Ownership and COVID-19 in care homes for older people: A living systematic review of outbreaks, infections, and mortalities

Abstract

BackgroundThe adult social care sector is being increasingly outsourced to for-profit providers, but the impacts of privatisation on service quality and resident outcomes are unclear. During the COVID-19 pandemic, for-profit providers have been accused of failing their residents by prioritising profits over care, prevention, and caution, which has been reported to result in a higher prevalence of COVID-19 infections and deaths in for-profit care homes. Although many of these reports are anecdotal or based on news reports, there is a growing body of academic research investigating ownership variation across COVID-19 outcomes, which has not been systematically appraised and synthesised.ObjectivesTo identify, appraise, and synthesise the available research on ownership variation in COVID-19 outcomes (outbreaks, infections, deaths, shortage of personal protective equipment (PPE) and staff) across for-profit, public, and non-profit care homes for older people, and to update our findings as new research becomes available.DesignLiving systematic review.MethodsThis review was prospectively registered with Prospero (CRD42020218673). We searched 17 databases and performed forward and backward citation tracking of all included studies. Search results were screened and reviewed in duplicate. Risk of bias (RoB) was assessed in duplicate according to the COSMOS-E guidance. The results were synthesised according to RoB, model adjustment, and country context and visualised using harvest plots.ResultsTwenty-eight studies across five countries were included, with 75% of included studies conducted in the Unites States. For-profit ownership was not consistently associated with a higher probability of COVID-19 outbreaks across included studies. However, there was compelling evidence of worse COVID-19 outcomes following an outbreak; with for-profit care homes having higher rates of accumulative infections and deaths. For-profit providers were also associated with shortages in PPE, which may have contributed to the higher incidence of infections and deaths.Chain affiliation was often found to be correlated with higher risk of outbreaks, but not consistently associated with an elevated number of deaths and infections. Private equity ownership was not consistently associated with worse COVID-19 outcomes.ConclusionFor-profit status was a consistent risk factor for higher cumulative COVID-19 infections and deaths. Thus, ownership among providers may be a key modifiable factor which can be regulated to improve health outcomes in vulnerable populations and reduce health disparities. This review will be updated as new research becomes published, which may change the conclusion of our synthesis.

Comparison of resident COVID-19 mortality between unionized and nonunionized private nursing homes

“…found robust evidence that higher average resident age, lower percentage of Medicare residents, small size, for-profit ownership, and chain organization affiliation were associated with a higher resident COVID-19 mortality percentage, consistent with prior literature on risk factors affecting nursing home COVID-19 mortality [15,16]. Compared to the prior research that examined nursing home unionization and resident COVID-19 mortality [4,5], our measurement of unionization has two main strengths [6,7].…”

“…As of April 24, 2022, 152,324 nursing home residents in the U.S. had died from COVID-19, representing 15.4% of all COVID-19 deaths (990,769) in the U.S. [1,2]. Understanding the factors associated with resident mortality has important implications for infection control policies and practice [3].…”

County-Level Social Determinants of Health and COVID-19 in Nursing Homes, United States, June 1, 2020–January 31, 2021

“…The forprofit ownership type was a significant predictor of COVID-19 infections in a recently published review. 47 In our study, overall star rating contributed to increased COVID-19 infection rates across all models. The overall score was based heavily on the survey score and may reflect a nursing home culture of providing high-quality care, which means staff members interact with the residents frequently and provide more opportunities for the virus to spread than in agencies with less interactions between staff members and residents.…”

The COVID-19 Pandemic in Care Homes: An Exploration of Its Impact across Regions in Spain

“…A great deal of research has analysed the impact of the type of care home ownership on COVID-19 outbreaks and mortality and, more specifically, whether private and for-profit status increased their likelihood [ 38 , 39 , 40 ]. Whereas some authors conclude that the type of ownership may have had a relevant influence [ 15 ], others argue that this association is mediated and largely explained by other factors, such as the type of private ownership (big chains) or architectural design [ 13 ], the larger size of private homes, and their tendency to be located in urban and suburban areas [ 29 ].…”