Why did so many people die of coronavirus in nursing homes of all places?

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Researcher Marlies Bär looks into the camera with a smile.

Nursing homes were hit very hard during the coronavirus pandemic. Nearly half of all Dutch people who died of coronavirus lived in a nursing home. Marlies Bär of the Erasmus School of Health Policy & Management conducted a study with colleagues Judith Bom, Pieter Bakx and Bram Wouterse on the possible causes. What was notable was that nursing homes with a high resident satisfaction rate tended to have lower excess mortality rates. Excess mortality may also have been related to staff sickness absence and the hiring of external staff.

When the first coronavirus wave hit, we soon learned that elderly people and people who were in poor health were much more likely to die of the virus. There was even a nursing home in Rotterdam where half the residents died in a matter of weeks in an outbreak. This was an extreme case, but nursing home residents proved to be a vulnerable group in general: nearly half the Dutch people who died of the coronavirus did so in a nursing home (12,500 deaths, out of an estimated excess mortality rate of 30,000), even though more than 96 per cent of the over-65s live in their own homes or in a different type of housing. ‘In other words, the excess mortality rate was very high in nursing homes. That’s why it’s so important that we look at possible causes,’ says researcher Marlies Bär.

Previously, politician Pieter Omtzigt called on MPs to look into the causes of the excess mortality. His motion was passed unanimously by the Dutch House of Representatives. This prompted ZonMw to conduct several research projects Opens external, one of which focused on nursing homes. Elderly people residing at nursing homes tend to be in relatively frail health and are harder to isolate, e.g. because of shared amenities and because of their interactions with healthcare providers. Furthermore, there was a severe dearth of protective equipment at the start of the pandemic, e.g. face masks. ‘This was true for all nursing homes, but with our study, we wish to determine whether nursing homes have certain characteristics that may have contributed to the excess mortality,’ the PhD student says.

High Zorgkaart Nederland scores correlate with low excess mortality rates 

The excess mortality rate was higher in nursing homes, but another thing that stood out is the significant variation between the various healthcare institutions. In normal years, 30 per cent of all residents pass away in a given year. However, in certain nursing homes, a whopping 44 per cent died during the pandemic. However, other nursing homes actually had reduced excess mortality rates during the pandemic. Healthcare institutions whose homes are highly rated on Zorgkaart Nederland (based on experiences reported by residents and their families) tended to have lower excess mortality rates. In other words, nursing homes that cater to happy residents had lower excess mortality rates. This was confirmed by healthcare providers, who stated that it was harder to comply with the coronavirus measures in older buildings – say, buildings where people did not have rooms or bathrooms of their own.

Share of freelancers and sickness absence rates

However, gaining a proper understanding of the characteristics that may have contributed to these varying excess mortality rates proved to be a challenge. It turned out that the size of the nursing home did not matter. Nor did the number of healthcare providers per resident. What was notable was that there does seem to be a correlation between the pre-pandemic sickness absence rate in nursing homes and the excess mortality rates of 2021, when most elderly people had already been vaccinated. Nursing homes which, even prior to the pandemic, had to hire many external care providers generally had higher excess mortality rates during the first year of the pandemic. ‘We are still trying to determine what happened there. Perhaps these freelance care providers work at multiple institutions, thus causing them to spread the virus more easily,’ says Bär.

The study focused on data about nursing home residents published by Statistics Netherlands (CBS), publicly available information on nursing homes obtained from documents such as annual reports, and, as mentioned, the Zorgkaart Nederland scores. These data are anonymised, meaning one cannot check for individual nursing homes what was going on there. ‘Furthermore, we don’t know how the national coronavirus measures were complied with at different places. To some extent, this was up to the nursing homes themselves, and unfortunately, we had no information on that.’

Better understanding of staff characteristics

According to Bär, the study shows that it is useful to gain a better understanding of staffing indicators that may have been at play. ‘In a follow-up study, we would like to look at, say, the influence of training and work experience. The healthcare industry is prone to higher sickness absence rates than other industries. And it’s interesting to determine who calls in sick and why. This study shows that sickness absence and excess mortality are related. And, as mentioned, the percentage of freelancers plays a role, too. For this reason, I feel that the study results should serve as an incentive for politicians to take a good look at the work-related aspects.’

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