@article {Stallcmaj.201197, author = {Nathan M. Stall and Aaron Jones and Kevin A. Brown and Paula A. Rochon and Andrew P. Costa}, title = {For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths}, elocation-id = {cmaj.201197}, year = {2020}, doi = {10.1503/cmaj.201197}, publisher = {CMAJ}, abstract = {Background: Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes. Methods: We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19.Results: The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7\%) were for profit, 162 (26.0\%) were nonprofit, and 101 (16.2\%) were municipal homes. There were 190 (30.5\%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8\%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95\% confidence interval [CI] 1.19{\textendash}3.05), the number of residents (adjusted OR 1.38, 95\% CI 1.18{\textendash}1.61), and older design standards of the home (adjusted OR 1.55, 95\% CI 1.01{\textendash}2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95\% CI 1.26{\textendash}3.05) and the number of resident deaths (adjusted RR 1.78, 95\% CI 1.03{\textendash}3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership.Interpretation: For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.}, issn = {0820-3946}, URL = {https://www.cmaj.ca/content/early/2020/07/22/cmaj.201197.1}, eprint = {https://www.cmaj.ca/content/early/2020/07/22/cmaj.201197.1.full.pdf}, journal = {CMAJ} }