By Jordan Rau and Lauren Weber and Rachana Pradhan, Kaiser Health News, November 12 2020
Nursing homes are still taking days to get back COVID-19 test results as many shun the Trump administration’s central strategy to limit the spread of the virus among old and sick Americans.
In late summer, federal officials began distributing to nursing homes millions of point-of-care antigen tests, which can be given on-site and report the presence or absence of the virus within minutes. By January, the Department of Health and Human Services is slated to send roughly 23 million rapid tests.
But as of Oct. 25, 38% of the nation’s roughly 15,000 nursing homes have yet to use a point-of-care test, a KHN analysis of nursing home records shows.
The numbers suggest a basic disagreement among the Trump administration, state health officials and nursing home administrators over the best way to test this population and how to strike the right balance between speed and accuracy. Many nursing homes still primarily send samples out to laboratories, using a type of test that’s considered more reliable but can take days to deliver results.
As a result, in 29% of the approximately 13,000 facilities that provided their testing speed to the government, results for residents took an average of three days or more, the analysis found. Just 17% of nursing homes reported their average turnaround time was less than a day, and the remainder tended to get results in one or two days. Wait times for test results of staff members were similar.
Those lags could have devastating consequences, because even one undetected infection can quietly but rapidly trigger a broad outbreak. It’s especially concerning as winter sets in and the pandemic notches daily records of infections.
In the meantime, the coronavirus continues its march through institutions. Nursing homes have reported more than 262,000 infections and 59,000 deaths since the government began collecting the information in May. Even without estimating how many residents died from COVID-19 before then, reported nursing home deaths amount to more than a quarter of all COVID-19 fatalities in the U.S. so far.
During the week ending Oct. 25, the most recent period for which data is available, a third of skilled nursing facilities reported a new suspected or confirmed coronavirus infection of a resident or staff member.
Many state public health authorities and nursing homes have ongoing reservations about the rapid tests. They are considered less accurate than the more expensive ones sent out to laboratories, which are known as polymerase chain reaction, or PCR, tests and identify the virus’s genetic material but often take days to complete. And their manufacturers say the rapid tests are designed for people with symptoms — not for screening a general population.
In early November, the Food and Drug Administration warned of false-positive results — in which someone is told incorrectly they are infected — associated with one type of rapid COVID test, and urged providers to follow Centers for Disease Control and Prevention recommendations for using them in nursing homes. False negatives are also a concern because people who don’t know they are infected can unwittingly spread the virus.
HHS bought millions of rapid tests to distribute to nursing homes as the federal government imposed new mandates for the facilities to test staffers at least once a month. Routine staff testing increases to as often as twice a week for homes in areas with the highest infection rates. The Centers for Medicare & Medicaid Services, which is part of HHS, does not recommend testing asymptomatic residents unless a new outbreak occurs or a resident routinely goes outside the facility.
Leaders in multiple states, including Nevada, Vermont and Illinois, have moved to ban antigen tests in nursing homes or limit their use.
“I thought the hard part was getting the testing to the different facilities,” said David Grabowski, a health care policy professor at Harvard Medical School. Instead, he said, “the major barriers to the use of rapid testing seem to be a lack of guidance on when and how to use the tests, coupled with concerns about their accuracy.”
Dr. Michael Wasserman, immediate past president of the California Association of Long Term Care Medicine, said the national effort has been chaotic and inadequate.
The federal government “just hands stuff off to nursing homes and then says, ‘Hey, it’s yours; go use it,’” he said. “And then when things fall apart, ‘We’re not to blame.’”
Nursing homes that don’t trust the rapid tests are having to shoulder the higher cost of lab tests. It costs Stuart Almer, president and CEO of Gurwin Jewish Nursing & Rehabilitation Center on New York’s Long Island, $125,000 a week to conduct lab tests on up to 1,500 residents and staff members.
“We embrace the testing,” Almer said. “But how are we supposed to continue operating and paying for this?”
Goodwin House in Virginia, which includes skilled nursing and assisted living facilities, had performed more than 9,500 tests for COVID-19 as of late October, said Joshua Bagley, an administrator. Only 100 of them were antigen tests. “The majority of our focus is still toward the PCR testing,” Bagley said.
The concerns of state health officials were perhaps most evident in Nevada, where in early October the state banned antigen testing in nursing homes. HHS said the order was illegal, and it was revoked within days.
“There is no such thing as a perfect test,” Adm. Brett Giroir, a senior HHS official who leads the Trump administration’s COVID testing efforts, said on a call with reporters Nov. 9. For example, Giroir said, a risk of PCR tests is that they could provide a positive diagnosis when a person is no longer “actually infectious.”
Although there have been widespread accuracy concerns over antigen tests, certain tests the administration is distributing nationwide have comparable accuracy to lab-based tests, he said.
Other state responses have not been as aggressive as Nevada’s but nonetheless demonstrated unease over how best to use the devices, if at all.
Vermont recommends the use of antigen tests after a known COVID exposure but says they should not be used to diagnose asymptomatic people.
Ohio was initially reluctant to deploy them after Republican Gov. Mike DeWine’s false-positive result from an antigen device, although the tests have since been adopted, said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents some skilled nursing facilities in the state.
Some nursing homes say relying on antigen tests has made a monumental difference. In Hutchinson, Kansas, Wesley Towers Retirement Community has used both types of tests, but it was Abbott’s BinaxNOW antigen test that detected its first two asymptomatic people with COVID-19, said Gretchen Sapp, Wesley Towers’ vice president of health services.
“We have more confidence that our staff are indeed COVID-free or that they are out and not exposing residents. And that is incredibly helpful,” Sapp said. “The biggest challenge is I need more tests.”
A total of 1,150 homes told the federal government they did not have enough supplies for point-of-care tests for all workers, the KHN analysis found. Nursing homes can go through millions of tests quickly when testing monthly or more often, depending on the level of COVID-19 in the area.
White House spokesperson Michael Bars said the administration is working “hand-in-hand with our state and local partners” and “doing more than ever to protect the health and safety of high-risk age groups most susceptible to the virus.”
Janet Snipes, executive director of Holly Heights Care Center in Denver, said antigen tests have been useful to screen staff members despite a few false-positive results. One test was used on a clergy member a resident had summoned.
“We wouldn’t have been able to allow him in, but we were able to do the antigen testing,” she said. “With the vulnerable residents we serve, we’re hoping for more antigen testing, more testing period, more testing of any type.”
Jordan Rau: firstname.lastname@example.org, @JordanRau
Lauren Weber: LaurenW@kff.org, @LaurenWeberHP
Rachana Pradhan: email@example.com, @rachanadixit