Why Similar Countries Have Very Different Coronavirus Mortality Rates

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An aid worker from the Spanish NGO Open Arms talking to an elderly woman before a test at a nursing home in Barcelona, Spain, April 1, 2020.
An aid worker from the Spanish NGO Open Arms talking to an elderly woman before a test at a nursing home in Barcelona, Spain, April 1, 2020. Credit: Santi Palacios/AP

Nursing home patients around the world have accounted for a high percentage of deaths from COVID-19. But is that because nursing home residents tend to be less healthy than the rest of the population and would have likely died had they not been confined to such facilities? Or is it because of the structural features of such facilities, such as the communal living areas and the presence of multiple caregivers for all of the care recipients?

After examining data from 32 European countries, a team of researchers at Tel Aviv University has concluded that the nursing homes themselves are the problem.

“We are talking here about basic long-term care facilities – not luxury retirement homes,” says Prof. Neil Gandal from the school of economics at Tel Aviv University, and the lead researcher in the brand new study that has yet to be submitted for publication in a peer-reviewed journal (although it has been published as a discussion paper on the portal of the Centre for Economic Policy Research – a network of 1,300 economists based mainly in Europe).

Gandal says he and his colleagues were trying to understand what could account for very different COVID-19 mortality rates in countries with otherwise similar characteristics.

"Long-Term Care Facilities as a Risk Factor for Death Due to COVID-19," CEPR DP #14844, Gandal, N., Yonas, M., Feldman, M., Pauzner, A., and Tabbach, A., 2020.

“A good example is Spain and Greece,” he notes. “If you look at the demographics of these countries, they are very similar, with pretty much the same median age and same life expectancy. They are both southern Mediterranean countries with similar climates. And yet in Greece you had 15 COVID-19 deaths per million residents, while in Spain you had 542.”

The one key difference the researchers found between the two countries was the number of long-term care beds per capita. In other words, the percentage of the population confined to nursing homes.

In Greece there were 156 long-term care beds per million residents, while in Spain there were 7,419 – more than 45 times as many. The study refers to death rates known in the middle of May.

“This was true of other European countries as well,” Gandal says. “Other things being equal, wherever there was a low number of nursing home beds per capita, there was also a low death rate. The most likely explanation is that in those countries, older people stayed at home, where they were protected by the same few members of the family and not seeing dozens of different caregivers rotating every day.”

The Tel Aviv University research team included professors from the departments of economics and computer science. Only countries in Europe were included in the study, says Gandal, because those were the only countries for which figures were available on nursing homes. The data was provided by the European Health Information Gateway, which comes under the auspices of the World Health Organization.

An elderly resident being transferred to hospital after a coronavirus outbreak was discovered at the nursing home in Rome, May 2, 2020. Credit: Roberto Monaldo/AP

The study found that the number of nursing home beds in a country on its own can explain about 28 percent of the variation in death rates. “That is a lot,” Gandal says. Even when controlling for other factors like population density, average population age and number of hospital beds per capita, he adds, there is a strong link between nursing home beds per capita and mortality rates.

Israel was not included in the study, but according to Gandal it fits the general pattern: It has a relatively low number of nursing home beds (2,200 per million residents) and a relatively low number of COVID-19 deaths (26 per million residents as of mid-May).

“I would cautiously say that this bodes well for us,” he says.

Worldwide, nursing home deaths accounted for a large percentage of national death rates. In the United States, some 40 percent of coronavirus-related deaths were nursing home residents; in Sweden, it was almost 50 percent. According to the WHO, anywhere between 24 to 82 percent of nursing home residents died in different nations.

Volunteers arriving to perform serological tests for COVID-19 at the Santa Maria del Prato nursing home in Campagnano Romano, near Rome, April 16, 2020. Credit: Mauro Scrobogna/AP

In Israel, nursing homes have been hard hit in terms of infection rates but have been relatively spared in terms of mortality rates: 141 deaths – about 45 percent of the total of the country’s COVID-19 deaths. Israel is unique in that only 10 percent of seniors in need of around-the-clock care live in facilities that provide such treatment.

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