Residents and staff of long-term care facilities account for at least 40% of U.S. deaths from the coronavirus. In reaction, nursing homes have banned family visitors, scrambled for scarce personal safety equipment, and attracted scrutiny from state and federal lawmakers.
What's received less attention is that many nursing homes have remained virtually COVID-19-free. If researchers could figure out what made the difference, that could help protect nursing home residents now and in the future.
But so far, their studies have drawn wildly different conclusions.
The federal government has weighed in on the controversy. The overall quality of nursing homes is rated on a scale of 1 to 5 stars. And according to the agency that regulates them, the lowest rated nursing homes have been hardest hit by COVID-19.
There are some independent researchers getting the same results.
"The nursing homes that before the pandemic had the most quality problems were, not surprisingly, are the ones that were more likely to get the virus when the pandemic hit because they were so vulnerable," says Charlene Harrington, professor emerita at the University of California, San Francisco.
Harrington looked at more than 1,000 nursing homes in California. Her study will be published later this summer in the journal Policy, Politics, & Nursing Practice.
But David Grabowski, a professor of health policy at Harvard Medical School, found no evidence that quality ratings matter when it comes to COVID-19. He looked at nursing homes across 30 states.
"In terms of your five-star status, in terms of your staffing, in terms of whether you'd had a prior infection control violation, we couldn't find any kind of measure of facility quality that was correlated with having a COVID case," says Grabowski.
Tamara Konetzka , a health economist and professor at the University of Chicago, has also looked at the quality of nursing homes and coronavirus. Like Grabowski, she found no correlation between quality ratings and COVID-19 cases.
"Even the highest quality nursing homes were caught completely off guard," says Konetzka.
Both say that one of the most important variables is location.
"If you happen to be a five-star facility in a community with lots of cases, it's likely to come into your building," says Grabowski. "If you're a one-star facility located in an area with very few cases, you're probably not going to have COVID enter your building."
UCSF's Charlene Harrington is not an outlier, however. Another study, focusing on Connecticut nursing homes, reached the same conclusions as Harrington's.
"We found that higher nurse staffing levels and higher quality ratings were associated with less COVID-19 cases and deaths," says Yue Li, a professor of health services research at the University of Rochester Medical Center in the Department of Public Health Sciences. He even was able to quantify the effect of staffing levels.
"We found that every 20-minutes [per patient per day] increase in the RN staffing level was associated with a 22 percent reduction in COVID-19 cases," he says.
There is one thing on which these researchers do agree. And that is the toll the virus has taken on Black and Latinx residents in large nursing homes. Facilities with larger populations of people of color are twice as likely to have COVID-19 outbreaks as facilities where most of the residents are white.
But that's where agreement ends. So policy makers looking for ways to make nursing homes better won't get clear guidance from these studies. That's because the researchers don't agree on solutions any more than they agree on the causes of nursing the home outbreaks.
Charlene Harrington's work leads her to conclude that lawmakers should focus on low quality nursing homes and inadequate nurse staffing, which is something that nursing homes won't fix on their own.
"And that's because 70% of them are for profit," says Harrington. "And the main way to make money is keep the labor costs low. And that means that they're leaving their residents unprotected."
She's especially concerned with low levels of registered nurse staffing. "They are very important for infection control and the overall quality of the nursing home," Harrington says.
Professor Yue Li, of the University of Rochester, thinks that low-rated facilities should be prioritized for government scrutiny and assistance. "I think that we should target these facilities," he says
But the University of Chicago's Tamara Konetzka thinks pressuring low rated nursing homes with fines and inspections could be a mistake.
"Ramping up fines and inspections is not going to give them what they need to fight this pandemic," she says.
What this pandemic has shown is that all nursing homes need help, says Harvard's Grabowski, with sufficient personal protective equipment, with more testing, and with better infection control.
With no consensus among researchers, it'll be up to policy makers to decide to what extent quality or location or staffing are responsible for the devastation of some nursing homes. Meanwhile, the lives of residents and the workers who care for them hang in the balance.