A systematic review of long‐term care facility characteristics associated with COVID‐19 outcomes

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.