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Imposing a blanket vaccine mandate for staff at all US nursing homes shortly after COVID-19 preventatives became available could have saved nearly 10,000 lives, a team of esteemed researchers report in a detailed new study.
Facilities that adopted their own mandates before federal regulators required the shots saw “life-saving spillovers” on the health of nursing home residents — and they also experienced far less worker turnover than many had predicted.
Staff departures that did occur were concentrated among part-time workers and reduced direct patient care averages by less than two minutes per day, according to a working paper summarized in the Bulletin on Health published by the National Bureau of Economic Research last week.
Evaluating several key patient care measures, researchers also found “only limited evidence of lower levels of care at mandate facilities,” most notably in an increase in incontinence.
“These limited effects stand in contrast to the industry-wide fear of mass departure of vaccine-hesitant staff that would cause a cascade of negative consequences in patient care,” they wrote. “The effectiveness of mandates in successfully motivating most staff to get vaccinated also stands in contrast to the limited demonstrated effectiveness of less coercive, more persuasion-based measures such as education, outreach and small-scale incentives.”
The study was led by Ashvin Gandhi, assistant professor at the University of California at Los Angeles Anderson School of Management. It is undergoing peer review for formal publication in Management Science.
Gandhi told McKnight’s Long-Term Care News Wednesday that it’s understandable that nursing home managers were hesitant to take steps that might have caused staff to quit, given the focus on hiring and retaining staff.
But he emphasized the fact that far fewer staff quit in response to vaccine mandates than feared.
“In retrospect, this makes sense, as vaccination represents a relatively brief and minor imposition relative to the efforts and uncertainty of quitting and finding a new job,” Gandhi said. “This suggests that managers should understand the extent and length of imposition and make a level-headed assessment of staff members’ plausible response. And, of course, they should assess the trade-off against the benefits of the imposition. In this case, the health benefits of imposing mandates were enormous.”
Accounting for tradeoffs
Other researchers on the project included Ian Larkin, also of UCLA; Brian McGarry, assistant professor and health services researcher at the University of Rochester; Katherine Wen, Assistant Professor of Medicine, Health, and Society and of Public Policy at Vanderbilt University; Sarah Berry, geriatric specialist at Hebrew SeniorLife; and Vincent Mor, Professor of Health Services, Policy & Practice at Brown University’s School of Public Health.
Using reporting from McKnight’s, the team identified 18 chains that adopted their own mandates after emergency vaccinations became available in December, 2020. They excluded those without robust payroll data to finalize a list of 13 chains that included 581 nursing homes. They then compared possible “tradeoffs” against a control group of more than 9,000 nursing homes without mandates.
Thirteen weeks after a chain announced its mandate, a typical 100-bed nursing home in its footprint lost an average equivalent of 0.73 certified nurse aides, or a 4.05% reduction. But data showed those facilities increased hiring or saw their full-time staff take on more hours to make up differences.
By weaving a tight data web that incorporated vaccination rates, case counts, resident mortality, hours worked and worker separations, the researchers also determined nursing homes that adopted mandates reduced patient deaths by 0.5 per 100 beds, or one patient life for every two facilities.
“The increases in staff vaccination led to tangible health benefits for both the vaccinated staff and the vulnerable residents they care for — mandate facilities experienced reductions in COVID cases among both staff and residents, and a large reduction in the rates of resident COVID mortality,” they wrote. “That vaccines work is extremely well documented. However, this study is the first to our knowledge to show that an employer mandate can increase vaccination to the extent that transmission and death is reduced by approximately two-thirds, with minimal turnover costs even in local labor markets where competitors were not issuing mandates.”
Using Centers for Medicare & Medicaid Services quality measures, the team also evaluated the effect of mandates on urinary tract infections, the use of physical restraints, fall injuries, the use of antipsychotics and pressure injury prevalence — all of which they deemed could be worsened by reduced staffing. Of these measures, most saw zero and “not statistically significant” influence, with the exception of a slight increase in bladder incontinence.
“Overall, our estimates do not suggest that patient care suffered dramatically,” the researchers reported. “The relatively small estimated degradation in care pales in comparison to the dramatic positive health effects of increased protection for the facility against COVID-19 outbreaks.”
One area where the researchers did raise an alarm was with the inequitable adoption of vaccine mandates. They noted that facilities in richer locations with a higher concentration of white residents were more likely to issue mandates, and as a result, “lower income patients and patients of color are less likely to benefit from the mortality reductions caused by the mandates.”
Preparing for next time
The team argued that their results show healthcare entities cannot wait for “slow and often controversial government-level decisions around mandates.”
They cited the drawn-out a legal fight over the federal vaccine mandate for healthcare workers and growing vaccine hesitancy amid ongoing COVID outbreaks throughout 2024.
“Future COVID variants, unknown future transmissible viruses, and the possibility of other pandemics all point to the importance of our study’s results on policies by health care managers,” they wrote.
They also theorized that amid today’s efforts to avoid burnout and improve morale, scholars have “underemphasized” human resource policies that may feel counterproductive to those goals — even when they might help achieve a goal such as protecting patient health.
“Especially in light of the disconnect between our results and the conventional wisdom on mandated vaccines and turnover, our study suggests that we need to build a greater understanding of how and when potentially unpopular HR policies can be used despite low morale and burnout,” they wrote.
They also noted that vaccine enforcement may offer benefits in other settings where customers and workers are in close proximity, including assisted living facilities, hospitals, schools, prisons, mines, manufacturing plants and hospitality venues.
“Based on recent history, we cannot necessarily expect government policy makers to act quickly or decisively to protect workers and customers in every situation,” they summarized. “This underscores the importance of our main finding: mandates by private organizations can and do make a difference.”