In the 470 nursing homes that operated in the Community of Madrid during the first wave of the pandemic, the hardest hit by covid in all of Spain, there were 9,468 deaths of residents between March and April 2020, according to figures provided by the Regional government through the Transparency Portal. With these data in hand, a study, published in the international journal Epidemiologia and led by the epidemiologist María Victoria Zunzunegui, analyzes the impact of mortality according to the public or private ownership of the centers and their management model ―public, indirect, concerted or private. Its main conclusion is that the “highest” mortality occurred in public residences and private or indirect management. Instead, the minor was registered in 100% public residences.
Zunzunegui, an honorary professor at the University of Montreal but to whom she remains closely linked through academic and scientific activities, the outbreak of the coronavirus in March 2020 caught her working as a grandmother in the US and when she had already been retired for four years. “I saw what was happening in the nursing homes in Madrid, a real catastrophe, and I decided that was reason enough to go back to work and get down to business with it,” this expert in the epidemiology of aging told EL PAÍS by phone.
In August 2020, it began collaborating with the Actuar Covid platform, which includes 1,200 health professionals, with which it published the first reports on what happened in residences in the second and third waves of covid. This new study focuses on the worst of the worst, the first wave. In addition to Zunzunegui, they are signed by François Béland, also a teacher in Montreal; Fernando García López, doctor from the National Epidemiology Center; and the journalist Manuel Rico, director of research at InfoLibre, who provided the databases and his research experience in the long-term care system.
In the two worst months of the pandemic, mortality in residences was 18.5%: about one in five residents died. Zunzunegui clarifies that, to make the calculation, the total number of available places was taken as a base and not those occupied. The reason is that they do not have the data, although they know that the occupation was “very high, the residences were very full”. An Imserso report puts the figure between 92% and 94%.
Mortality according to ownership and management of residences in Madrid: from 1 to 4, all models of public-private agreement, 5 and 6 100% private and 7 is 100% public. Epidemiology
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It is also about deaths from all causes, of which 7,290 occurred in the residences themselves and without medical assistance. Only 2,178 of the deaths, 23%, occurred in hospitals. How many were due to covid? Nor is it known, since the data they have been able to collect is partial. “Of the 7,290 in residences, 1,118 were confirmed by covid, 4,676 had compatible symptoms and 1,496 for other causes,” details the expert. However, nothing is known about the people who ended their days in hospitals. “The cause of death is not available,” regrets the researcher.
For this reason, they decided to focus the study on all causes of death, especially considering that many of those who died for other reasons are actually indirect deaths from covid, since the exclusion protocol of March 18, which denied the transfer to hospitals of the elderly with disabilities, prevented their referral. “The protocol lasted three weeks, but the return to referral was gradual,” recalls Zunzunegui. In his opinion, the covid crisis showed that “the long-term care system was not prepared to resist a pandemic” and the decisions that were made led to “a massacre.” The protocol “was a very cruel and unfair decision” and Zunzunegui is now working to estimate how many deaths could have been avoided if it had not been applied.
Of the 470 operating residences in the first wave, 405 were private and 65 public – 43 regional and 22 municipal. Within the 43 regional public, 25 were managed directly by the Administration and 18 through a concert. Of the 22 municipal ones, only two are 100% public. This, which may seem like a nuance, is not at all trivial because, as the report shows, the lives of the residents depended on whose hands their residence was in.
The report’s findings are revealing. In residences owned and managed by the public, which accounted for 12% of the total of 51,938 places available, mortality was the lowest of all the types of centres, 7.4%. However, in the 18 residences that were publicly owned but privately managed, which accounted for 5% of the beds, mortality was the highest of all the ownership and management models: 21.9%.
In residences owned by private non-profit entities -for example, religious entities- and with all their private places, it was 12.7%. In centers they provided 8% of the places. In 100% private centers, that is, privately owned and managed for profit and without concerted places ―26% of the total number of places―, it rose to 13.8%. In private for-profit residences but which have positions arranged with the administration – the bulk of the available places, 42% – mortality rose to 20.6%. And, finally, in private non-profit centers that have places agreed with the public sector ―12% of the total―, it was 17%.
These figures are calculated “equalizing the conditions after taking into account other factors that influence mortality, such as the size of the center, the population where the residence is located, the number of positive residents and the reference hospital.” Studying which was the reference hospital was key “to consider the effect of the protocol of the Ministry of Health that excluded elderly people living in residences from hospital care.”
“All things being equal, mortality in 100% private residences is almost double that in 100% public ones,” underlines the epidemiologist. But the “even more important” fact is that mortality in centers with concerted places or indirect management was almost three times higher than that which occurred in those with public management and ownership, adds Zunzunegui, for whom it is clear that “when the public sector contracts with the private sector, mortality skyrockets”.
The epidemiologists conclude that the results of their research are “a testimony to the lethal consequences of public-private collaboration in the residential care sector in the Community of Madrid” and highlight the need for a “profound transformation of the sector” . They also call for “measures to be taken so that it does not happen again” and to carry out “an investigation into what happened in the residences in Madrid those two months.”
For Zunzunegui, it is urgent to develop “an information system that allows establishing quality control” and “systematic and effective inspections”, since those that exist are “isolated and the residence is notified of the visit” and the fines, “very little”. “The control system is very deficient,” criticizes the expert, who cites an article, published in 2019 by this newspaper, in which it is revealed that of the 18 residences of indirect management there were trials in 14 and many were fined, but 13 They renewed the concession. “The residences are the most opaque thing there is and it is a conscious strategy that obeys the interests of the Administration and of the companies”, since it prevents accountability to the families of the residents and to public opinion, the expert censures, which emphasizes that the elderly “are the most vulnerable population, without voice or vote or ability to defend themselves.”
The researcher, who also worked at the Andalusian School of Public Health and at the Public Health Center of the Autonomous University, has first-hand knowledge of the nursing home sector in Madrid, as she participated in an international study in which she followed the health of 2,000 elderly people from the Leganés centers from 1992 to 1999. That study, which produced 45 scientific articles, concluded that the city in the Madrid belt had the highest life expectancy of all those analyzed in Finland, Holland, Israel, Sweden and Italy. “Now, with the covid, it has been lowered a lot,” laments Zunzunegui, who celebrates the agreement reached on Tuesday by the Ministry of Social Rights and the communities to carry out “a very profound reform of the sector.” Although the initial proposal was “much better and perfectly feasible”, what was agreed upon represents “a step forward”.
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