Data analysis by Ontario civil servants has found that for-profit ownership of long-term care homes was a significant factor contributing to larger outbreaks and increased deaths in the second wave of COVID-19, compared with outbreaks in non-profit homes.
The work replicates and builds on an analysis of the first wave of the pandemic by independent researchers — but it found the impact of profit status was even more pronounced when the pandemic devastated the long-term care sector for a second time.
The work was presented to the independent commission into long-term care last week.
However, it remains to be seen what the analysis will mean to the provincial government. The senior bureaucrat who explained the research to the long-term care commission included several caveats and cautioned the commissioners about drawing conclusions about for-profit care based on the analysis. He characterized the findings somewhat differently than the independent researcher who conducted the original work.
The next step the government and the for-profit long-term care sector should take is acknowledging that the research signifies a problem, said Dr. Nathan Stall, the lead author of the wave one study published in the Canadian Medical Association Journal.
"Let's look at the sector with a deep dive, let's strive to improve quality within our homes so that we can actually save lives and improve the care that we're providing residents," said Stall, a geriatrician with the Sinai Health System.
The government research found first wave outbreaks in for-profit homes were larger — involving nearly twice as many resident cases as those in non-profit homes — and mortality was 78 per cent higher, replicating Stall's research. It found that in the second wave outbreaks in for-profit homes were two-and-a-half times larger than in non-profits and with three times the deaths, said Stall.
Those figures were reached after the researchers controlled for factors that were external to the home — the level of COVID-19 in the surrounding community and the size of the community.
(The chart below shows the findings of the government's model of long-term care mortality for both waves, with significant factors highlighted in yellow, and the bounds of a 95 per cent confidence interval in brackets. The partially adjusted profit-status figures have been controlled for health region characteristics, the adjusted figures have been adjusted for all of the characteristics.)
However, when the civil servants used a statistical model that adjusted the findings in order to isolate the for-profit nature of the homes from other factors, it fell below the bar of statistical significance for the first wave and for the entire pandemic to date. It persisted as significant for the second wave alone, as a factor in both the extent of the outbreak and the resulting mortality.
The analysis did that by using a statistical model to control for, or equalize, a longer list of factors — including the physical design of the homes, the number of residents, chain ownership and the number of rostered staff positions per bed.
The government analysis also found that a home having more than half of its residents infected in the first wave was highly protective against large outbreaks and high mortality in the second wave, suggesting that the initial infections left residents with immunity, according to Stall.
Stall is the first to acknowledge that the research is nuanced and complex. For-profit ownership doesn't have a direct impact on the care residents receive — there are mediating factors related to for-profit care that do, he said.
One major mediating factor is captured in the research, according to Stall. Old LTC homes that don't meet modern design standards — marked by shared bathrooms and multi-bed ward rooms that make infection prevention and control challenging — are more common in the for-profit sector than municipal and non-profit.
The research showed the physical design of homes was a particularly significant factor in increased cases and deaths in both waves. And when the civil servants did the statistical analysis that controlled for the longer list of criteria — including the design standard — the for-profit status remained significantly associated with increased cases and deaths, but only in the second wave.
That means there are other factors, not captured in the research, that also contributed to the for-profit disadvantage, at least in the second wave, according to Stall. While there is reliable data on the design standards of long-term care homes, there isn't data available for other factors that likely contributed to poorer outcomes.
For example, the government analysis did not include real-time data about staffing levels during outbreaks and acute staffing shortages are believed by many experts to be a factor.
Other potential factors aren't quantifiable — like poor leadership and management, said Stall. There is research from outside the pandemic that suggests for-profit homes have worse inspection results than their municipal and non-profit counterparts and that could shed light on why for-profit homes had worse outcomes, he said.
While Stall and the civil servants used essentially the same methodology, Stall places an emphasis on the modelling that examined the impact of for-profit care when only factors external to the home were controlled — which showed worse outcomes in for-profit homes in both waves. He characterized the other factors within the home — such as the home's design standards — as explanations of why for-profit homes had poorer outcomes.
"If you've (adjusted for) factors that we know are more common within for-profit versus non-profit homes, like older design standards, you may adjust away that association (between for-profit care and worse outcomes), but it explains, it doesn't obviate that association," Stall explained.
When Michael Hillmer, assistant deputy minister of the capacity planning and analytics division of the Ministry of Health, presented to the long-term care commission, he focused on the models that controlled for all available factors, reducing the for-profit disadvantage below the bar of statistical significance when the pandemic was looked at as a whole.
Both Stall and Hillmer noted that severe COVID-19 outbreaks in a small proportion of long-term care homes where all, or nearly all of the residents were infected, influenced the overall trends. And both noted that outcomes were uneven across individual homes of all kinds.
"Overall, I think that we have seen in wave one and wave two, there is enough evidence to suggest that for-profit homes have performed worse than the not-for-profit homes," said Stall. "But there are some important considerations when looking at this data."
Hillmer, meanwhile, concluded the presentation by noting that no effect of ownership was found when using all of the data from the beginning of the pandemic.
(The chart below shows the outcome of the government's fully adjusted modelling of mortality for nearly the entire pandemic, with the dots indicating the model's estimates and the bars indicating the bounds of a 95 per cent confidence interval.)