHs to guarantee the health of the residents.
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Affiliation(s)
- Mayara Louise Torres
- Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
- Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - David Palma Díaz
- Servei d’Epidemiologia, Agència de Salut Pùblica de Barcelona, Barcelona, Catalonia, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Alba Oliver-Parra
- Consorci Sanitari de Barcelona, Barcelona, Catalonia, Spain
- Oficina de Residències de Barcelona, Barcelona, Catalonia, Spain
| | - Joan-Pau Millet
- Servei d’Epidemiologia, Agència de Salut Pùblica de Barcelona, Barcelona, Catalonia, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Delfí Cosialls
- Consorci Sanitari de Barcelona, Barcelona, Catalonia, Spain
- Oficina de Residències de Barcelona, Barcelona, Catalonia, Spain
| | - Montserrat Guillaumes
- Servei d’Epidemiologia, Agència de Salut Pùblica de Barcelona, Barcelona, Catalonia, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Cristina Rius
- Servei d’Epidemiologia, Agència de Salut Pùblica de Barcelona, Barcelona, Catalonia, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Hugo Vásquez-Vera
- Servei d’Epidemiologia, Agència de Salut Pùblica de Barcelona, Barcelona, Catalonia, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Yang H, Rigsby M, Zhu X, Lee C, Ory M. COVID-19 in Long-Term Care Facilities: A Rapid Review of Infection Correlates and Impacts on Mental Health and Behaviors. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2022; 15:277-294. [PMID: 35411795 DOI: 10.1177/19375867221092149] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term care facilities (LTCFs) with compact, group-living arrangements have become COVID-19 hot spots during the pandemic. Systematic research is needed to understand factors associated with COVID-19 infections in LTCFs and the inadvertent effects of preventive measures adopted by LTCFs. OBJECTIVES This rapid review identifies factors associated with LTCF residents' COVID-19 infections and the impacts of the pandemic and the corresponding preventive measures on residents' mental health and behavioral problems. METHODS Following the preferred reporting items for systematic reviews and meta-analyses guidelines, we identified and reviewed relevant literature in Medline, PsycINFO, and AgeLine. RESULTS Thirty-seven articles were identified and reviewed, including 30 reporting factors associated with COVID-19 infections in LTCFs and seven reporting the impact of the pandemic and corresponding prevention measures on LTCF residents. Results revealed four domains of factors associated with COVID-19 infections: facility physical environments, resident characteristics, facility management and testing, and community factors. The pandemic and infection control measures increased residents' depression, anxiety, loneliness, and behavioral problems (e.g., agitation, hallucinations). Residents without cognitive impairments were more vulnerable to these adverse effects. CONCLUSION AND IMPLICATIONS LTCF managers/policymakers and healthcare designers can help mitigate COVID-19 infections by (1) providing additional resources to vulnerable LTCFs; (2) enhancing the training of personal protective equipment use and guideline compliance; and (3) investing in amenities, such as sinks, quarantine rooms, and outdoor spaces. Digital activities and accessible green spaces can mitigate mental health and behavior issues. Future LTCF design can benefit from flexible spaces, natural ventilation, and reducing crowding.
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Affiliation(s)
- Haoyue Yang
- Department of Landscape Architecture and Urban Planning, Texas A&M University, College Station, TX, USA
| | - Matilin Rigsby
- School of Public Health, Texas A&M University, College Station, TX, USA
| | - Xuemei Zhu
- Department of Architecture, Texas A&M University, College Station, TX, USA
| | - Chanam Lee
- Department of Landscape Architecture and Urban Planning, Texas A&M University, College Station, TX, USA
| | - Marcia Ory
- School of Public Health, Texas A&M University, College Station, TX, USA
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Hass Z, Abrahamson K, Arling G. Ownership Change and Care Quality: Lessons from Minnesota’s Experience with Value-Based Purchasing. Innov Aging 2022; 6:igac022. [PMID: 35712326 PMCID: PMC9196681 DOI: 10.1093/geroni/igac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Minnesota’s implementation of a new nursing home value-based reimbursement (VBR) system in 2016 presented an opportunity to compare the response of nursing homes (NHs) to financial incentives to improve their quality and efficiency. The state substantially increased reimbursement for care-related costs and tied this rate increase to a composite quality score. Coinciding with rate increases of the new VBR system was an increase in ownership changes, with new owners being primarily for-profit entities from outside of Minnesota, including several private equity firms. Our objective was to examine NHs that underwent a change in ownership to determine their cost and quality response to the change. Research Design and Methods Our sample consists of 342 Minnesota NHs that submitted Medicaid cost reports each year from 2013 to 2019. A time differential two-way fixed-effects difference-in-difference model is used to assess changes in quality metrics by comparing measures in years prior to and years following the sale for NHs that changed ownership versus NHs with consistent ownership. Nursing home characteristics, revenue, and spending patterns are examined to understand differences in performance. Results Those NHs with ownership change experienced a decline in quality scores with notable changes to expenditure patterns. They performed worse on Minnesota Department of Health inspection scores and had nonsignificant declines in measures of quality of life and clinical care. They had declining staff dental and medical benefits and occupancy rates, greater revenue growth from Medicare Part B, and larger increases in administrative management fees. Discussion and Implications Minnesota like many other states has given wide latitude for nursing home ownership changes, without specific oversight for the quality of care and expenditure patterns of new owners. Recommendations include strict guidelines for the transparency of ownership structures, quality performance targets, rigorous financial auditing, and enhanced regulatory oversight.
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Affiliation(s)
- Zachary Hass
- Schools of Nursing and Industrial Engineering, Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Kathleen Abrahamson
- School of Nursing, Center for Aging and the Life Course, Purdue University, West Lafayette, Indiana, USA
| | - Greg Arling
- School of Nursing, Center for Aging and the Life Course, Purdue University, West Lafayette, Indiana, USA
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Cerullo M, Yang K, Joynt Maddox KE, McDevitt RC, Roberts JW, Offodile AC. Association Between Hospital Private Equity Acquisition and Outcomes of Acute Medical Conditions Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e229581. [PMID: 35486398 PMCID: PMC9055457 DOI: 10.1001/jamanetworkopen.2022.9581] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE As private equity (PE) acquisitions of short-term acute care hospitals (ACHs) continue, their impact on the care of medically vulnerable older adults remains largely unexplored. OBJECTIVE To investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used a generalized difference-in-differences approach to compare 21 091 222 patients admitted to PE-acquired vs non-PE-acquired short-term ACHs between January 1, 2001, and December 31, 2018, at least 3 years before to 3 years after PE acquisition. The analysis was conducted between December 28, 2020, and February 1, 2022. Differences were estimated using both facility and hospital service area fixed effects. To assess the robustness of findings, regressions were reestimated after including fixed effects of patient county of origin to account for geographic differences in underlying health risks. Two subset analyses were also conducted: (1) an analysis including only hospitals in hospital referral regions with at least 1 PE acquisition and (2) an analysis stratified by participation in the Hospital Corporation of America 2006 acquisition. The study included Medicare beneficiaries 66 years and older who were hospitalized with 1 of 5 acute medical conditions: acute myocardial infarction (AMI), acute stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and pneumonia. EXPOSURES Acquisition of hospitals by PE firms. MAIN OUTCOMES AND MEASURES Comorbidity burden (measured by Elixhauser comorbidity score), hospital length of stay, in-hospital mortality, 30-day mortality, 30-day readmission, and 30-day episode payments. RESULTS Among 21 091 222 total Medicare beneficiaries admitted to ACHs between 2001 and 2018, 20 431 486 patients received care at non-PE-acquired hospitals, and 659 736 received care at PE-acquired hospitals. Across all admissions, the mean (SD) age was 79.45 (7.95) years; 11 727 439 patients (55.6%) were male, and 4 550 012 patients (21.6%) had dual insurance; 2 996 560 (14.2%) patients were members of racial or ethnic minority groups, including 2 085 128 [9.9%] Black and 371 648 [1.8%] Hispanic; 18 094 662 patients (85.8%) were White. Overall, 3 083 760 patients (14.6%) were hospitalized with AMI, 2 835 777 (13.4%) with acute stroke, 3 674 477 (17.4%) with chronic obstructive pulmonary disease exacerbation, 5 868 034 (27.8%) with congestive heart failure exacerbation, and 5 629 174 (26.7%) with pneumonia. Comorbidity burden decreased slightly among patients admitted with acute stroke (difference, -0.04 SDs; 95% CI, -0.004 to -0.07 SDs) at acquired hospitals compared with nonacquired hospitals but was unchanged across the other 4 conditions. Among patients with AMI, a greater decrease in in-hospital mortality was observed in PE-acquired hospitals compared with non-PE-acquired hospitals (difference, -1.14 percentage points, 95% CI, -1.86 to -0.42 percentage points). In addition, a greater decrease in 30-day mortality (difference, -1.41 percentage points; 95% CI, -2.26 to -0.56 percentage points) was found at acquired vs nonacquired hospitals. However, 30-day spending and readmission rates remained unchanged across all conditions. The extent and directionality of estimates were preserved across all robustness assessments and subset analyses. CONCLUSIONS AND RELEVANCE In this cross-sectional study using a difference-in-differences approach, PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI.
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Affiliation(s)
- Marcelo Cerullo
- Department of Surgery, Duke University, Durham, North Carolina
- National Clinician Scholars Program, jointly administered through Duke University and Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Kelly Yang
- Department of Economics, Duke University, Durham, North Carolina
| | - Karen E. Joynt Maddox
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Ryan C. McDevitt
- Fuqua School of Business, Duke University, Durham, North Carolina
| | - James W. Roberts
- Department of Economics, Duke University, Durham, North Carolina
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Anaeze C. Offodile
- Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
- Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas
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Fogel AL, Hogan S, Dover J. Surgical Dermatology and Private Equity: A Review of the Literature and Discussion. Dermatol Surg 2022; 48:339-343. [PMID: 34985045 DOI: 10.1097/dss.0000000000003363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While there has been substantial investment in dermatology by private equity (PE), the relevance of this trend to the dermatologic surgeon has not been assessed. OBJECTIVE The literature on PE investment in medicine was reviewed to provide interdisciplinary data relevant to the dermatologic surgeon. MATERIALS AND METHODS The PubMed database was queried for all peer-reviewed articles containing the term "private equity" and identified 70 unique articles across 18 medical specialties, comprising 20 original research articles and 50 commentary articles. RESULTS Significant PE growth across multiple medical specialties occurred in the 2010s. Private equity ownership was associated with higher levels of nonphysician providers relative to physicians. Pooled data suggest that PE ownership is associated with lower staffing levels, particularly for non-revenue-generating staff, as well as potentially lower levels of medical supplies on hand. Data on financial performance suggests that PE-ownership results in higher profits, revenues, and costs. Surveys of physicians demonstrate concern about autonomy, ethics, and career prospects. CONCLUSION For the dermatologic surgeon, issues related to consolidation, provider scope of practice, support staff availability, and supply management are important due to the nature of procedural intervention and the increased risk of adverse events.
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Affiliation(s)
- Alexander L Fogel
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sara Hogan
- Division of Dermatology, University of California Los Angeles, Los Angeles, California
| | - Jeffrey Dover
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
- Skin Care Physicians, Boston, Massachusetts
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Zhu X, Lee H, Sang H, Muller J, Yang H, Lee C, Ory M. Nursing Home Design and COVID-19: Implications for Guidelines and Regulation. J Am Med Dir Assoc 2022; 23:272-279.e1. [PMID: 34990585 PMCID: PMC8702402 DOI: 10.1016/j.jamda.2021.12.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/11/2021] [Accepted: 12/16/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Nursing homes (NHs) are important health care and residential environments for the growing number of frail older adults. The COVID-19 pandemic highlighted the vulnerability of NHs as they became COVID-19 hotspots. This study examines the associations of NH design with COVID-19 cases, deaths, and transmissibility and provides relevant design recommendations. DESIGN A cross-sectional, nationwide study was conducted after combining multiple national data sets about NHs. SETTING AND PARTICIPANTS A total of 7785 NHs were included in the study, which represent 50.8% of all Medicare and/or Medicaid NH providers in the United States. METHODS Zero-inflated negative binomial models were used to predict the total number of COVID-19 resident cases and deaths, separately. The basic reproduction number (R0) was calculated for each NH to reflect the transmissibility of COVID-19 among residents within the facility, and a linear regression model was estimated to predict log(R0 - 1). Predictors of these models included community factors and NHs' resident characteristics, management and rating factors, and physical environmental features. RESULTS Increased percentage of private rooms, larger living area per bed, and presence of a ventilator-dependent unit are significantly associated with reductions in COVID-19 cases, deaths, and transmissibility among residents. After setting the number of actual residents as the exposure variable and controlling for staff cases and other variables, increased number of certified beds in the NH is associated with reduced resident cases and deaths. It also correlates with reduced transmissibility among residents when other risk factors, including staff cases, are controlled. CONCLUSIONS AND IMPLICATIONS Architectural design attributes have significant impacts on COVID-19 transmissions in NHs. Considering the vulnerability of NH residents in congregated living environments, NHs will continue to be high-risk settings for infection outbreaks. To improve safety and resilience of NHs against future health disasters, facility guidelines and regulations should consider the need to increase private rooms and living areas.
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Affiliation(s)
- Xuemei Zhu
- Department of Architecture, Center for Health Systems & Design, Texas A&M University, College Station, TX, USA.
| | - Hanwool Lee
- Department of Landscape Architecture and Urban Planning, Center for Health Systems & Design, Texas A&M University, College Station, TX, USA
| | - Huiyan Sang
- Department of Statistics, Texas A&M University, College Station, TX, USA
| | - James Muller
- Muller Consulting & Data Analytics, LLC, Washington, DC, USA
| | - Haoyue Yang
- Department of Landscape Architecture and Urban Planning, Center for Health Systems & Design, Texas A&M University, College Station, TX, USA
| | - Chanam Lee
- Department of Landscape Architecture and Urban Planning, Center for Health Systems & Design, Texas A&M University, College Station, TX, USA
| | - Marcia Ory
- Department of Environmental and Occupational Health, Center for Population Health & Aging, Texas A&M University, College Station, TX, USA
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Braun RT, Jung HY, Casalino LP, Myslinski Z, Unruh MA. Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents. JAMA HEALTH FORUM 2021; 2:e213817. [PMID: 35977267 PMCID: PMC8796926 DOI: 10.1001/jamahealthforum.2021.3817] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted. Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.
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Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hye-Young Jung
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Zachary Myslinski
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Mark Aaron Unruh
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Cerullo M, Yang KK, Roberts J, McDevitt RC, Offodile AC. Private Equity Acquisition And Responsiveness To Service-Line Profitability At Short-Term Acute Care Hospitals. Health Aff (Millwood) 2021; 40:1697-1705. [PMID: 34724425 DOI: 10.1377/hlthaff.2021.00541] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As private equity firms continue to increase their ownership stake in various health care sectors in the US, questions arise about potential impacts on the organization and delivery of care. Using a difference-in-differences approach, we investigated changes in service-line provision in private equity-acquired hospitals. Relative to nonacquired hospitals, private equity acquisition was associated with a higher probability of adding specific profitable hospital-based services (interventional cardiac catheterization, hemodialysis, and labor and delivery), profitable technologies (robotic surgery and digital mammography), and freestanding or satellite emergency departments. Moreover, private equity acquisition was associated with an increased probability of providing services that were previously categorized as unprofitable but that have more recently become areas of financial opportunity (for example, mental health services). Finally, private equity-acquired hospitals were less likely to add or continue services that have unreliable revenue streams or that may face competition from nonprofit hospitals (for example, outpatient psychiatry), although fewer shifts were noted among unprofitable services. This may reflect a prevailing shift by acute care hospitals toward outpatient settings for appropriate procedures and synergies with existing holdings by private equity firms.
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Affiliation(s)
- Marcelo Cerullo
- Marcelo Cerullo is a resident in the General Surgery Residency Program, Duke University Hospital, in Durham, North Carolina
| | - Kelly Kaili Yang
- Kelly Kaili Yang is a graduate student in the Department of Economics, Duke University, in Durham, North Carolina
| | - James Roberts
- James Roberts is a professor in and chair of the Department of Economics, Duke University, and a research associate with the National Bureau of Economic Research
| | - Ryan C McDevitt
- Ryan C. McDevitt is a professor in the Fuqua School of Business, Duke University
| | - Anaeze C Offodile
- Anaeze C. Offodile II is an assistant professor in the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, in Austin, Texas, and a nonresident fellow in Domestic Health Policy at the Baker Institute for Public Policy, Rice University, in Houston, Texas. He is the current Gilbert Omenn Fellow of the National Academy of Medicine
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Billig JI, Kotsis SV, Chung KC. Trends in Funding and Acquisition of Surgical Practices by Private Equity Firms in the US From 2000 to 2020. JAMA Surg 2021; 156:1066-1068. [PMID: 34431968 DOI: 10.1001/jamasurg.2021.3642] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Jessica I Billig
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Sandra V Kotsis
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Kevin C Chung
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Michigan
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Bach-Mortensen AM, Verboom B, Movsisyan A, Degli Esposti M. A systematic review of the associations between care home ownership and COVID-19 outbreaks, infections and mortality. NATURE AGING 2021; 1:948-961. [PMID: 37118328 DOI: 10.1038/s43587-021-00106-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/02/2021] [Indexed: 04/30/2023]
Abstract
Social care markets often rely on the for-profit sector to meet service demand. For-profit care homes have been reported to suffer higher rates of coronavirus disease 2019 (COVID-19) infections and deaths, but it is unclear whether these worse outcomes can be attributed to ownership status. To address this, we designed and prospectively registered a living systematic review protocol ( CRD42020218673 ). Here we report on the systematic review and quality appraisal of 32 studies across five countries that investigated ownership variation in COVID-19 outcomes among care homes. We show that, although for-profit ownership was not consistently associated with a higher risk of a COVID-19 outbreak, there was evidence that for-profit care homes had higher rates of COVID-19 infections and deaths. We also found evidence that for-profit ownership was associated with personal protective equipment (PPE) shortages. Variation in COVID-19 outcomes is not driven by ownership status alone, and factors related to staffing, provider size and resident characteristics were also linked to poorer outcomes. However, this synthesis finds that for-profit status and care home characteristics associated with for-profit status are linked to exacerbated COVID-19 outcomes.
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Affiliation(s)
| | - Ben Verboom
- Institute for Medical Information Processing, Biometry and Epidemiology, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Ani Movsisyan
- Institute for Medical Information Processing, Biometry and Epidemiology, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
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Konetzka RT, White EM, Pralea A, Grabowski DC, Mor V. A systematic review of long-term care facility characteristics associated with COVID-19 outcomes. J Am Geriatr Soc 2021; 69:2766-2777. [PMID: 34549415 PMCID: PMC8631348 DOI: 10.1111/jgs.17434] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND/OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths. DESIGN Systematic review. SETTING Long-term care facilities (nursing homes and assisted living communities). PARTICIPANTS Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021. MEASUREMENTS Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably. RESULTS Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes. CONCLUSION Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.
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Affiliation(s)
- R. Tamara Konetzka
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | - Elizabeth M. White
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Alexander Pralea
- Program in Liberal Medical EducationBrown UniversityProvidenceRhode IslandUSA
| | - David C. Grabowski
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusettsUSA
| | - Vincent Mor
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
- Providence Veterans Administration Medical Center Research ServiceProvidenceRhode IslandUSA
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Shen K, Loomer L, Abrams H, Grabowski DC, Gandhi A. Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data. JAMA Netw Open 2021; 4:e2122885. [PMID: 34499136 PMCID: PMC8430452 DOI: 10.1001/jamanetworkopen.2021.22885] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/24/2021] [Indexed: 02/04/2023] Open
Abstract
Importance Federal data underestimate the impact of COVID-19 on US nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020. Objective To assess the magnitude of unreported cases and deaths in the National Healthcare Safety Network (NHSN) and provide national estimates of cases and deaths adjusted for nonreporting. Design, Setting, and Participants This is a cross-sectional study comparing COVID-19 cases and deaths reported by US nursing homes to the NHSN with those reported to state departments of health in late May 2020. The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021. Exposures Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state. Main Outcomes and Measures The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN. Results Among 15 415 US nursing homes, including 4599 with state case data and 7405 with state death data, a mean (SE) of 43.7% (1.4%) of COVID-19 cases and 40.0% (1.1%) of COVID-19 deaths prior to May 24 were not reported in the first NHSN submission in sample states, suggesting that 68 613 cases and 16 623 deaths were omitted nationwide, representing 11.6% of COVID-19 cases and 14.0% of COVID-19 deaths among nursing home residents in 2020. Conclusions and Relevance These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.
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Affiliation(s)
- Karen Shen
- Department of Economics, Harvard University, Cambridge, Massachusetts
| | - Lacey Loomer
- Department of Economics and Health Care Management, Labovitz School of Business and Economics, University of Minnesota, Duluth
| | - Hannah Abrams
- Department of Medicine, Massachusetts General Hospital, Boston
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ashvin Gandhi
- Anderson School of Management, University of California, Los Angeles
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Lee DS, Ma S, Chu A, Wang CX, Wang X, Austin PC, McAlister FA, Kalmady SV, Kapral MK, Kaul P, Ko DT, Rochon PA, Schull MJ, Rubin BB, Wang B. Predictors of mortality among long-term care residents with SARS-CoV-2 infection. J Am Geriatr Soc 2021; 69:3377-3388. [PMID: 34409590 DOI: 10.1111/jgs.17425] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND While individuals living in long-term care (LTC) homes have experienced adverse outcomes of SARS-CoV-2 infection, few studies have examined a broad range of predictors of 30-day mortality in this population. METHODS We studied residents living in LTC homes in Ontario, Canada, who underwent PCR testing for SARS-CoV-2 infection from January 1 to August 31, 2020, and examined predictors of all-cause death within 30 days after a positive test for SARS-CoV-2. We examined a broad range of risk factor categories including demographics, comorbidities, functional status, laboratory tests, and characteristics of the LTC facility and surrounding community were examined. In total, 304 potential predictors were evaluated for their association with mortality using machine learning (Random Forest). RESULTS A total of 64,733 residents of LTC, median age 86 (78, 91) years (31.8% men), underwent SARS-CoV-2 testing, of whom 5029 (7.8%) tested positive. Thirty-day mortality rates were 28.7% (1442 deaths) after a positive test. Of 59,702 residents who tested negative, 2652 (4.4%) died within 30 days of testing. Predictors of mortality after SARS-CoV-2 infection included age, functional status (e.g., activity of daily living score and pressure ulcer risk), male sex, undernutrition, dehydration risk, prior hospital contacts for respiratory illness, and duration of comorbidities (e.g., heart failure, COPD). Lower GFR, hemoglobin concentration, lymphocyte count, and serum albumin were associated with higher mortality. After combining all covariates to generate a risk index, mortality rate in the highest risk quartile was 48.3% compared with 7% in the first quartile (odds ratio 12.42, 95%CI: 6.67, 22.80, p < 0.001). Deaths continued to increase rapidly for 15 days after the positive test. CONCLUSIONS LTC residents, particularly those with reduced functional status, comorbidities, and abnormalities on routine laboratory tests, are at high risk for mortality after SARS-CoV-2 infection. Recognizing high-risk residents in LTC may enhance institution of appropriate preventative measures.
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Affiliation(s)
- Douglas S Lee
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Ted Rogers Centre for Heart Research, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Shihao Ma
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Department of Computer Science, University of Toronto, Toronto, Canada.,Vector Institute of Artificial Intelligence, University of Toronto, Toronto, Canada
| | - Anna Chu
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Chloe X Wang
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Xuesong Wang
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Peter C Austin
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Finlay A McAlister
- Alberta SPOR Unit, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sunil V Kalmady
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Moira K Kapral
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of General Internal Medicine, University of Toronto, Toronto, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, University of Alberta, Edmonton, Canada
| | - Dennis T Ko
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Paula A Rochon
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Women's College Hospital, Toronto, Canada
| | - Michael J Schull
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Barry B Rubin
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Bo Wang
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Department of Computer Science, University of Toronto, Toronto, Canada.,Vector Institute of Artificial Intelligence, University of Toronto, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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Risk Factors Associated with Nursing Home COVID-19 Outbreaks: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168434. [PMID: 34444183 PMCID: PMC8394924 DOI: 10.3390/ijerph18168434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 12/12/2022]
Abstract
Background: The coronavirus disease 2019 (COVID-19) pandemic had a devastating impact on nursing homes/long-term care facilities. This study examined the relationship between geography, size, design, organizational characteristics, and implementation of infection prevention and control (IPC) measures and the extent of COVID-19 outbreaks in nursing homes in the Autonomous Province of Trento (Italy) during the time frame of March-May 2020. Methods: The analysis included 57 nursing homes (5145 beds). The association between median cumulative incidence of COVID-19 cases among residents and characteristics of nursing homes was assessed by Mann–Whitney U test, Kruskal–Wallis test or Spearman rho. To evaluate the potential confounding of geographical area, a 2-level random intercept logistic model was fitted, with level 1 units (patients in nursing homes) nested into level 2 units (nursing homes), and “being a COVID-19 case” as the dependent variable. Results: Median cumulative incidence was not significantly associated with any of the variables, except for geographical region (p = 0.002). COVID-19 cases clustered in the part of the province bordering the Italian region most affected by the pandemic (Lombardy) (45.2% median cumulative incidence). Conclusions: Structural/organizational factors and standard IPC measures may not predict the epidemiology of COVID-19 outbreaks and be sufficient alone to protect nursing homes against them.
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Offodile II AC, Cerullo M, Bindal M, Rauh-Hain JA, Ho V. Private Equity Investments In Health Care: An Overview Of Hospital And Health System Leveraged Buyouts, 2003-17. Health Aff (Millwood) 2021; 40:719-726. [PMID: 33939504 DOI: 10.1377/hlthaff.2020.01535] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Private equity firms have increased their participation in the US health care system, raising questions about incentive alignment and downstream effects on patients. However, there is a lack of systematic characterization of private equity acquisition of short-term acute care hospitals. We present an overview of the scope of private equity-backed hospital acquisitions over the course of 2003-17, comparing the financial and operational differences between those hospitals and hospitals that remained unacquired through 2017. A total of 42 private equity deals occurred, involving 282 unique hospitals across 36 states. In unadjusted analyses, hospitals that were acquired had larger bed sizes, more discharges, and more full-time-equivalent staff positions in 2003 relative to nonacquired hospitals; private equity-acquired hospitals also had higher charge-to-cost ratios and higher operating margins, and this gap widened during our study period. These findings motivate evaluations by policy makers and researchers on the impact, if any, of private equity acquisition on health care access, spending, and risk-adjusted outcomes.
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Affiliation(s)
- Anaeze C Offodile II
- Anaeze C. Offodile II is an assistant professor in the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, in Austin, Texas, and a nonresident fellow in Domestic Health Policy at the Baker Institute for Public Policy, Rice University, in Houston, Texas. He is the current Gilbert Omenn Fellow of the National Academy of Medicine
| | - Marcelo Cerullo
- Marcelo Cerullo is a resident in the General Surgery Residency Program, Duke University Hospital, in Durham, North Carolina
| | - Mohini Bindal
- Mohini Bindal is a research assistant in the Baker Institute for Public Policy, Rice University, and a medical student at Baylor College of Medicine, in Houston, Texas
| | - Jose Alejandro Rauh-Hain
- Jose Alejandro Rauh-Hain is an assistant professor in the Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center
| | - Vivian Ho
- Vivian Ho is the James A. Baker III Institute Chair in Health Economics at Rice University and a professor in the Department of Medicine at Baylor College of Medicine
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Ryskina KL, Yun H, Wang H, Chen AT, Jung HY. Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020. J Am Med Dir Assoc 2021; 22:960-965.e1. [PMID: 33705743 PMCID: PMC7877199 DOI: 10.1016/j.jamda.2021.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/14/2021] [Accepted: 02/07/2021] [Indexed: 11/24/2022]
Abstract
Objective To measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff. Design Retrospective cross-sectional study. Setting and Participants Centers for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts). Methods We estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics. Results Of the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant. Conclusions and Implications These findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Hyunkyung Yun
- Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Hannah Wang
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela T Chen
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hye-Young Jung
- Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, New York, NY, USA.
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