key: cord-0286830-99t874k1
authors: Wong, E. K.-C.; Thorne, T.; Estabrooks, C.; Straus, S. E.
title: Recommendations from long-term care reports, commissions, and inquiries in Canada
date: 2020-11-18
journal: nan
DOI: 10.1101/2020.11.17.20233114
sha: 766410e0de1dedbebce135af9d9d1982772ef98f
doc_id: 286830
cord_uid: 99t874k1

Background Multiple long-term care (LTC) reports over the last 30 years issued similar recommendations for improvement across Canadian LTC homes. Our primary objective was to identify the most common recommendations made over the past 10 years. Our secondary objective was to estimate the total cost of studying LTC issues repeatedly over the past 30 years. Methods The qualitative and cost analyses were conducted in Canada from July to October 2020. Using a list of reports, inquiries and commission from The Royal Society of Canada Working Group on Long-Term Care, we coded recurrent recommendations in LTC reports. We contacted the sponsoring organizations for a cost estimate, including direct and indirect costs. All costs were adjusted to 2020 Canadian dollar values. Results Of the 80 Canadian LTC reports spanning the years of 1998 to 2020, twenty-four (30%) were based on a national level and 56 (70%) were focused on provinces or municipalities. Report length ranged from 4 to 1491 pages and the median number of contributors was 14 (interquartile range, IQR, 5-26) per report. The most common recommendation was to increase funding to LTC to improve staffing, direct care and capacity (67% of reports). A median of 8 (IQR 3.25-18) recommendations were made per report. The total cost for all 80 reports was estimated to be $23,626,442.78. Interpretation Problems in Canadian LTC homes and their solutions have been known for decades. Despite this, governments and non-governmental agencies continue to produce more reports at a monetary and societal cost to Canadians.

The COVID-19 pandemic led to a high proportion of deaths in Canadian long-term care 62 homes (LTCH) compared with those of other developed countries. The proportion of deaths from 63 COVID-19 in LTCH in Canada was 81% compared with a mean of 42% in other Organisation 64

for Economic Cooperation and Development (OECD) countries [1] . This statistic is surprising 65 since Canada is considered to have a relatively low number of COVID-19 deaths overall [2] . 66

There were also significant differences between provinces that were attributed to pandemic 67 preparedness, integration of services (LTCH, public health and hospitals), funding and resources, 68 daily care hours for residents, comprehensiveness of inspections and differences in ownership 69 model (profit versus non-profit) [3] . suffering from a lack of basic personal care and delays in identifying medical problems [7] . 80

Reduced staffing levels and wage compression in Canada's LTC sector compelled individuals to 81 work at more than one facility to make a living wage. An Ontario study comparing for-profit and 82 non-profit facilities found lower staffing levels in for-profit LTCHs, which was associated with 83 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . The opportunity to support residents and care providers 99 between wave 1 and wave 2 has passed. Sadly, the consequences of the lack of action will be 100 disproportionately carried by the most vulnerable residents and the lowest paid, most 101 marginalized members of the LTC workforce, personal support workers (PSW), who provide 102 90% of the direct care [15] . 103

The primary objective of this study was to examine the recurring recommendations over 104 the past 10 years. Our secondary objective was to calculate the total costs of generating all of the 105 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; https://doi.org/10.1101/2020.11.17.20233114 doi: medRxiv preprint LTC reports, commissions, and inquiries in Canada over the last 30 years. We aimed to put the 106 cost of repeatedly studying the same problems into context of the current pandemic. 107 inquire about the estimated cost of producing each report. We requested both direct and indirect 119 costs. Direct costs included consultancy fees, salaries, compensation for expert witnesses, 120 graphics, layout, printing, and dissemination. Indirect costs included time donated from authors 121 who volunteered their time to produce the report. When an estimated budget was not available, 122 we searched online for global budget reports from the sponsoring organization. Total annual 123 expenses for research, advocacy, or reports were divided by the number of reports published that 124

year by the organization to generate an estimated cost. We also searched for media reports about 125 costs of commissions or coroner's inquests. If no costs were available, the estimate was based on 126 length, depth of research, inclusion of external experts/witnesses, and the sponsoring 127 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. publication year, geographic region, scope of report, number of contributors, number of pages, 132 and duration of the project. The primary outcome was recurrent recommendations. Secondary 133 outcomes included contributors, total costs of producing the reports and median page count. 134

No ethics approval was required for this analysis. 136

The list of Canadian LTC reports from the Royal Society commission spans the years 138 1998 to 2020 (n=80). There was an increase in the number of reports over time, with 10 reports 139 in the first half of 2020 ( Figure 1 ). Most of the reports were focused at a provincial level (n=55, 140 68.8%), 24 reports were based on a national level (30.0%). We found one municipal report and 141 no reports from the territories. Ontario (n=31, 55.0%) produced the majority of the provincial 142 reports, followed by British Columbia (n=11, 19.6%) ( Table 1) preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; https://doi.org/10.1101/2020.11.17.20233114 doi: medRxiv preprint on continuing care, older adults, or the health care system as well. The median report length was 150 40 pages (interquartile range, IQR, 21-84), with 16 reports (20.0%) over 100 pages. The median 151 number of contributors, including authors, witnesses, and consultants, was 14 (IQR 5-26). 152

Reviewing the reports from the last 10 years (n=48), we identified a median of 8 (IQR 154 3.25-18) recommendations per report. Numerous recommendations were repeated in these 155 reports (Table 2) The least common recommendation made by professional associations was for improved 169 transparency, reporting and tracking of critical incidents (n=1, 5.0%). 170

Critical incidents received the most attention from governments (n=6, 17.1%), followed 171 by non-profits (n=2, 10.5%) and a professional association (n=1, 5.0%). Recommendations 172 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; https://doi.org/10.1101/2020.11.17.20233114 doi: medRxiv preprint regarding quality of care or data utilization were more likely to be made by government (n=18, 173 51.4%) or professional associations or unions (n=20, 64.5%) than by non-profits (n=3, 15.8%). 174

Staff wellness support was most recommended by non-profits (n=7, 36. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; https://doi.org/10.1101/2020.11.17.20233114 doi: medRxiv preprint Long-Term Care Homes System (The Wettlaufer Report) in 2019, which involved 79 196 contributors, witnesses, and experts [18] . increasing direct care hours, while essential, is only one of the many recommendations from 218 1 1 existing reports. Identifying the right staff mix and care team composition, providing proper 219 education and training, and supporting staff wellness are also critical to developing a long-term 220 workforce that has sufficient resilience to confront future crises [27] . Furthermore, we should 221 focus more attention on resident quality of life, which should be the ultimate goal of our efforts. 222

Although the total cost of $23 million in generating LTC reports may seem insignificant 223 compared to a government budget, it represents a lost opportunity to continually improve 224 Canadian LTCHs. Studying the same problems repeatedly means Canadian experts are confined 225 to fixing critical deficiencies in LTC instead of innovating new care models. 226

There are several strengths of this study. Two reviewers extracted key recommendations 227 from each LTC report in the last 10 years and created a consensus coding scheme. We 228 systematically tracked down the cost of each report by contacting the sponsoring organization or 229

consulting their global budgets. The total costs, including time donated of experts authoring 230 these reports, were accounted for. For reports that did not have available cost data, we estimated 231 the total cost by using reports with known costs with similar length and depth. 232

The main limitation of this study was the lack of true cost estimates for half of the LTC 233 reports. Some organizations lacked transparency about costing, and others lacked detailed 234 accounting of spending. Staff turnover and record keeping practices were barriers to accessing 235 data, particularly for the reports produced over 10 years ago. For government agencies, we often 236 had to call multiple departments and speak with numerous representatives and noted 237 considerable variation in the level of disclosure. For the two military reports during COVID-19, 238

we likely underestimated the cost since they were generated as part of military duty. However, 239 there were still considerable costs incurred by the public by having the military deployed to those 240

LTCHs [28] . We also grouped reports on health system improvement and care of older adults in 241 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; https://doi.org/10.1101/2020.11.17.20233114 doi: medRxiv preprint preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; https://doi.org/10.1101/2020.11.17.20233114 doi: medRxiv preprint *Some reports had more than 1 funding organization All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 18, 2020. ; 

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