Infectious Disease · Medical Literature
Current Impact of COVID-19 in Long-Term Care Facilities in the United States: A Systematic Literature Review.
Abstract
Background: COVID-19 disproportionately affects older adults, placing residents of closed-community settings, such as long-term care facilities (LTCFs), at increased risk for severe illness and death. Objective: To describe the epidemiology and healthcare resource utilization associated with acute COVID-19 in LTCFs in the United States during Omicron variant predominance. Data Sources: MEDLINE and Embase databases were searched on January 15, 2025 for full-text citations published on or after January 1, 2022. Conference abstracts from long-term care conferences in 2023 and 2024 were hand-searched. Records were included if they described acute COVID-19 in LTCFs (nursing homes, assisted living facilities, or Veterans Affairs Community Living Centers). Records were excluded if they were conducted outside the United States, published in languages other than English, focused on long COVID, did not include data from the Omicron predominance period (beginning November 1, 2021), or were clinical trials, case reports/case series, narrative reviews, editorials, or commentaries. Data Synthesis: Forty-three articles met the inclusion criteria, most of which reported COVID-19 cases (20 studies), mortality (18 studies), and/or healthcare resource utilization (11 studies). Although all studies included COVID-19 data during the Omicron period, most also included earlier periods during which other COVID-19 variants were predominant. In the United States, weekly incidence rates for COVID-19 infections and hospitalizations among nursing home residents ranged from 614 to 1338 and from 38 to 71 per 1,000 residents, respectively. Approximately 1 in 6 COVID-19 hospitalizations occurred among LTCF residents. Compared with community-dwelling individuals, mortality was 4.6-fold higher among LTCF residents. Conclusion: COVID-19 in LTCFs was associated with high rates of hospitalization and mortality among residents, including vaccinated individuals, during the study period.
Clinical relevance
Among residents of U.S. long-term care facilities (nursing homes, assisted living facilities, and VA Community Living Centers), what is the epidemiology and healthcare resource utilization associated with acute COVID-19 during the period of Omicron variant predominance (November 2021 onward)? __SNAPSHOT__ {"studyDesign":"Systematic literature review (no meta-analysis reported)","setting":"United States long-term care facilities: nursing homes, assisted living facilities, and Veterans Affairs Community Living Centers; database search conducted January 15, 2025","sampleSize":"43 studies met inclusion criteria (aggregate patient-level n not reported in available abstract)","population":"Residents of closed-community long-term care settings in the United States with acute COVID-19 during the Omicron predominance period (beginning November 1, 2021); excluded: non-U.S. settings, long COVID, pre-Omicron-only data, case reports/series, narrative reviews, editorials, commentaries, and non-English publications","intervention":"Exposure to acute COVID-19 (SARS-CoV-2 Omicron variant and subvariants) in a long-term care facility setting","comparator":"Not applicable (descriptive systematic review; no formal comparator arm reported)","primaryOutcome":"Epidemiology of acute COVID-19 (cases reported in 20 of 43 included studies) and healthcare resource utilization in U.S. LTCFs during Omicron predominance; full enumeration of additional outcomes not provided in available abstract","followUp":"Not reported (cross-sectional and retrospective study designs assumed given observational scope; individual study follow-up durations not specified in available abstract)","fundingSource":"Not reported in available abstract"}
Key findings
Based solely on the available abstract: 43 studies published on or after January 1, 2022 met inclusion criteria after searching MEDLINE, Embase, and hand-searching conference abstracts from long-term care conferences in 2023 and 2024. The most common outcome reported across included studies was COVID-19 cases, described in 20 of the 43 studies (47%; calculated). The abstract does not report pooled incidence rates, case fatality rates, hospitalization rates, p-values, confidence intervals, or effect sizes for any outcome. Healthcare resource utilization was identified as a key domain of synthesis, but specific utilization metrics, magnitude of effect, and direction of findings are not available from the abstract alone. No NNT or NNH can be calculated from the available data. Quantitative synthesis (meta-analysis) was not described.
Practice implications
This systematic review addresses a clinically important and undercharacterized gap: the burden of COVID-19 in U.S. LTCFs specifically during the Omicron era, a period during which high vaccination coverage, widespread prior immunity, and reduced intrinsic virulence altered the epidemiological landscape compared to earlier pandemic waves. The review's focus on nursing homes, assisted living facilities, and VA Community Living Centers is appropriate given the well-established disproportionate vulnerability of LTCF residents to severe COVID-19 outcomes. However, because only the abstract is available, it is not possible to assess the specific epidemiological findings, the directionality of resource utilization trends, the quality or risk-of-bias appraisal of included studies, or the degree of heterogeneity across the 43 included studies. Which specific LTCF resident subpopulations (e.g., by vaccination status, frailty level, comorbidity burden, or facility type) were most or least represented in the evidence base cannot be determined. Assisted living facility residents and VA Community Living Center residents may be underrepresented relative to nursing home residents in the underlying literature, limiting generalizability across care settings. Practice implications cannot be derived from the abstract alone. __LIMITATIONS__ 1. Only the abstract is available for review; quantitative findings, risk-of-bias assessments, and data synthesis details cannot be evaluated. 2. Restriction to English-language, U.S.-only, full-text publications (with limited conference abstract supplementation) may introduce selection bias and limit breadth of evidence. 3. The Omicron predominance period encompasses multiple distinct subvariants (BA.1 through XBB, JN.1, and subsequent lineages) with potentially differing transmissibility and severity profiles; subvariant-level heterogeneity cannot be assessed from the abstract. 4. Inclusion of conference abstracts from only two years (2023–2024) and only from long-term care conferences introduces potential indexing gaps and grey literature bias. 5. Absence of meta-analytic pooling (based on abstract description) limits the ability to derive precise aggregate effect estimates. 6. Studies reporting only COVID-19 cases (20/43) may reflect publication bias toward facilities or periods with notable outbreaks. 7. Heterogeneity in case ascertainment, testing protocols, and reporting standards across included studies is expected but cannot be quantified from the abstract. 8. Funding source is not reported, precluding assessment of potential sponsorship bias. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ This systematic review synthesizes 43 U.S. studies on the epidemiology and healthcare resource utilization of acute COVID-19 in long-term care facilities during the Omicron era, a period that has been relatively undercharacterized in the LTCF-specific literature. Because only the abstract is available, specific quantitative findings cannot be evaluated; clinicians should access the full publication to determine whether the synthesized evidence supports changes to infection prevention, surveillance, or treatment protocols in their LTCF settings. The study's scope—spanning nursing homes, assisted living facilities, and VA Community Living Centers—positions it as a potentially valuable reference for pharmacists, physicians, and infection preventionists managing COVID-19 risk in institutionalized older adults.