Background The adult social care sector is increasingly outsourced to for-profit providers, who constitute the largest provider of care homes in many developed countries. 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 SARS-CoV-2 infections and deaths in for-profit care homes. However, the growing body of academic research investigating ownership variation across COVID-19 outcomes has not been systematically synthesised.We aimed to identify, appraise, and synthesise the available research on ownership variation in COVID-19 resident and staff outcomes (outbreaks, infections, deaths, shortages of personal protective equipment (PPE) and staff) across care homes for older people, and to update our findings as new research becomes available.
Methods This living systematic review was prospectively registered with PROSPERO (CRD42020218673) and on OSF (https://osf.io/c8dq9/). 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. Data were extracted by a single review author and independently validated by a second. The results were synthesised by country, RoB, and model adjustments, and visualised using harvest plots.
Results Twenty-nine studies across five countries were included in the first iteration of this review, with 75% of included studies conducted in the Unites States. For-profit ownership was not consistently associated with a higher probability of a COVID-19 outbreak. 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 care homes were also associated with a number of risk factors, such as crowdedness, size, client vulnerability, inferior quality ratings, and PPE shortages, which may have contributed to the higher incidence of infections and deaths.
Discussion Understanding and analysing systematic variation across ownership groups is of immense policy relevance, given that the vast majority of care homes in many developed countries are for-profit entities. Our synthesis demonstrates that for-profit ownership and associated characteristics were consistent risk factors for higher cumulative COVID-19 infections and deaths in the first wave of the pandemic. Thus, ownership and the characteristics associated with for-profit care home providers may present key regulatable factors that can be addressed to improve health outcomes in vulnerable populations and reduce health disparities.
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