Variation inSARS-CoV-2 Prevalence inUSSkilled Nursing Facilities

OBJECTIVE To identify county and facility factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in skilled nursing facilities (SNFs). DESIGN Cross-sectional study linking county SARS-CoV-2 prevalence data, administrative data, state reports of SNF outbreaks, and data from Genesis HealthCare, a large multistate provider of post-acute and long-term care. State data are reported as of April 21, 2020; Genesis data are reported as of May 4, 2020. SETTING AND PARTICIPANTS The Genesis sample consisted of 341 SNFs in 25 states, including a subset of 64 SNFs that underwent universal testing of all residents. The non-Genesis sample included all other SNFs (n = 3,016) in the 12 states where Genesis operates that released the names of SNFs with outbreaks. MEASUREMENTS For Genesis and non-Genesis SNFs: any outbreak (one or more residents testing positive for SARS-CoV-2). For Genesis SNFs only: number of confirmed cases, SNF case fatality rate, and prevalence after universal testing. RESULTS One hundred eighteen (34.6%) Genesis SNFs and 640 (21.2%) non-Genesis SNFs had outbreaks. A difference in county prevalence of 1,000 cases per 100,000 (1%) was associated with a 33.6 percentage point (95% confidence interval (CI) = 9.6-57.7 percentage point;P =.008) difference in the probability of an outbreak for Genesis and non-Genesis SNFs combined, and a difference of 12.5 cases per facility (95% CI = 4.4-20.8 cases;P =.003) for Genesis SNFs. A 10-bed difference in facility size was associated with a 0.9 percentage point (95% CI = 0.6-1.2 percentage point;P < .001) difference in the probability of outbreak. We found no consistent relationship between Nursing Home Compare Five-Star ratings or past infection control deficiency citations and probability or severity of outbreak. CONCLUSIONS Larger SNFs and SNFs in areas of high SARS-CoV-2 prevalence are at high risk for outbreaks and must have access to universal testing to detect cases, implement mitigation strategies, and prevent further potentially avoidable cases and related complications.