For-profit nursing homes provide "inferior" care to seniors, and though the evidence isn't perfect it's strong enough that policy makers should pay attention, argue authors of a new paper published today in the peer-reviewed joural PLOS Medicine.

The authors draw on years of research, in the U.S., Canada and elsewhere, comparing for-profit long-term residential care facilities to ones run by public bodies, or nonprofit groups.

"The weight of the evidence says that for-profit delivery models provide inferior care," in terms of staffing hours, pressure sores, and other measures, says author Dr. Margaret McGregor, a Vancouver family physician and researcher with the University of B.C.'s faculty of medicine.

"There is this conflict of interest between the profit motive and actually spending money on things like staffing."

Past studies on the topic, which McGregor and colleagues reviewed for the current paper, have been criticized as inconclusive, because they're observational studies rather than experiments, she said.

The researchers make a case that the observational data is strong enough, especially when making decisions that affect vulnerable and frail seniors.

"This is a highly vulnerable population, who are not able to get up and leave if the care is poor. It's very difficult even to complain."

McGregor hopes the paper spurs debate among policy makers, at a time when aging populations mean more care facilities will be needed, and the trend has been toward for-profit care in Canada and elsewhere.

Observation vs. experiment

There is a valid concern with observational studies: if they see X after Y happens, how do they know X is because of Y and not some unrelated reason or bias? As the saying goes, correlation does not equal causation.

But, it's simply not feasible to conduct a gold-standard controlled experiment, randomly assigning seniors to long-term care without telling them where they're going, says McGregor.

So, the researchers evaluated the observational data based on a set of criteria developed in the 1960s by British epidemiologist Sir Austin Bradford Hill, in part to look at the link between smoking and lung cancer.

They found the result — that for-profit nursing homes have inferior care — was consistent across various types of studies from different countries.

They also found what's known as a "dose-response," another key part of the Bradford Hill criteria, which means that a greater dose of X is associated with more Y.

"When facilities make more profit, they're more likely to have serious deficiency citations compared to facilities that still make profit, but make less profit," said McGregor.

'Our seniors deserve better'

In Canada, 37 per cent of nursing home beds are in for-profit facilities, compared to 78 per cent in the U.K. and 67 per cent in the U.S., according to the paper.

In B.C., 34 per cent of the 292 long-term residential care facilities catering to seniors are private for-profit, according to the Office of the Seniors Advocate.

McGregor cautions that the evidence only describes the average for each type of care, and there are surely exceptions — stand-out, for-profit facilities or poor public ones.

But — like the proverbial pack-a-day smoker who lives to 90 — those exceptions aren't what policy makers should be making decisions based on, she says.

"Decision-makers have a responsibility to ensure nursing home public policy is most consistent with the available evidence and least likely to cause harm," the authors state in the paper.

"It is time to re-align policy with evidence. Our seniors deserve better."