Older individuals are more vulnerable to the COVID-19. In some European countries such as Spain, 87% of COVID-19 deaths are among individuals aged 70 years and above (Spanish National Network for Epidemiological Monitoring, 2020a, 2020b), and a significant share of COVID-19 fatalities has taken place in nursing homes. Thirteen per cent of all nursing home residents died from COVID-19 in the first wave of the pandemic in Spain. The figure rises to 22% of nursing home residents over the age of 80 years (Costa-Font et al, 2021).
Certainly, not all countries were equally prepared to face the healthcare consequences of the first wave of the COVID-19 pandemic. Before the pandemic, hospital admissions were slower among nursing homes residents than equivalent populations in the community (Lee et al., 2003, Robins et al., 2013). Furthermore, community infections in Spain do not correlate with nursing home infections (Costa-Font et al, 2021). What can explain nursing home fatalities?
Austerity and underfunding
Alongside other Southern European countries, Spain has been heavily exposed to austerity cuts in the 2008–2013 period. A significant reduction in long-term care funding available (Costa-Font et al, 2018) might have magnified the effects of a pandemic in nursing homes.
Underfunded nursing homes might lack sufficient spare human resources to perform its duties at its expected quality. A common reaction to underfunding has been the reduction in the hiring of permanent staff. Underfunding led to the increased size of the nursing homes, which made it challenging for high-occupancy facilities to find rooms available for social distancing.
One way to test for the underfunding hypothesis with the limited data available is to examine the association between proxy measures of nursing home underfunding, including understaffing (staff to places ratio) and nursing home fatalities (relative to excess deaths). Other proxies include the role of average nursing home size (larger nursing homes might not guarantee access to protective equipment) and nursing home occupancy rate (as occupancy plays a role in limiting the availability of spare rooms for self-isolation). Figure 1 below shows some evidence of the regional variation in COVID-19 fatalities as share of excess deaths and nursing home occupancy rate.
Costa-Font et al (2021) show evidence of an association between nursing home deaths relative to excess deaths, whereby larger-sized nursing home exhibit higher fatalities relative to excess deaths. Similarly, they find a reduction in relative fatalities per additional staff per place in a nursing home. However, these estimates come from a small number of observations and report an adjusted association that cannot be interpreted as causal.
Figure 1. Average occupancy rate (number of users/number of beds) and COVID-19 nursing home deaths by region
Other explanations as announced in previous articles (Costa-Font, Norton and Siciliani, 2017) refer to limited investment and coordination of health and long-term care, giving rise to the well-known ‘bed-blocking’ problem, which is deemed the cause of a significant share of excessive hospital care use. Health and long-term care services in Spain have traditionally been subject to several types of ‘coordination failures’ both between health and social care services, and between different levels of government. Coordination failures can explain that on average, most regions took between 26 and 31 days to report a case.
Coordination plans for health and social care have been limited to a few regions. Only 8 of 17 regions in Spain had developed health and social care coordination plans at the time of the pandemic. The Spanish government made coordination failures worth after centralising health care stewardship whilst social care remains uncoordinated in the hands of regional authorities. Finally, in some regions, older age patients were refused emergency health care from major hospitals. Clinical guidelines explicitly stated not to admit older patients residing in nursing homes.
To take forward
Underinvestment in nursing home care, and specifically regions exhibiting lower staff to nursing home places, correlate with a higher nursing home fatality relative to excess deaths. Similarly, coordination failures make things worse. In evaluating long-term care programs, one needs to bear in mind the externalities that they engender in other areas of economic activity sicu as health care, especially during a pandemic.
Joan Costa-Font is an associate professor (reader) at LSE’s department of health policy. He is an economist affiliated with CESIfo in Munich and IZA, Bonn. The core of his current research is on health economics.
Sergi Jiménez-Martín is professor of economics at Universitat Pompeu Fabra and affiliated professor of the Barcelona GSE. He is the director of the Barcelona Microeconometrics Summer School (BMiSS, Barcelona GSE) and chair of the FEDEA-La Caixa Economía de la Salud y Hábitos de Vida.
Analía Viola is a researcher at Fundación de Estudios de Economía Aplicada (FEDEA) and a PhD in economics at Universidad Nacional de Educación a Distancia (UNED).
This article was first published in LSE Business Review
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