key: cord-0750909-5yk4fnzj
authors: Belmin, Joël; Georges, Scarlett; Franke, Florian; Daniau, Come; Cochet, Amandine; Durand, Cécile; Noury, Ursula; Gomes do Espirito Santo, Maria Eugênia; Fonteneau, Laure; Pariel, Sylvie; Lafuente-Lafuente, Carmelo; Danis, Kostas
title: Coronavirus disease 2019 in French residential care facilities: a nationwide study
date: 2021-03-20
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.03.013
sha: 870df2bc3e632d2204281f147c0005f0a1702581
doc_id: 750909
cord_uid: 5yk4fnzj

Objectives The Coronavirus 2019 (COVID-19) pandemic caused a considerable mortality in long-term care facilities (LTCFs), including residential care setting and nursing homes. This study aimed to estimate COVID-19 incidence and mortality in residential care facilities and to compare them with those recorded in nursing homes. Design Nationwide observational study conducted by French health authorities. Settings and participants Since March 1, 2020, all LTCFs in France reported all COVID-19 cases and COVID-19-related deaths among their residents. Methods Possible cases were those with COVID-19 related symptoms without laboratory confirmation and confirmed cases those with a RT-PCR test or serology positive for SARS-CoV-2. We included facilities with at least one confirmed case of COVID-19 and estimated the cumulative incidence of COVID-19 cases and mortality due to COVID-19 reported until June 30th, 2020, using the maximum bed capacity as a denominator. Results Of the 2,288 residential care facilities, 310 (14%) and of the 7,688 nursing homes, 3,110 (40%) reported COVID-19 cases among residents (p<0.001). The cumulative incidence of COVID-19 was significantly lower in residential care facilities as compared with nursing homes (1.10 vs 9.97 per 100 beds, p<0.001. Mortality due to COVID-19 was also lower in residential care facilities compared with nursing homes (0.07 vs 1.29 per 100 beds, p<0.001). Case fatality was lower in residential care facilities (6.49% vs 12.93%, p<0.001). Conclusion and implications: French residential care facilities experienced a much lower burden from COVID-19 than nursing homes. Our findings may inform the implementation of better infection control practices in these settings.

The Coronavirus 2019 (COVID-19) pandemic had dramatic consequences for the elderly [1] [2] [3] . Age was 29 the main factor associated with COVID-19 related mortality, with the mortality rate being 60 times 30 higher in people over 80 years of age than in adults <50 years 4 . Several studies have reported on the 31 burden of COVID-19 in long-term care facilities (LCTF), with large outbreaks and high mortality rates 5-32 9 . A recent study reported that COVID-19-related deaths in LTCF accounted for 30-60% of all COVID-33 19 deaths in many European countries 10 . 34

Residential care settings, also named assisted living facilities (Résidences autonomie in France), are a 35 type of LTCF for the elderly that has some special features compared to nursing homes. These 36 facilities offer their residents an independent private accommodation including a kitchen, bathroom, 37 television and telephone connections, the provision and maintenance of common areas, access to a 38 restaurant service, laundry service, access to 24-hour security assistance, access to group events or 39 outdoor activities organized by the residence 11 . Community services operating in their district take 40 care of the residents who require assistance for dependency or medical care. Nursing homes, on the 41 other hand, provide residents with rooms in group housing with meals served in collective dining 42 rooms and a wide variety of care and services, including assistance for activities of daily living and 43 nursing care. 44

Many studies have described the consequences of COVID-19 infection in long-term care residents 8,12-45 14 . However, apart from media reports, there have not been published studies reporting the 46 occurrence of COVID-19 in residential care facilities, although those account for about one-fifth of the LTCF in France 15,16 , and their number is similar to that of nursing homes in the United States 17 .

We aimed to determine whether these facilities were affected by the COVID-19 pandemic at the 49 same extent as nursing homes. We estimated the proportion of facilities with at least one confirmed case of COVID-19. We also 67 calculated the cumulative incidence of COVID-19 cases and mortality due to COVID-19 declared 68 between March 1st and June 30 th , 2020, using the maximum bed capacity of the facility as 69 denominator, because we did not have access to the exact occupancy rate of the facilities during this 70 period. Since the pandemic severity varied across French regions, we stratified the analysis by the 71 regional level of COVID-19 cumulative incidence. We defined three types of regions, based on the 72 regional incidence of COVID-19 in LTCFs: high incidence (>9% of residents), intermediate incidence homes using chi-square test and Fisher's exact test, or ANOVA. We calculated rate ratios (RR) and 77 95% confidence intervals using Poisson regression. P values of <0.05 were considered as significant. 78

We used Stata16 software (StataCorp, TX, USA) to perform the analysis. 79

Among the 9,976 LTCFs recorded in the national database, there was 2,288 residential facilities and 82 7,688 nursing homes. Of those, 310 (14%) residential care facilities and 3,110 (40%) nursing homes 83 reported at least one confirmed COVID-19 case among their residents (p<0.001) ( Table 1) . Three 84 regions were classified as high incidence (Grand-Est, Hauts-de-France, Ile-de-France), six regions 85 were classified as low incidence (Bretagne, Corse, Normandie, Nouvelle Aquitaine, Occitanie, Pays de 86 Loire) and the four remaining regions were classified as intermediate incidence (Auvergne-Rhone-87 Alpes, Bourgogne-Franche Comté, Centre-Val de Loire, Provence Côte d'Azur). The risk of having at 88 least one confirmed case in a residential care facility was 67% (RR 0. 33; 95%CI 0.30-0.37) lower than 89 in a nursing home. The same pattern was observed when we stratified by level of regional incidence 90 (Table 1) . 91

The cumulative incidence rate of COVID-19 was 89% (RR 0.11; 95% CI 0.09-0.13) lower in residential 92 care facilities compared with that of nursing homes (1.10 vs 9.97 per 100 beds, p<0.001 (Table 2) . 93 was much lower in residents of residential care facilities than those of nursing homes. This could be 103 related to several factors, including differences in living conditions, staff exposure and general health 104 status of those populations. Testing practices did not differ in the different types of settings during 105 the study period. 106

One factor that could explain the lower occurrence of COVID-19 in residential care facilities is the 107 smaller number of contacts among the residents, and between residents and staff members 108 compared to those observed in nursing homes. In France, residents of residential care facilities are 109 provided with a private housing including a kitchen, and many of them can easily take their meals in 110 their own premises and using meals-on-wheels services. In contrast, residents in nursing homes do 111 not have these options and eat their meals in dining rooms where interactions with other residents 112 and staff are numerous. In addition, the number of staff members in nursing homes is higher than in 113 residential care facilities. Staff members may be responsible for the transmission of SARS-CoV-2 to 114 the residents as they move back and forth between the facility and the community. 9 In France, the 115 staff ratio is about 64 per 100 beds in nursing homes compared with 13 per 100 beds in independent 116 living residences 16 . Even if the residents of residential care facilities who are dependent for daily 117 living activities or who require medical care, meet additional home-aid staff and health care 118 professionals from the community, they probably still interact with a smaller number of professionals 119 than nursing home residents. Furthermore, In France, special care units for people with dementia 120 and severe behavioral disorders are included in nursing homes, but not in residential care facilities, 121 with the prevalence of dementia being much higher in nursing homes. Dementia patients are less 122 likely to adopt protective measures leading to increased transmission of COVID-19 in those units. reduced the number of contacts between nursing home residents and reduced the differences 126 between residential care and nursing home facilities for this aspect. 127

In our study, the case-fatality for COVID-19 among residents of residential care facilities was half that 128 observed in nursing homes. This is likely related to some differences in the profile of residents in 129 residential care facilities. Residents in residential care facilities are generally healthier than the 130 nursing home population, with the prevalence of comorbidities being higher among the first 16 . 131

According to a French Ministry of Health survey conducted in 2005, the average age of residents was 132 83 years in residential care facilities and 86 years in nursing homes 16 . In the same survey, severe 133 dependence for activities of daily living, defined by Groupe Iso-Ressources (GIR) 1 or 2, was recorded 134 in 54% of residents in nursing homes and in only 1.3% of residents in residential care facilities, and 135 the corresponding values for mild or no dependence (GIR 5 or 6) were 8.6% and 64% respectively 16 . 136 This indicates that residents in residential care facilities are on average younger and less disabled 137 than nursing home residents, and that may explain the lower fatality observed in the former. In 138 addition, due to the high prevalence of disability and severe chronic illness, including dementia, 139 many nursing home residents are not eligible for transfer to an intensive care unit to be cared for 140 with mechanical ventilation, and the proportion of ineligible patients is probably higher than in 141 residential care facilities. This could also contribute to differences in death rates. 142

It should be noted that the definition of COVID-19 confirmed cases 18,19 used in our study differs 143 somewhat from the definition given by the World Health Organization 20 and the Center for Disease 144 and Prevention Control 21 , according to which a positive RT-PCR test for CoV2-SARS is the only 145 confirmatory laboratory element. When defining the confirmed cases of COVID-19, the French health 146 authorities accepted a positive serology for CoV2-SARS as the confirmatory laboratory element for 147 cases with clinical symptoms of COVID-19 and a negative RT-PCR test or if RT-PCR was not 148 performed 19 . This may influence the balance between confirmed and possible cases and should be 149 taken into account when comparing the incidence rate of confirmed cases observed in our study with that of other studies. However, same case definition was applied to residential care facilities and 151 nursing homes, so this cannot explain the differences in incidence rates observed. 152

Our study had several limitations. Firstly, we can't exclude that cases of COVID-19 may have been 153 under diagnosed and also under reported in residential care facilities despite the request of health 154 care authorities. This is very unlikely due to the daily on site presence of staff in these facilities and 155 their high level of awareness to the risk of COVID-19 among the residents. Moreover, access to 156 medical and laboratory care is very easy in these facilities, similar to nursing homes. Second, in this 157 study, we estimated incidence and mortality using the maximum facility capacity as denominator. 158

The use of the occupancy rates in the LTCFs would have allowed more precise estimates. Thirdly, 159 there could also have been a bias related to the practice of COVID-19 testing which could have been 160 different depending on the type of facilities. In nursing homes, wide testing among residents and 161 staff should be carried out when an outbreak occurs in the facility, and thus making it possible to 162 detect large number of cases, particularly asymptomatic cases. However, facility-wide testing for 163 COVID-19 among residents and staff after the identification of the first case in the facility was not 164 performed during the study period (first wave of the pandemic), due to unavailability of tests. In 165 addition and to our knowledge, COVID-19 outbreaks occurring in residential care facilities were not 166 frequent, unlike nursing homes. Nonetheless, it is unlikely that a possible bias related to differences 167 in testing practices would have influenced mortality related to COVID-19. Finally, we included French long-term care facilities, by type of facility and regional level of COVID-19 incidence. The 261 differences in incidence between residential care facilities (RCF) and nursing homes (NH) were 262 significant in each type of regions. 263 264 265 J o u r n a l P r e -p r o o f 

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