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Poorer preparation, slower response to COVID-19 led to more deaths in Ontario long-term-care homes, study finds

Poorer preparation, slower response to COVID-19 led to more deaths in Ontario long-term-care homes, study finds
Canada
Residents of long-term-care homes in Ontario were at much greater risk of dying during the first wave of COVID-19 compared to their counterparts in British Columbia because B.C’s health-care system was better prepared and responded more effectively than Ontario’s, according to a new study.

The study published Wednesday in the Canadian Medical Association Journal examines both pre-existing factors that made a clear difference as well as actions taken during the pandemic. Researchers found that after adjusting for the difference in population, there were about four times as many deaths in Ontario care homes compared to B.C. As of Sept. 10, Ontario recorded 1,817 deaths in long-term care, while B.C. had 156.

There is no single circumstance that led to the drastic difference in outcomes, but rather a confluence of factors, said Dr. Irfan A. Dhalla, a vice president and physician at Unity Health Toronto, and one of the study’s authors.

“It’s almost certainly not just all about the response during the pandemic,” Dhalla said. “We found that there were some pretty striking differences between the long-term-care system in the two provinces that existed even before the pandemic.”

Actions such as Ontario calling in the military to assist some care homes illustrates how stark the difference in outcomes was between the two provinces, Dhalla said.

“I don’t think anybody could have imagined that we would be calling in the military. And the fact that we had to do that just shows how badly we failed,” Dhalla said.

The study notes that prior to the pandemic, B.C’s care system was in better shape than Ontario’s. There was better co-ordination in B.C. between homes, public health systems and hospitals, allowing for a faster and more effective response.

Provincial governments determine policies, funding and standards at care homes. The study found on average, combined funding per resident per day was higher in B.C. ($222) than in Ontario ($203). Most of that funding is used to pay staff.

The study did not compare staff wages but it said some estimates suggest before the pandemic B.C. residents received more daily hours of direct care (3.25) than those in Ontario (2.71) and that there is a relation between staffing levels, care hours and higher rates of infection.

One clear difference between the provinces is in the use of shared rooms. Prior to the pandemic, residents in Ontario were more than twice as likely to shared a room, at 63 per cent versus 24 per cent in B.C. A recent study in Ontario showed that residents living in shared rooms are more likely to contract COVID-19.

There is evidence different business models result in different outcomes. In Ontario, 58 per cent of care homes are managed on a for-profit basis, compared to 34 per cent in B.C. The study says evidence suggests that on average, for-profit homes deliver inferior care compared to non-profits. A preliminary study found an association between for-profit status, the extent of COVID-19 outbreaks and the number of resident deaths.

It’s also clear the frequency of inspections at homes can make a difference. Both provinces require annual inspections of care homes. But the study says in late 2018, Ontario transitioned to a “risk-based framework where narrower inspections are conducted in response to critical incidents and complaints.”

In 2019, inspections were carried out mostly in response to complaints or critical incidents. As a result, only nine of 626 long-term-care homes in Ontario received a comprehensive inspection that year.

Actions taken during the pandemic also made a significant difference. The study says leadership and communication was better in B.C., with health officials and elected leaders delivering “consistent messages.” In Ontario, elected leaders and government bureaucrats sometimes conveyed “conflicting messages in separate briefings,” although the report does not elaborate.

The study suggests orders limiting staff to working in a single home were effective in reducing the spread of COVID-19. B.C. announced such a policy on March 26. Ontario did not do so until April 14.

In total, Ontario long-term-care homes saw almost 6,000 COVID cases compared to 466 in B.C.

Differences in how the two provinces approached infection prevention and control also contributed to contrasting outcomes. Starting with the first outbreak in B.C. on March 7, the province sent specialized health teams with expertise in infection control to all homes with outbreaks. Ontario did not start working with public health units and hospitals to form similar teams until April 15.

In B.C., the threshold for an outbreak at a long-term-care home was a single case among residents or staff. Ontario did not revise its definition of an outbreak until April 15.
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