For-profit status is associated with the extent of an outbreak of coronavirus disease 2019 (COVID-19) in long-term care (LTC) homes and the number of resident deaths from COVID-19, but not the likelihood of an outbreak, which was related to the infection rate in the surrounding local public health unit and the total number of beds in the home, found new research published in CMAJ (Canadian Medical Association Journal).
"Our findings suggest that the incidence of COVID-19 in the public health unit region surrounding an LTC home and the size of the home -- but not for-profit status -- are important risk factors for outbreaks of COVID-19 in LTC homes, whereas for-profit status (with for-profit homes more commonly having outdated design standards and chain ownership) is an important risk factor for transmission of SARS-CoV-2 after an outbreak has been established in a home," writes Dr. Nathan Stall, Sinai Health and the University of Toronto, with coauthors.
The study looked at all 623 long-term care homes in Ontario from March 29 to May 20, 2020, and their 75 676 residents. It excluded retirement residences, which are privately funded and not administered by the Ministry of Long-term Care. For-profit homes were usually smaller, housed fewer residents, and had older design standards from before 1972 with multiple-occupancy rooms and chain ownership.
About 30% (190) of long-term care homes in Ontario experienced outbreaks during the study period, with 110 (30.6%) occurring in for-profit homes, 55 (34%) in nonprofit homes and 25 (24.8%) in municipal homes.
For-profit status of LTC homes was associated with about a two-fold increase in the extent of a COVID-19 outbreak (number of resident cases) and a 178% increase in the number of resident deaths compared with homes with non-profit status. These associations were mediated in large part by the higher proportion of outdated design standards (which meet or fall below standards set in the year 1972) and chain ownership in for-profit homes. Of the 10 homes with the highest death rates, 7 were for-profit-homes with older design standards and chain ownership.
"Newer design standards provide for larger and more private room accommodations, as well as less crowded and self-contained common spaces, whereas older design standards can have ward-style accommodation and centralized common spaces in which all residents can interact. Beyond promoting quality of life, newer design standards promote infection prevention and control, given that they limit infection both within resident bedrooms and among areas of a facility," write the authors.
"With governments such as Ontario's already committing to independent commissions and inquiries into their LTC systems, it is important that policy recommendations and changes consider all root causes of the present crisis, including supporting capital projects to retrofit or rebuild older LTC homes," the authors write.
In a related commentary https://www.cmaj.ca/content/cmaj/early/2020/07/22/cmaj.201714.full.pdf, Dr. Margaret McGregor and co-author write "85% of Ontario's for-profit LTC facilities are part of a chain (v. 31% of nonprofit, and no chains among municipally run homes), which begs the question of whether for-profit chain status of a facility is a significant and independent risk factor for more extensive outbreaks and deaths, even after controlling for multi-bed rooms. If so, simply ensuring building upgrades, while important, is unlikely to be enough to address systemic deficiencies."
The commentary authors point to research that indicates that inadequate staffing, particularly at for-profit LTC homes, is associated with worse outcomes for patients in these facilities. They suggest governments should also focus on staffing levels when preparing for the next wave of COVID-19.
Canadian Medical Association Journal