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In Belgium, residents of a nursing home are 50% more likely to die within two years than if they had stayed at home
A carte blanche from Xavier Flawinne (HEC Liège – University of Liège), Mathieu Lefebvre (Aix Marseille University, CNRS, AMSE, Marseille), Sergio Perelman (HEC Liège – University of Liège), Pierre Pestieau (HEC Liège – University of Liège; CORE, UCLouvain) and Jerome Schoenmaeckers (HEC Liège – University of Liège; CIRIEC Belgium).
Since the start of the Covid-19 pandemic, there has been a lot of talk about excess mortality in rest and care homes (MRS in Belgium, Ehpad in France). During the first wave in spring 2020, the number of deaths linked to Covid-19 in the MRS represented around 66% of the total deaths linked to Covid-19 in Spain, 48% in France, 34% in Germany and only 15% in the Nederlands. For Belgium, this figure was 50%, while the fraction of its population over 65 in MRS is only 8.5%.
Differences from country to country
In view of these figures, two questions arise. Do they reveal a failure of MRS and how can we explain these differences from one country to another? To answer these questions, it is necessary to distinguish between two types of factors: the intrinsic characteristics of MRS residents and the functioning of MRS. It is clear that, if in Belgium the elderly join the MRS in poor health, whereas in the Netherlands they go there rather because, following a death or another family event, they find themselves alone and prefer to live in a community , one should expect a higher mortality rate in the first country than in the second. Moreover, if the Dutch MRS are better designed (in terms of equipment and personnel) than their Belgian equivalents to accommodate people with fragile health, we will end up with a difference going in the same direction.
The Share survey, before Covid
We do not currently have good data on the characteristics of the residents and on the more or less deadly side of the MRS to explain this apparent excess mortality linked to Covid-19. It is without any doubt too early. On the other hand, for the years preceding the pandemic, the Share survey (Survey on Health, Aging and Retirement in Europe) provides us with a great deal of information on the elderly who live at home and on those who live in MRS. This makes it possible to study what is attributable to the characteristics of the residents or to the functioning of the SRMs in possible differences in mortality according to the place of residence.
Compare two samples
This is done using a statistical methodology that involves identifying a sample of seniors who have chosen to stay at home but who have the same inherent characteristics as MRS residents. These characteristics relate in particular to the state of health, the degree of dependence, age, sex, level of wealth and the availability of informal help. From this sample, we only need to compare its mortality rate with that prevailing in the MRS. The difference (positive or negative) is attributable to the way in which the MRS are designed, organized and managed.
The results of this comparison are interesting and may help explain what is happening today. In all of the European countries for which we had sufficient observations, three groups can be distinguished: the Nordic countries (Sweden, Denmark and the Netherlands), the countries of the South (Italy and Spain), the countries concerned (Switzerland , Germany, Luxembourg, France, Belgium or the Czech Republic). In the first two groups, we do not observe excess mortality in the MRS, which is not the case for the third, that of the countries concerned. In France or Belgium, residents of an MRS are 50% more likely to die within two years than if they had been able to stay at home. In Germany or Switzerland, the risk is even greater, close to double.
Culture of dying at home in the South
How to explain these differences? The Central European countries described have some specific characteristics compared to other countries. In particular, there is a mix of rather low average public spending on long-term care (from 1.6% of GDP in Germany to 2.4% in Switzerland), a low relative number of workers in the care sector ( particularly in France) and a high proportion of for-profit retirement homes (from 22% in France to 40% in Germany or Switzerland). These figures tend to show less concern for the elderly, which could be associated with a lower quality of care. On the contrary, the northern European countries (Denmark, the Netherlands and Sweden) devote more resources to long-term care than the other countries. These countries are also characterized by a low proportion of private nursing homes (less than 20% of the available supply). The countries of the South are, on the contrary, those which spend the least; they weigh less on SRMs and moreover on a culture of “dying at home, surrounded by loved ones” which can bias the decision to stay at home or to live in an SRM. The daily help provided by relatives is important. Without concluding that there is any causal effect, these countries do not show excess mortality linked to being in a nursing home.
Quality reforms
It should be remembered that these initial results concern Europe before the pandemic. We can bet that in the years to come we will be able to apply the same methodology to study the possible excess mortality due to Covid in the MRS. The comparisons presented at the beginning are indeed misleading since they do not take into account the characteristic characteristics of the residents. We can also maintain that it will soon be possible to distinguish between the different MRS those which are public, private and non-profit. Unfortunately, the Share data does not allow the nature of the retirement home to be identified for each resident.
Finally, what lessons can we draw from this exercise? Let us recall the two major factors of excess mortality in retirement homes: the intrinsic characteristics of the residents and the functioning of the MRS. It seems clear that it is necessary to be interested only in the factors which act on the design, the management and the effectiveness of the SRMs. It is on these factors that produce the quality of an SRM that reforms must focus. A recent US study shows that the quality of SRMs led to lower mortality during the first wave of the pandemic. Americans have survey data on the quality of their retirement homes. These data are not available to us. They would be damn useful. It is not acceptable to know that SRMs are places of death and not to act accordingly.
