Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review

Denis Boucaud-Maitre; Luc Letenneur; Moustapha Dramé; Nadine Taubé-Teguo; Jean-François Dartigues; Hélène Amieva; Maturin Tabué-Teguo

doi:10.1371/journal.pone.0286527

. 2023 May 31;18(5):e0286527. doi: 10.1371/journal.pone.0286527

Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review

Denis Boucaud-Maitre ^1,^2,^*, Luc Letenneur ³, Moustapha Dramé ^2,⁴, Nadine Taubé-Teguo ^2,⁴, Jean-François Dartigues ³, Hélène Amieva ³, Maturin Tabué-Teguo ^2,⁴

Editor: Charlotte Beaudart⁵

PMCID: PMC10231833 PMID: 37256888

Abstract

Residential care facility may provide a transition between living at home and a nursing home for dependent older people or an alternative to nursing homes. The objective of this review was to compare mortality and hospitalizations of older adults living in residential care facilities with those living in nursing homes or in the community. We searched Medline, Scopus and Web of Science from inception to December 2022. Fifteen cohort studies with 6 months to 10 years of follow-up were included. The unadjusted relative risk (RR) of mortality was superior in nursing homes than in residential care facilities in 6 of 7 studies (from 1.3 to 1.68). Conversely, the unadjusted relative risk of hospitalizations was higher in residential care facilities in 6 studies (from 1.3 to 3.37). Studies conducted on persons with dementia found mixed results, the only study adjusted for co-morbidities observing no difference on these two endpoints. Compared with home, unadjusted relative risks were higher in residential care facilities for mortality in 4 studies (from 1.34 à 10.1) and hospitalizations in 3 studies (from 1.12 to 1.62). Conversely, the only study that followed older adults initially living at home over a 10-year period found a reduced risk of heavy hospital use (RR = 0.68) for those who temporarily resided in a residential care facilities. There is insufficient evidence to determine whether residential care facilities might be an alternative to nursing homes for older people with similar clinical characteristics (co-morbidities and dementia). Nevertheless, given the high rate of hospitalizations observed in residential care facilities, the medical needs of residents should be better explored.

Introduction

According to the World Health Organization (WHO), the number of people aged 60 and over will have overtaken the number of children under 5 by 2020 [1]. Population projections estimate that the proportion of people aged 60+ will almost double between 2015 and 2050, from 12% to 22% (or 2.1 billion people) [1]. The development of strategies for the care and housing of the older people, depending on their individual needs, is a priority. These individual needs depend on the physical and cognitive functions, their psychological state, their comorbidities and their social environment [2]. Older adults want to age at home and avoid institutionalization. The proportion of community-dwelling older people with functional limitations has increased in recent years [3]. Keeping these individuals at home often requires the implementation of medical (home care services, mobile geriatric teams, hospitalization at home) and other social aids (caregivers, meal delivery) which have an individual and collective cost. For older people who have severe medical and disability problems, the most widespread social model in developed countries remain nursing home care.

However, other housing models exist such as residential care facilities or foster families [4]. Residential care facilities (also called “senior housing", "independent living communities”, "assisted living facilities", or "continual care retirement communities") have developed over the past decades. In general, each resident has a private apartment and access to common areas and services. Residential care facilities differ in size, type (residence or village), services offered and costs. These structures aim to promote the autonomy and social life of older people [5]. The socio-demographic and medical characteristics of residents in nursing homes and residential care facilities are not similar. Nevertheless, in the US, the age of residents is comparable and residential care facilities are increasingly admitting residents with functional limitations and/or Alzheimer’s and other dementia. Indeed, the prevalence of Alzheimer’s disease or other dementia in residential care facilities has increased from 5% in 2002 to 42% in 2010 [3].

Thus, determining the most appropriate care for dependent older adults is a public health priority. The place of residential care facilities, as an intermediate stage or final place of residence is therefore a key issue for the older adults, their families and health policies. Depending on the characteristics of the patient, existing models need to be properly assessed and compared to determine the effectiveness and cost-utility of each model. This is particularly true for older adults with dementia in the current debate over whether residential care facilities can substitute for, or delay the transfer to nursing homes. The effectiveness of residential care facilities, particularly in terms of mortality and hospitalizations, has been poorly studied in the literature. In 2012, a systematic review on patients with dementia found only one study suggesting that mortality and hospitalizations did not differ in residential care facilities and nursing homes [6]. The objective of this review was therefore to compare mortality and hospitalization rates reported among residents living in residential care facilities, nursing homes and/or in the community and to look for studies conducted on similar patients profiles with regard to dementia status and dependency.

Methods

Our review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines [7]. The protocol for this review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022327207).

Data source

We systematically searched Medline, Scopus, and Web of Science from inception up to 31 December 2022. We developed and conducted the literature search, using a combination of the MeSH terms “senior housing” or “independent living communities” or “residential care” or “continual care retirement” in the title or abstract and “mortality” or “death” or “hospitalizations” in the full text of the articles. Two reviewers (DBM, LL) screened the titles and abstracts. S1 Appendix provides the comprehensive search strategy used to identify original research articles for inclusion in our systematic review. The same two reviewers independently assessed the full text of the articles for eligibility. Discrepancies were resolved by discussion. We also checked the reference lists of all reviews on this topic to identify articles that might have been missed. We limited the search to articles written in English and French.

Eligibility criteria

Population

We only selected cohort studies conducted among older persons (≥65 years old).

Intervention

We selected studies that had a cohort design (prospective or retrospective cohort design) and at least six months of follow-up and that measured mortality or hospitalizations as outcomes. For duplicate publications from the same cohort, we selected those with the largest number of participants. We excluded cross-sectional studies and, reviews.

Comparison

We selected cohort studies comparing residential care facilities with nursing homes and/or communities.

Outcomes

To be included, we considered studies that reported the number of participants or person years and the number of deaths or hospitalizations in both groups (residential care facilities versus nursing home and/or communities).

Data extraction and management

After the study selection process, one reviewer (DBM) extracted data from the original cohort studies. The characteristics extracted from each cohort were: name of the first author, year of publication, study design, length of follow-up, number of participants, mean age, percentage of dementia and percentage of participants with disability (functional status assessed by the Instrumental Activities of Daily Living (IADL) scale [8] or the Activities of Daily Living (ADL) scale [9]), number and percentage of deaths, number and percentage of hospitalizations and risk estimates.

Quality assessment

The risk of bias was assessed using the Quality Assessment Tool for Observational Cohort and Cross-sectional studies [10], a recommended tool for analytic studies [11] by one reviewer (DBM). This process ensures that the quality of included studies is good enough to provide reliable results. Based on a series of questions, the goal was to identify potential flaws in the publication that could affect the measurement of the outcome. The quality of the studies was rated as “poor”, “fair”, or “good”. Question 6 “For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?”, question 7 “Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?” and question 14 “Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?” were considered critical because this review focuses on the relationship between mortality/hospitalization and types of accommodations. Potentially confounding variables affecting the results were age, gender, comorbidities, levels of dependency and cognitive function. In cases where studies answered “no” to questions 7 and 14, quality was rated as “poor”.

Statistical analysis

Unavailable relative risks (RR) and confidence intervals were calculated from the number of events and the number of residents for each study. After reviewing each of the studies included in this review, we considered that a meta-analysis was not relevant, due to the low methodological quality of the studies, the diversity of study designs and follow-up and the heterogeneity of populations, for which essential baseline characteristics were not available.

Results

Our search yielded 8,716 records, of which 6,975 remained after eliminating duplicates (Fig 1). When screening tittles and abstracts, 6,918 records were excluded, leaving 24 full texts to be assessed. Nine studies were excluded, among them two focused on specific mortality endpoints (respiratory mortality and suicide [12, 13]), one related to emergency department visits rather than hospital admission [14], one pooled data from residential care facilities and nursing home data [15], three were systematic review [6, 16, 17] and two were sub-studies of other studies. A total of 15 studies met the eligibility criteria and were included in this review [18–32].

Characteristics of the included studies

The studies were published between 2000 and 2020, 5 studies were prospective cohort studies [18, 19, 21, 23, 24] and 10 were retrospective cohort studies [20, 22, 25–32]. The number of participants ranged from 158 to 691,388 for the studies comparing residential care facilities with nursing homes, and from 808 to 3,366,303 for the studies comparing residential care facilities to home-based care. The studies follow-up ranged from 6 months to 10 years. In three studies [22, 25–26], age was not available, and in the remaining 12 studies, the mean age of participants was greater than 80 years or a majority of participants were 75 and older. For eight studies, MMSE score or the percentage of dementia among participants were not available for one or the both groups of participants. Three studies comparing residential care facilities to nursing homes focused only on dementia patients [19–21]. For the other 5 studies, the oldest adults with dementia were reported in nursing homes rather than in residential care facilities in two studies (72.7% versus 30.3% [20], MMSE score = 17.88 versus 16.03 [24]), there was no difference for one study (MMSE score = 23.3 versus 23.1 [18] and one study reported oldest adults with dementia in residential care facilities rather than at home (33.9% versus 8.4%) [31]. Functional ability was available for three studies, all comparing residential care facilities to nursing homes, with a lower disability score in nursing homes than in residential care facilities [18, 19, 24]. Six studies assessed cohorts from US, 3 from Canada, 3 from United Kingdom, 1 from Ireland, Taiwan and Australia.

Risk of bias

Of the 15 studies, two were rated “good” [18, 31], six “fair” [18, 20, 22, 28, 29, 32] and seven “poor” [21, 24–27, 30] (S1 Appendix). Quality was considered good when similar clinical baseline characteristics were observed or when adjustments on age, sex, dementia and dependency (question 14) were implemented. We considered that failure to adjust for any of this variables downgraded the quality of the study to “fair”, no adjustment or insufficient time (inferior to one year) were rated as “poor” studies (S1 Annex).

1. Comparison of mortality between residential care facilities and nursing homes

Nine studies compared mortality between residential care facilities and nursing homes [18–26] (Table 1). Six of the seven studies with at least one year of follow-up described a higher unadjusted relative risk in nursing homes than in residential care facilities, ranging from 1.3 to 1.68. The only other study with more than 1 year of follow-up suggesting a lower risk [26] had in-hospital mortality, not total mortality as its endpoint.

Table 1. Studies comparing residential care facilities versus nursing homes on mortality.

Author, year, Country	Study design and follow-up	Participants/ cases	Age (mean or %), years	Percentage of dementia	Percentage of mortality	Unadjusted relative risk	Adjusted risk ratio or hazard ratio
Pruchno, 2000, US [18]	Prospective, 15 months	• Nursing Homes: 76 • Residential care facilities:82	• Nursing Homes: 87.4 • Residential care facilities: 86.2	• Nursing Homes: MMSE score = 23,3 • Residential care facilities: MMSE score = 23.1	• Nursing Homes: 18.4% (14/76) • Residential care facilities: 12.2% (10/82)	1.51 [0.71–3.19]	No
Sloane, 2005, US [19]	Prospective, 1 year	• Nursing Homes: 479 • Residential care facilities: 773	• Nursing Homes:: 84.9 • Residential care facilities: 84.4	• Nursing Homes: Moderate to severe: 49.3% • Residential care facilities: Moderate to severe: 29.4%	• Nursing Homes: 22.5% (108/479) • Residential care facilities: 14.7% (114/773)	1.53 [1.21–1.94]	Incidence rate per 100 participants (mild dementia): nursing homes: 4.2 versus residential care facilities: 3.2 (not-significant) Moderate to severe dementia: 4.2 versus 3.7 (non-significant) Incidence rate adjusted for baseline age, gender, race, education, marital status, length of stay, cognition and number of comorbidities
Thomas, 2020, US [20]	Retrospective, 1 year	• Nursing Homes: 602,521 • Residential care facilities: 88,867	• Nursing Homes: >75 years: 80.6% • Residential care facilities: >75 years: 88.2%	• Nursing Homes: 100% • Residential care facilities: 100%	• Nursing Homes: 31.1% (187350/602521) • Residential care facilities: 19.7% (17491/88867)	1.58 [1.56–1.6]	No
Resnick, 2015, US [21]	Prospective, 6 months	• Nursing Homes: 103 • Residential care facilities: 93	• Nursing Homes: 83.7 • Residential care facilities: 85.7	• Nursing Homes: 100% (MMSE score: 8.7) • Residential care facilities: 100% (MMSE score: 5.8)	• Nursing Homes: 0% (0/103) • Residential care facilities: 0% (0/93)	-	No
Shah, 2013, England and Wales [22]	Retrospective, 1 year	• Nursing Homes: 4109 • Residential care facilities: 4320	Not specified	Nursing Homes and residential care facilities combined: 38,9%	Nursing Homes: 30.8% (1265/4109) Residential care facilities: 22.3% (963/4320)	1.38 [1.28–1.48]	Age and sex-adjusted hazard ratios: 1.48. The ratio for nursing homes alone was 419 (396–442) and that for residential homes was 284 (266–302). Further standardization for dementia diagnosis reduced the ratio to 309 (292–326) for nursing homes and to 218 (205–232) for residential homes.
McCann, 2009, Ireland [23]	Prospective, 5 years	• Nursing Homes: 895 • Residential care facilities: 577	>75 years: • Nursing Homes: 88% • Residential care facilities: 89%	Not specified	• Nursing Homes: 70% (626/895) • Residential care facilities: 54% (311/577)	1.3 [1.19–1.42]	No
Liu, 2010, Taiwan [24]	Prospective, 9 months	• Nursing Homes: 140 • Residential care facilities: 185	>75 years: • Nursing Homes: 65% • Residential care facilities: 73%	• Nursing Homes: MMSE score = 17.88±8.91 • Residential care facilities: MMSE score = 16.03±6.90	• Nursing Homes: 0% (0/140) • Residential care facilities: 3.2% (6/185)	-	No
Rothera, 2002, UK [25]	Retrospective, 20 months	• Nursing Homes: 499 • Residential care facilities: 866	Not specified	Not specified	• Nursing Homes: 39.1% (195/499) • Residential care facilities: 23.3% (202/866)	1.68 [1.42–1.97]	No
Godden, 2001, UK [26]	Retrospective, 1 year	• Nursing Homes: 1700 • Residential care facilities:1504	Not specified	Not specified	• Nursing Homes: 5.7% (97/1700) • Residential care facilities: 8.8% (133/1504)	0.65 [0.5–0.83] (Hospital death and not total mortality)	No.

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Three studies [19–21] focused specifically on patients with dementia and a fourth adjusted for dementia [18]. The study by Thomas et al. [20], comparing 88,867 residents in residential care facilities with 602,521 residents of nursing homes (1-year follow-up) reported a risk of 1.58 [1.56–1.6]. The study by Sloane et al. [19] found no significant difference in mortality between residential care facilities and nursing homes for mild dementia or moderate/severe dementia after adjustment for age, gender, race, education, marital status, length of stay, cognition and comorbidities. Finally, the study by Shah et al. [22] found a gender and age-adjusted ratio of 419 (396–442) for nursing homes alone versus 284 (266–302) for residential care facilities. Further standardization for dementia diagnosis reduced the ratio to 309 (292–326) and to 218 (205–232), respectively.

2. Comparison of hospitalizations between residential care facilities and nursing homes

Seven studies [19–21, 26–29] compared hospitalization rates between residential care facilities and nursing homes (Table 2). All studies were North American (3 in Canada, 3 in the US) with an exception of one study from the UK. All described an unadjusted increased relative risk of hospitalizations in residential care facilities compared with nursing homes, ranging from 1.3 to 3.37, except for one small study. Five studies had 1 year follow-up, with hospitalization rates of 30% to 40% in residential care facilities versus 10% to 30% in nursing homes.

Table 2. Studies comparing hospitalizations between residential care facilities and nursing homes.

Author, year, Country	Study design and follow-up duration	Participants/ cases	Age (mean and %), years	Percentage of dementia	Percentage of hospitalizations	Unadjusted relative risk	Adjusted risk ratio or hazard ratio
McGregor, 2014, Canada [27]	Retrospective, 3 years	• Nursing homes:12209 • Residential care facilities:842	• Nursing homes: 83.1 • Residential care facilities: 81.5	Not specified	• Nursing homes: 42.0% (5125/12209) • Residential care facilities: 69.1% (582/842)	1.65 [1.57–1.73]	No
Maxwell, 2015, Canada [28]	Retrospective, 1 year	• Nursing homes: 691 • Residential care facilities: 609	• Nursing homes: 86.4 • Residential care facilities: 85.7	• Nursing homes: 100% • Residential care facilities:: 100%	• Nursing homes: 10.7% (74/691) • Residential care facilities: 36.1% (220/609)	3.37 [2.65–4.29]	No
Hogan, 2014, Canada [29]	Retrospective, 1 year	• Nursing homes: 976 • Residential care facilities: 1066	• Nursing homes: Not specified • Residential care facilities: 84.9	• Nursing homes: not specified • Residential care facilities:: 57.1%	• Nursing homes: 14.0% (137 /976) • Residential care facilities: 38.7% (413/1066)	2.76 [2.32–3.28]	No
Sloane, 2005, US [19]	Prospective, 1 year	• Nursing homes: 479 • Residential care facilities: 773	• Nursing homes: 84.9 • Residential care facilities: 84.4	• Nursing homes: Moderate to severe: 49.3% • Residential care facilities:: Moderate to severe: 29.4%	Mild dementia: • Nursing homes: 8.4% (20/243) • Residential care facilities: 14.2% (78/546) Moderate to Severe dementia: • Nursing homes: 10.0% (24/236) • Residential care facilities: 14.2% (32/227)	1.55 [1.11–2.16]	Mild dementia: P = 0.009 adjusted for baseline age, gender, race, education, marital status, length of stay, cognition and number of comorbidities. Moderate to severe dementia: P = 0.115 adjusted for baseline age, gender, race, education, marital status, length of stay, cognition and number of comorbid conditions.
Thomas, 2020, US [20]	Retrospective, 1 year	• Nursing homes: 602521 • Residential care facilities: 88867	• Nursing homes: >75 years: 80.6% • Residential care facilities: >75 years: 88.2%	• Nursing homes: 100% • Residential care facilities: 100%	• Nursing homes: 29% (174323/602521) • Residential care facilities: 37.6% (33457/88867)	1.30 [1.29–1.31]	No
Godden, 2001, UK [26]	Retrospective, 1 year	• Nursing homes: 1132 • Residential care facilities:1504	Not specified	Not specified	• Nursing homes: 22,3% (253/1132) • Residential care facilities: 31,2% (469/1504)	1.4 [1.22–1.59]	No
Resnick, 2015, US [21]	Prospective, 6 months	• Nursing homes: 103 • Residential care facilities: 93	• Nursing homes: 83.7 • Residential care facilities: 85.7	• Nursing homes: 100% (MMSE score: 8.7) • Residential care facilities: 100% (MMSE score: 5.8)	• Nursing homes: 0% (0/103) • Residential care facilities: 0% (0/93)	-	No

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Four studies included only residents with dementia. The study with the highest relative risk was conducted in Canada [28]. It found hospitalization rates of 36.1% in residential care facilities versus 10.7% in nursing homes. Less severe cognitive impairment (Hazard Ratio: 0.35 [0.18–0.67]) was associated with a lower hospitalization rate in this study. The study by Thomas et al. [20] reported a relative risk of 1.30 [1.29–1.31]. Conversely, in the study by Sloane et al. [19] adjusted for age, gender, ethnicity, education, marital status, length of stay, cognition and number of comorbidities, the risk of hospitalization was higher for patients with mild dementia (14.2% versus 8.4%, p = 0.009) in residential care facilities but not for those with moderate or severe dementia (14.2% versus 10.0%, p = 0.115).

3. Comparison of mortality between residential care facilities and the community

Four studies have been conducted to compare mortality of older patients living in residential care facilities and the community (Australia [30], Ireland [23], two in the US [20, 31]) (Table 3). All suggest a higher mortality rate in residential care facilities, with unadjusted RRs ranging from 1.34 to 10.1. In these four studies, the characteristics of the elderly differed by age and/or dementia between the two groups. The Australian study [30] comparing 3,330,987 older people at home versus 35,316 residents in residential care facilities observed 1-year mortality rates of 3.6% versus 34.6% respectively, giving an age and gender adjusted odd-ratio (OR) of 10.1 (95% CI: 9.8–10.5). The Irish study [23] found an OR of 1.63, adjusted for age, sex, general health and marital status with a 5-year follow-up. Bartley’s study [30] retrieved an OR of 2.4, adjusted for Charlton Comorbidity Index and marital status. Finally, Thomas et al.’s study [20] of patients with dementia reported an unadjusted relative risk of 1.34 [1.33–1.36].

Table 3. Studies comparing mortality of older adults living in residential care facilities and the community.

Author, year, Country	Study design	Participants/ cases	Age (mean and %), years	Percentage of dementia	Percentage of mortality	Unadjusted relative risk	Adjusted risk ratio or hazard ratio
Inacio, 2020, Australia [30]	Retrospective, 1 year	• Community: 3330987 • Residential care facilities: 35316	>75 years: • Community: 63.0% • Residential care facilities: 88.2% (mean: 85 years)	Not specified	• Community: 3.6% (119815/3330987) • Residential care facilities: 34.6% (12225/35316)	9.62 [9.48–9.77]	OR: 10.1 (95% CI: 9.8–10.5) adjusted by sex and age
Bartley, 2018, USA [31]	Retrospective, with age- and sex-matched, 1 year	• Community: 404 • Residential care facilities: 404	• Community: 86.8 • Residential care facilities: 86.8	Community: 8.4% Residential care facilities: 33.9%	• Community: 9.4% (38/404) • Residential care facilities: 20.3% (82/404)	2.16 [1.51–3.09]	OR: 2.4 Adjusted for Charlson Comorbidity Index and marital status
McCann, 2009, Ireland [23]	Prospective, 5 years	• Community: 205566 • Residential care facilities: 577	>75 years: • Community: 42% • Residential care facilities: 89%	Not specified	• Community: 22% (45224/205566) • Residential care facilities: 54% (311/577)	2.45 [2.27–2.64]	HR: 1.63 (1.44–1.85) Adjusted for age, sex, general health and marital status
Thomas, 2020, US [20]	Retrospective, 1 year	• Community: 2074420 • Residential care facilities: 88867	>75 years: Community: 80.6% Residential care facilities: >75 years: 88.2%	• Community: 6.1% • Residential care facilities: 30.3%	• Community: 14.7% (303891/2074420) • Residential care facilities: 19.7% (17491/88867)	1.34 [1.33–1.36]	No

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4. Comparison of hospitalizations of older adults living in residential care facilities and the community

Three 1-year longitudinal studies from the US or the UK suggest a greater risk of hospitalization of older adults living in residential care facilities than in the community ranging from 1.12 to 1.65 [20, 26, 31] (Table 4). One-year hospitalization rates ranged from 31 to 48%. Only one study, by Park et al. [32], followed elderly people initially living at home and compared the 10-year hospitalization rate between those who went to residential care facilities and those who did not. In this study, the risk of hospitalization among those entering residential care facilities was decreased for heavy hospital use (RR 0.68 (p<0.001)) but not for moderate hospital use.

Table 4. Studies comparing hospitalizations of older adults living in residential care facilities and the community.

Author, year, Country	Study design	Participants/ cases	Age (mean and %), years	Percentage of dementia	Percentage of hospitalizations	Unadjusted risk ratio	Adjusted risk ratio or hazard ratio
Park, 2018, US [32]	Retrospective, 10 years	• Community: 975 • Residential care facilities: 214	• Community: 82.4 • Residential care facilities: 83.3	Not specified	Not specified		RR: 0.68 (p<0.001) for heavy hospital use RR: 0.89 (NS) for moderate hospital use. Adjusted with death, sociodemographics, health, social support, regions
Bartley, 2018, USA [31]	Retrospective, with age- and gender-matched, 1 year	• Community: 404 • Residential care facilities: 404	• Community: 86.8 • Residential care facilities: 86.8	• Communities: 8.4% • Residential care facilities: 33.9%	• Community: 31.4% (127/404) • Residential care facilities: 48.3% (195/404)	1.54 [1.29–1.83]	OR: 2.03 [CI: 1.5–2.7] Adjusted for Charlson Comorbidity Index and marital status
Thomas, 2020, US [20]	Retrospective, 1 year	• Community: 2074420 • Residential care facilities: 88867	>75 years: 80.6% Residential care facilities: 88.2%	• Communities: 6.1% • Residential care facilities: 30.3%	• Community: 33.6% (697968/2074420) • Residential care facilities: 37.6% (17491/88867)	1.12 [1.11–1.13]	No
Godden, 2001, UK [26]	Retrospective, 1 year	• Community: 83606 • Residential care facilities:1504	Not specified	Not specified	• Community: 18.9% (15239/80402) • Residential care facilities: 31.2% (469/1504)	1.65 [1.52–1.78]	No

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Discussion

In this literature review, we analyzed 15 studies comparing older adults living in residential care facilities with older adults living in nursing homes or the community.

In general, a twofold increase in mortality was observed in nursing homes compared to residential care facilities. This result was expected since nursing homes generally accommodate patients at the end of life, with significant co-morbidities and a severe degree of dependency. We observed that the age of patient was generally similar in studies comparing nursing homes and residential care facilities, suggesting that co-morbidities may have a greater impact on mortality than biological age [33]. Unfortunately, in several studies, comorbidities, in particular the level of dependency or severity of dementia, were poorly documented and/or not considered, except in the study by Sloane et al. The studies included in the review also reported an increased risk of hospitalizations in residential care facilities compared to nursing home, with hospitalization rates of about 30% per year in residential care facilities. From a public health perspective, the cost of these hospitalizations is important to consider when evaluating the efficiency of this model. The causes of hospitalizations could be different between these two settings, especially concerning falls [34, 35] or polymedication. Targeted geriatric interventions such as telemonitoring [36] could reduce avoidable hospitalizations in residential care facilities. Moreover, this high risk of hospitalization raises questions about the ability of residential care facilities to meet the medical needs of older adults. In the US, only 48.2% of community-based residential settings offer a range of services including nursing care, medication assistance, meals, laundry, cleaning, transportation, and recreation and 29.1% have access to all these services except for nursing care and medication assistance [37]. It seems important to better define the clinical profile of the older adults who may be candidates for residential care facilities. Indeed, residential care facilities are often considered an appropriate setting for cognitively impaired patients in the US and Canada. In these countries, a high rate of residents suffers from dementia (58% in the Canadian study by Maxwell et al. [28] or 68% of individuals in the American study by Watson et al. [38]). Yet dementia is reported to be the most common predisposing factor (>90%) that precipitates the move of older adults to an assisted living or nursing home [39]. Previous research indicates that the percentage of facilities that provide staff training related to psychiatric disorders in older adults is low and generally inadequate in the US [40]. Increased medical and nursing support may be an option to reduce hospitalization rates.

The vast majority of studies have been conducted in the US and Canada. In other countries, the clinical characteristics of residents may be different in residential care facilities. From this point of view, residential care facilities could be a step when patients at home require more care or become frail, before the development of severe cognitive impairment [40]. In the UK, the proportion of resident with severe dementia in residential care facilities appears to be low (2.1% versus 24.1% in nursing homes [41]). In Sweden, only 20% of residents suffered from dementia [42]. In France, residents in residential care facilities tend to be frail (53.7%), without being systematically disabled (mean ADL score; SD = 5.4; 0.9) and the role of residential care facilities is rather to address social isolation, social vulnerability, and loneliness [43]. Further studies in Europe are needed to determine whether the hospitalization rate is comparable to that of the North American studies.

Compared to living at home, mortality in residential care facilities was much higher, with RR ranging from 1.34 to 10.1. Again, the methodological quality of these studies was critical, as none of them at least adjusted for dementia status or level of dependency. Studies are needed to compare home care systems with residential care facilities for older adults suffering from social isolation or comorbidity. Indeed, several devices have been developed over time to promote home care, such as remote monitoring, telemedicine, or home care services [44, 45]. In particular, telemedicine has shown encouraging results in the management of care, prevention or management of chronic pathologies (particularly cardiovascular or diabetes) or adherence to medication [46]. With regards to hospitalizations, a higher risk was found in residents living in residential care facilities compared to those living at home in 3 of the 4 studies with a follow-up of one year. However, the study by Park et al. [32] contrasts with these results, both because of the methodological quality of the study and because of the results obtained. This study suggests that residential care facilities may reduce the risk of major hospitalization, based on a cohort of patients initially at home, some of whom may or may not enter a residential care facilities during the 10 years of follow-up of the study.

The main limitation of this review is the methodological quality of the studies. No study compared these models of care up to institutional entry with minimal adjustment for age, gender, dementia, and dependency, and only the study by Park et al. [32] analyzed the health trajectory over time of older adults initially living at home. The medical characteristics of residents in terms of dementia and standardized cognitive assessment, activities of daily living, frailty and length of stay were poorly described. Moreover, the type of residential care facilities and services offered may vary from country to country or from institution to institution [47, 48]. Finally, socioeconomic characteristics (marital status, income, etc.), which may influence the choice of institution (public or private), have rarely taken into account in the studies. For all these reasons, we considered that meta-analyses were not relevant because the studies did not compare patients with similar characteristics profile. The level of evidence for the effectiveness of residential care facilities on mortality and hospitalizations compared to nursing home or communities is therefore low. Nevertheless, the particularly high rate of hospitalization in residential care facilities raises the question of the lack of medical and paramedical staff and the cost of these hospitalizations. Nevertheless, the potential benefits of residential care facilities versus nursing homes or home care are not limited to mortality and hospitalizations. The effects on physical function, quality of life, happiness, cognition and other aspects of health would need to be compared. A final limitation is that the search strategy was limited to Medline, Scopus and Web of Science and to articles written in English or French. Nevertheless, It has been established that the exclusion of non-English language articles has only a minimal effect on the overall conclusions of the reviews [49]. A single reviewer conducted the data extraction and quality assessment of the studies, which may reduce the diversity of the studies included.

Conclusion

This systematic review raises important clinical and policy questions. The place of residential care facilities in the health care pathway of older adults, as an intermediate or alternative step to home or nursing home, has not been sufficiently studied. Although patient’s profiles are likely to differ and care systems are not identical across the world, the particularly high rate of hospitalizations in these settings requires further investigations to assess the effectiveness and efficiency of this model. If residential care facilities are considered as an alternative for older people with mild to moderate dementia, studies of good methodological quality have to be implemented. Preventive and palliative care, depending of levels and types of medical, functional, and psychosocial needs, may be useful to reduce avoidable hospitalizations.

Supporting information

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

Click here for additional data file.^{(31.8KB, docx)}

S1 Appendix. Search strategy.

(DOCX)

Click here for additional data file.^{(12.1KB, docx)}

S1 Annex. Quality studies.

(DOCX)

Click here for additional data file.^{(17.3KB, docx)}

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0286527.r001

Decision Letter 0

Mickael Essouma

28 Mar 2023

PONE-D-23-05379Comparison of mortality and hospitalizations of older people living in residential care facilities versus nursing homes or communities. A systematic review.PLOS ONE

Dear Dr. Boucaud-Maitre,

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Reviewer #1: The manuscript is based on a systematic literature review of an important topic, namely studies comparing either mortality or hospitalizations of older people living in residential care facilities versus nursing homes or communities. According to my evaluation the analysis has been carried out correctly and the manuscript is well written so I can recommend publication. The manuscript leaves the impression of only a limited number of available high quality studies and hence, the conclusion is wisely cautiously formulated. The Discussion is thorough and all central limitations are mentioned. The only detail that caught my attention was that study 19 is classified as fair but nevertheless, is described as lacking data on age. In this research area I find that the age distribution is of central importance. Second, I mention probably a typo as abbreviations are consistently used but on page 10 for some reason 'nursing home' is written out, although the abbreviation NH has already earlier been introduced.

Reviewer #2: Peer review for the article: "Comparison of mortality and hospitalizations of older people living in residential care facilities versus nursing homes or communities. A systematic review."

1. Recommendation

Manuscript ref no. PONE-D-23-05379

Major revision.

2. Comments

2.1. General comment

The authors have attempted a systematic review of the literature (SLR) to assess the impact (the effectiveness) of the care delivered to elderlies at residential care facilities (compared to that delivered at their homes and in nursing homes [exposures]0 on elderlies future health outcomes (all-cause hospitalizations and case fatality). However, this message is not clearly stated throughout the manuscript, and the methods used are highly questionable. There is a need for a major revision of the SLR and the manuscript.

2.2. Specific comments

2.2.1. Major comments

2.2.1.1. Introduction

This is a global SLR, but not s SLR of COVID-19 or US-based data. So, there is no reason why you emphaisze on COVID-19 and USA in the introduction. I understand that the demand could have increased with the advent of the COVID-19 pandemic (West et al. Age and Ageing, Volume 50, Issue 2, March 2021, Pages 294–306, https://doi.org/10.1093/ageing/afaa289), but this could just be mentioned within the text as one among the many reasons why it is more and more important now to address the importance of residential care facilities when deciding about the place of care for elderlies.

Your introduction should not exceed one page, although it is important that you revise the current introduction providing information to these important questions (obviously for the global population), because PLOS One is a generalist not specialist journal: Is the health of older people a concern in the society? Notably, what is the proportion of older people in the current population and how will change in the coming decades? In general, how is the health state of older people: disease, disability-adjusted life years, years lived with disease, most frequent diseases, comorbidities, drug-consumption level? What are the available care delivery systems for older people? What is the place of residential care facilities in those delivery systems? How have the covid-19 pandemic and other stressors increased the demand for care delivery systems (including residential care facilities) in recent years? What should be done for a remedial to this alarming situation? How will your SLR help to remedy to the situation: is it intended to inform older people health experts? Stakeholders? End with a clear statement of the aim of your SLR. Writing and subsequent editing, will help you to deliver all those important messages within a short text of one page.

2.2.1.2. Methods

The reference 6 is irrelevant, because the registration number from PROSPERO is sufficiently informative.

Provide a reference for the PRISMA guidelines used. the latest one which is better to provide is: Page et al. BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n71.

The searched databases: I advise to include those that capture data for usually forgotten regions of Africa (e.g. AJOL, Africa Index Medicus), Asia (see DOI: 10.1097/EDE.0000000000000325) and South America (e.g. LILACS), as a global SLR should fairly provide data from across the globe. I would also include EMBASE (see Bramer et al. J Med Libr Assoc. 2018 Oct; 106(4): 531–541. doi: 10.5195/jmla.2018.283).

The search terms should be revised. The search strategy should be based on three main concepts: the population of interest (elderly people: all the terms referring to this phrase and available in the searched databases should be sought), the exposure (residential care facilities again with all the terms referring to it, the nursing home with all synonyms, the home-based care with all synonyms) and the outcomes (hospitalizations with all synonyms such as admission, emergency visit; case fatality with all synonyms such as mortality and death). Did you perform hand searching? This should be clearly stated and explained in the manuscript. Work with an expert librarian.

Inclusion and exclusion criteria: Do not place limits on the language of articles because this increases the selection bias, and the study is funded. So, you can request help from certified translators for articles written in languages which you are not familiar with, or use websites such as deepl translator. I am concerned by the fact that you excluded articles that focused on specific diseases, but you focused on dementia. Can you explain this inconsistency ? (which should be resolved throughout the manuscript). I am also concerned by the fact that you compare the outcome resulting from the care at residential care facility with that from original homes and nursing homes, but you exclude cross-sectional analytical studies that can also do this well: is there a justification? As stated above, it is also important that you clarify for authors the exposure and the outcomes assessed. Along this line, I would use the term "case fatality" throughout the text, instead of "mortality" (see Kelly and Cowling. Epidemiology 24(4):p 622-623, July 2013. | DOI: 10.1097/EDE.0b013e318296c2b6).

What do the IADL and ADL scores mean (page 4, line 86)?

-The data extraction should be revised as well, and the standardized data abstraction sheet uploaded as supplemental material with your submission. These are mandatory data for high-quality epidemiological studies: type of sampling, setting [community versus hospital-based, registry], response rate [for surveys], locality [urban versus rural vs semi-urban], region of origin [based on which classification: world bank? UNSD?], country of origin, study design (please, go through this paper to gain an insight on types of traditional epidemiological observational studies . It should be noted that cohorts are always longitudinal studies, so the repetition in the text is not warranted), timing of data collection (retrospective/prospective/ambispective i.e., prospective + retrospective. Note that the mode of data collection is more important than when authors collected data i.e., in a registry with prospectively collected data but which can be retrospectively consulted by authors of a given manuscript, it is the fact that data were collected prospectively which is relevant; and this type of study is different from a retrospective chart review [Vassar and Holzmann. J Educ Eval Health Prof 2013, 10: 12 • http://dx.doi.org/10.3352/jeehp.2013.10.12.] where data were collected as usual in the clinic without aim to conduct a study, but subsequently some researchers conduct a study with those data that they therefore collect retrospectively).

References 7 and 8 should be omitted because they are irrelevant and outdated. The tool used for quality assessment (choose anyone reliable that you are comfortable with among those provided here: Munn et al. Int J Health Policy Manag

. 2014 Aug 13;3(3):123-8. doi: 10.15171/ijhpm.2014.71.) should be clearly stated, and how you did the assessment should be illustrated in tables for each study, in the supplemental material.

There is a need for a meta-analysis. The between-study heterogeneity is a conditional limitation of the meta-analysis (see Valentine et al. Journal of Educational and Behavioral Statistics April 2010, Vol. 35, No. 2, pp. 215–247 DOI: 10.3102/1076998609346961), and there are indeed methods to deeply assess the heterogeneity and publication bias (see Richardson et al. https://doi.org/10.1016/j.cegh.2018.05.005 and Ioannidis JPA, Trikalinos TA. The appropriateness of assymmetry tests for publication bias in meta-analyses: a large survey. CMAJ. 2007; 176 (8): 1091-1096. https:// 10.1503/cmaj.060410).

Based on my previous comments, there is a need to extensively revise the results, discussion, conclusion, abstract, keywords, article title and references. Just to add that in the discussion, it is important to start by presenting your main results that should be discussed with regard to data from the literature in the subsequent paragraphs, feasible recommendations to appropriate bodies should be made, and strengths as well as unavoidable limitations should be discussed.

2.2.2. Minor comments

As already said, extensive editing of the manuscript ideally with the aid of a native English speaker is warranted.

The abbreviation RCF is not conventional in Medicine, so it is not warranted.

Page 4 line 67, consider writing Data source instaed of search strategy

Page 4 line 68 Consider writing Medline (pubMed)

Page 4, lines 87-88: just say that you reported the risk estimates as mentioned in the primary studies articles

Page 4 line 82, please write "dat aextraction and mangement".

Revise the supplemental materials.

When revising, make sure there is no citation gaming (see Macdonald. https://doi.org/10.1177/05390184221142218) in the manuscript as this will be asessed.

Questions I find important for your SLR: can you compare the outcomes of residential care facilities with places for homeless elderlies (e.g. shelters...)? Does the status (migrant/elderly in his home country) affect the outcome ( I did not see interest for this in the manuscript)? I leave you with this reflection and this article: Om et al. BMC Geriatr

. 2022 Apr 25;22(1):363. doi: 10.1186/s12877-022-02978-9.

Finally, build a supplementary material with your work: see how others have done: Emmons-Bell et al. Heart

. 2022 Aug 11;108(17):1351-1360. doi: 10.1136/heartjnl-2021-320131.

Mickael Essouma

Available online on 28 March 2023

**********

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PLoS One. 2023 May 31;18(5):e0286527. doi: 10.1371/journal.pone.0286527.r002

Author response to Decision Letter 0

13 Apr 2023

Reviewers' comments:

Reviewer #1:

The manuscript is based on a systematic literature review of an important topic, namely studies comparing either mortality or hospitalizations of older people living in residential care facilities versus nursing homes or communities. According to my evaluation the analysis has been carried out correctly and the manuscript is well written so I can recommend publication. The manuscript leaves the impression of only a limited number of available high quality studies and hence, the conclusion is wisely cautiously formulated. The Discussion is thorough and all central limitations are mentioned.

1. The only detail that caught my attention was that study 19 is classified as fair but nevertheless, is described as lacking data on age. In this research area I find that the age distribution is of central importance.

Authors comment: We would like to thank the reviewer for her/his encouraging comments. Regarding study 19 (Mortality in older care home residents in England and Wales, Shah et al., PMID: 23305759), it is true that baseline characteristics of age were not described in this study. In fact, the study has compared “care home” versus “communities” with different age categories (65-74 years old, 75-84, 85-94 and 95-104). Nevertheless, further analysis have been provided with a distinction between “residential care” and “nursing care home” and the mortality has been compared between these two types of residences with adjustment on age and sex, and a further adjustment on dementia. It is why we have considered this study as “fair” and not “poor” according to our quality assessment methodology. We agree with you that age distribution is of central importance.

2. Second, I mention probably a typo as abbreviations are consistently used but on page 10 for some reason 'nursing home' is written out, although the abbreviation NH has already earlier been introduced.

Authors comment: Apologize for this mistake. We have deleted the abbreviation NH throughout the manuscript.

Reviewer #2:

Major comment

Introduction

1. This is a global SLR, but not s SLR of COVID-19 or US-based data. So, there is no reason why you emphaisze on COVID-19 and USA in the introduction. I understand that the demand could have increased with the advent of the COVID-19 pandemic (West et al. Age and Ageing, Volume 50, Issue 2, March 2021, Pages 294–306, https://doi.org/10.1093/ageing/afaa289), but this could just be mentioned within the text as one among the many reasons why it is more and more important now to address the importance of residential care facilities when deciding about the place of care for elderlies.

Authors comment: We thank the reviewer for this comment and we have now focused the introduction on the main recommended points within a short text of one page: 1. global data of older people and projections, 2. individual needs of older people, 3. available care delivery system, 4. lack of literature on residential care facilities and 5. clear statement of the aim on this systematic review.

Methods

2. The reference 6 is irrelevant, because the registration number from PROSPERO is sufficiently informative.

Authors comment: Agree with reviewer’s comments. We have deleted reference 6.

3. Provide a reference for the PRISMA guidelines used. the latest one which is better to provide is: Page et al. BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n71.

Authors comment: We thank the reviewer’s for this recent reference that we have added this reference as requested.

4. The searched databases: I advise to include those that capture data for usually forgotten regions of Africa (e.g. AJOL, Africa Index Medicus), Asia (see DOI: 10.1097/EDE.0000000000000325) and South America (e.g. LILACS), as a global SLR should fairly provide data from across the globe. I would also include EMBASE (see Bramer et al. J Med Libr Assoc. 2018 Oct; 106(4): 531–541. doi: 10.5195/jmla.2018.283).

Authors comment: We agree with the reviewer’s comment that other databases coming from forgotten regions could have been studied. Nevertheless, nursing homes and residential care facilities are relatively underdeveloped in Africa and South America. An interesting analysis from the WHO (file:///C:/Users/423540/Downloads/9789241513388-eng.pdf) pointed out that published studies and reports of the long-term care comes from families in sub-Saharan Africa and are limited and skewed overwhelmingly to southern, western and eastern parts of the region, particularly to Ghana, Kenya, Nigeria, and South Africa. Organized systems of long-term care are generally lacking, families constitute the major source of care for older people who are no longer able to live independently. Published studies and reports of organized long-term care in sub-Saharan Africa are even more limited than the evidence base on family care. Most research comes from South Africa and concerns a particular sub-setting: residential facilities. Two major service models appear to dominate: charitable care for the most destitute older people (usually operated with few resources by faith-based, civil society or public welfare bodies) and private for-profit services, mostly in the form of residential homes for those who are able to pay. There appear to be few, if any, organized services for the majority of older people who fall between these extremes of the spectrum.

Nevertheless, lack of nursing homes or residential care facilities in Africa is rather a good new to our point of view. These facilities are associated with unfavourable outcomes for older people. It is a mode of accommodation “by default” in the face of situations of major dependence and the organizations of the society. Moreover, nursing homes are very expansive (around 3000 euros per month). Is this model of accommodation for older people with dependency the one that should be replicated in Africa for example? We are not convinced, the covid-19 pandemic has shown the vulnerability of nursing home’s residents with a very high mortality. Other models exist and should be studied and developed, like foster families in the French Caribbean islands. We are working on this model and we consider that foster families could be an alternative to nursing homes (see comment 17).

With the aging of the population, it will be a matter of interest in the future and we hope that we could do epidemiological studies in other countries than North American and Europe. Regarding Asia, we have included studies from Australia and South Korea. We propose to include this limit of our study on the discussion section.

5. The search terms should be revised. The search strategy should be based on three main concepts: the population of interest (elderly people: all the terms referring to this phrase and available in the searched databases should be sought), the exposure (residential care facilities again with all the terms referring to it, the nursing home with all synonyms, the home-based care with all synonyms) and the outcomes (hospitalizations with all synonyms such as admission, emergency visit; case fatality with all synonyms such as mortality and death). Did you perform hand searching? This should be clearly stated and explained in the manuscript. Work with an expert librarian.

Authors comment: we tried to do the most extensive research possible and reviewed over 7000 titles (and abstracts if necessary). We put a lot of thought into the best possible strategy, and we concluded that it is unlikely that we missed several studies if the terms “residential care” or “senior housing” or “independent living communities” or “continual care retirement” were not in the abstract, and the terms “mortality” or “hospitalizations” or “death” in the full text of the articles. We do not used the terms “nursing homes” or synonyms, nor the terms home base care or synonyms in our strategy. We could have narrowed our search with these keywords, with the risk of missing articles in which these words were not included. It is also true if we restrict our research to the population of interest as proposed. For example, if we add the filter “Aged: 65+ years” in our strategy on medline, we do not find the study of Inaccio et al. (Mortality in the first year of aged care services in Australia; PMID: 32815606) which is however relevant for our systematic review.

6. Inclusion and exclusion criteria: Do not place limits on the language of articles because this increases the selection bias, and the study is funded. So, you can request help from certified translators for articles written in languages which you are not familiar with, or use websites such as deepl translator. I am concerned by the fact that you excluded articles that focused on specific diseases, but you focused on dementia. Can you explain this inconsistency ? (which should be resolved throughout the manuscript). I am also concerned by the fact that you compare the outcome resulting from the care at residential care facility with that from original homes and nursing homes, but you exclude cross-sectional analytical studies that can also do this well: is there a justification? As stated above, it is also important that you clarify for authors the exposure and the outcomes assessed. Along this line, I would use the term "case fatality" throughout the text, instead of "mortality" (see Kelly and Cowling. Epidemiology 24(4):p 622-623, July 2013. | DOI: 10.1097/EDE.0b013e318296c2b6).

Authors comment: For the language, we agree with you and we have added this limit in the discussion section. We have excluded articles focused on specific mortality or hospitalizations, like suicide mortality, not articles from specific populations. We are interested by total mortality and total hospitalizations, not by specific mortality or hospitalizations that are not the topic of our study. We exclude cross-sectional studies since these studies cannot provide incidence data. We prefer the term mortality instead of case fatality in accordance with the scientific literature.

7. What do the IADL and ADL scores mean (page 4, line 86)?

Authors comment: The Instrumental Activities of Daily Living (IADL) scale (Lawton’s IADL scale) and the Activities of Daily Living (ADL) scale (Katz's scale) assessed functional status. We have added theses information and associated references as requested.

8. The data extraction should be revised as well, and the standardized data abstraction sheet uploaded as supplemental material with your submission. These are mandatory data for high-quality epidemiological studies: type of sampling, setting [community versus hospital-based, registry], response rate [for surveys], locality [urban versus rural vs semi-urban], region of origin [based on which classification: world bank? UNSD?], country of origin, study design (please, go through this paper to gain an insight on types of traditional epidemiological observational studies . It should be noted that cohorts are always longitudinal studies, so the repetition in the text is not warranted), timing of data collection (retrospective/prospective/ambispective i.e., prospective + retrospective. Note that the mode of data collection is more important than when authors collected data i.e., in a registry with prospectively collected data but which can be retrospectively consulted by authors of a given manuscript, it is the fact that data were collected prospectively which is relevant; and this type of study is different from a retrospective chart review [Vassar and Holzmann. J Educ Eval Health Prof 2013, 10: 12 • http://dx.doi.org/10.3352/jeehp.2013.10.12.] where data were collected as usual in the clinic without aim to conduct a study, but subsequently some researchers conduct a study with those data that they therefore collect retrospectively).

Authors comment: The tables in the manuscript describe all the requested information: setting (nursing homes, residential care facilities or communities), country, study design, number of participants and outcomes. The locality ([urban versus rural vs semi-urban]) or region of origin are not useful or not available. Agree to delete the term “longitudinal”.

9. References 7 and 8 should be omitted because they are irrelevant and outdated. The tool used for quality assessment (choose anyone reliable that you are comfortable with among those provided here: Munn et al. Int J Health Policy Manag

. 2014 Aug 13;3(3):123-8. doi: 10.15171/ijhpm.2014.71.) should be clearly stated, and how you did the assessment should be illustrated in tables for each study, in the supplemental material.

Authors comment: We respectfully ask the reviewer to reconsider his position. The tool we used for this systematic review has been developed by the National Institution of Health (NIH) and this tool is far from irrelevant and outdated. It has been used in more than 300 reviews, including several recent studies like Argote M et al; Schizophrenia (Heidelb). 2022 Sep 29;8(1):78.PMID: 36175509 or Theoh et al., BMJ Open Diabetes Res Care. 2023 Feb;11(1):e003203, PMID: 36792169. The tool assessed the studies based on several criteria: (1) research objective; (2) study population and recruitment; (3) exposure measurement and assessment; and (4) statistical analyses methods. We have reflected beforehand on the major biases we have identified and believe that using another tool like ROBIN-I will lead to the same conclusions.

10. There is a need for a meta-analysis. The between-study heterogeneity is a conditional limitation of the meta-analysis (see Valentine et al. Journal of Educational and Behavioral Statistics April 2010, Vol. 35, No. 2, pp. 215–247 DOI: 10.3102/1076998609346961), and there are indeed methods to deeply assess the heterogeneity and publication bias (see Richardson et al. https://doi.org/10.1016/j.cegh.2018.05.005 and Ioannidis JPA, Trikalinos TA. The appropriateness of assymmetry tests for publication bias in meta-analyses: a large survey. CMAJ. 2007; 176 (8): 1091-1096. https:// 10.1503/cmaj.060410).

Authors comment: We have argued throughout the discussion that a meta-analysis is not clinically relevant due to 1. the methodological quality of the studies, 2. the lack of standard medical characteristics allowing us to adjust the analysis and 3. that the characteristics of residents are different between countries in terms of dementia. 4. Studies of good methodological quality describe opposite results to the others. Indeed, this systematic review pointed out the lack of good epidemiological studies allowing to compare nursing homes versus residential care facilities with similar clinical characteristics (co-morbidities and dementia).

11. Based on my previous comments, there is a need to extensively revise the results, discussion, conclusion, abstract, keywords, article title and references. Just to add that in the discussion, it is important to start by presenting your main results that should be discussed with regard to data from the literature in the subsequent paragraphs, feasible recommendations to appropriate bodies should be made, and strengths as well as unavoidable limitations should be discussed.

Authors comment: We have modified the manuscript as recommended.

Minor comments As already said, extensive editing of the manuscript ideally with the aid of a native English speaker is warranted.

12. The abbreviation RCF is not conventional in Medicine, so it is not warranted.

Authors comment: Agree, we have deleted the abbreviation RCF throughout the manuscript.

13. Page 4 line 67, consider writing Data source instaed of search strategy

Authors comment: Agree.

14. Page 4 line 68 Consider writing Medline (pubMed)

Authors comment: Agree

15. Page 4, lines 87-88: just say that you reported the risk estimates as mentioned in the primary studies articles

Authors comment: Agree

16. Page 4 line 82, please write "dat aextraction and mangement".

Authors comment: Agree

17. Revise the supplemental materials.

When revising, make sure there is no citation gaming (see Macdonald. https://doi.org/10.1177/05390184221142218) in the manuscript as this will be asessed.

Authors comment: all authors have contributed to this work, we are the same team who work on residential care facilities and alternatives models to nursing homes. We just publish three articles on this matter:

1. Boucaud-Maitre D, Meillon C, Letenneur L, Villeneuve R, Dartigues JF, Amieva H, Tabué-Teguo M. Health trajectories of elderly living in senior housing: A Longitudinal Perspective. Sci Rep 13, 5471 (2023).

2. Boucaud-Maitre D, Cesari M, Tabue-Teguo M. Foster families to support older people with dependency: a neglected strategy. Lancet Healthy Longev. 2023 Jan;4(1):e10.

3. Boucaud-Maitre D, Villeneuve R, Simo-Tabué N, Dartigues JF, Amieva H, Tabué-Teguo M. The Health Care Trajectories of Older People in Foster Families: Protocol for an Observational Study. JMIR Res Protoc. 2023 Feb 8;12:e40604.

18. Questions I find important for your SLR: can you compare the outcomes of residential care facilities with places for homeless elderlies (e.g. shelters...)? Does the status (migrant/elderly in his home country) affect the outcome ( I did not see interest for this in the manuscript)? I leave you with this reflection and this article: Om et al. BMC Geriatr

. 2022 Apr 25;22(1):363. doi: 10.1186/s12877-022-02978-9.

Authors comment: Thanks for your proposal, we do not have this information in our studies but this could be the subject of another dedicated study.

19. Finally, build a supplementary material with your work: see how others have done: Emmons-Bell et al. Heart. 2022 Aug 11;108(17):1351-1360. doi: 10.1136/heartjnl-2021-320131.

Authors comment: the supplementary material contains the assessment of the quality of the studies of our systematic review. We thank the reviewer for the interesting reference and we have added a supplementary figure with the countries with Studies comparing residential care facilities versus nursing homes or communities on mortality and hospitalizations. As mentioned in the article, the studies comes from United States, Canada, England, Ireland, Australia and South Korea.

PLoS One. doi: 10.1371/journal.pone.0286527.r003

Decision Letter 1

Charlotte Beaudart

12 May 2023

PONE-D-23-05379R1Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or communities. A systematic review.PLOS ONE

Dear Dr. Boucaud-Maitre,

Please submit your revised manuscript by Jun 26 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Charlotte Beaudart

Academic Editor

PLOS ONE

Additional Editor Comments:

As the editor assigned to your submission, I have carefully reviewed your responses to the reviewers' comments. While I believe your responses are appropriate, I would like to provide you with some additional feedback for further clarification. Please find my comments below:

There seems to be some confusion in the article regarding patients living in the community. The abstract and inclusion criteria are not clear in this regard. I only understood what you did in relation to this patient group when reading the later part of the results section.
According to the PRISMA and AMSTAR2 criteria, authors are required to provide an example of their search strategy for at least one of the investigated bibliographic databases.
Any limitations in the search process should be justified, including limitations on the language of articles. There are scientific references available that can be cited to support this argument (e.g., doi: 10.1017/S0266462312000086).
Data extraction is typically expected to be performed in duplicate. Please acknowledge this as a limitation of the study.
Has the assessment of study quality been conducted in duplicate?
The "Statistical Analysis" paragraph appears to be incomplete. It is important to explain why a meta-analysis was not conducted.
I would like the research question to be formulated using the PICO format.

Thank you for considering these comments and suggestions. I believe addressing these points will significantly improve the clarity and rigor of your article.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

**********

6. Review Comments to the Author

Reviewer #1: Nothing further to add. My few comments have been properly adressed. I have also read the second reviewer's comments and found that also they have been well adressed.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

PLoS One. 2023 May 31;18(5):e0286527. doi: 10.1371/journal.pone.0286527.r004

Author response to Decision Letter 1

16 May 2023

Comments to the editor:

1. There seems to be some confusion in the article regarding patients living in the community. The abstract and inclusion criteria are not clear in this regard. I only understood what you did in relation to this patient group when reading the later part of the results section.

Authors comment: We would like to thank the editor for raising these points in order to improve the quality of the article . We have compared the mortality and hospitalizations rates of older people living in residential care facilities or in the community. We agree with you and we have clarified this point in the abstract and inclusion criteria, using only the term “communities” throughout the article.

2. According to the PRISMA and AMSTAR2 criteria, authors are required to provide an example of their search strategy for at least one of the investigated bibliographic databases.

Authors comment: We have added an example of our strategy based on Pubmed in an additional file.

3. Any limitations in the search process should be justified, including limitations on the language of articles. There are scientific references available that can be cited to support this argument (e.g., doi: 10.1017/S0266462312000086).

Authors comment: We have added in the limitation section “It has been established that the exclusion of non-English language articles has only a minimal effect on the overall conclusions of the reviews” with the following recent reference:

Nussbaumer-Streit B, Klerings I, Dobrescu A, et al. Excluding non-English publications from evidence-syntheses did not change conclusions: a meta-epidemiological study. J Clin Epidemiol 2020;118:42–54.

4. Data extraction is typically expected to be performed in duplicate. Please acknowledge this as a limitation of the study.

Authors comment: We have added this limitation as suggested.

5. Has the assessment of study quality been conducted in duplicate?

Authors comment: the quality assessment of the study was conducted by a senior methodologist and not in duplicate. We have added this as a limitation.

6. The "Statistical Analysis" paragraph appears to be incomplete. It is important to explain why a meta-analysis was not conducted.

Authors comment: We agree with this comment and explain why we did not perform a meta-analysis in the statistical analysis:

“After reviewing each of the studies included in this review, we considered that a meta-analysis was not relevant, due to the low methodological quality of the studies, the diversity of study designs and follow-up and the heterogeneity of populations, for which essential baseline characteristics were not available.”

7. I would like the research question to be formulated using the PICO format.

Authors comment: We agree with you and formulated the research question using the PICO format in the method section (eligibility criteria) as proposed by the PRISMA guidelines:

“Population: We only selected cohort studies conducted among older persons (≥65 years old).

Intervention: We selected studies that had a cohort design (prospective or retrospective cohort design) and at least six months of follow-up and that measured mortality or hospitalizations as outcomes. For duplicate publications from the same cohort, we selected those with the largest number of participants. We excluded cross-sectional studies and, reviews.

Comparison: We selected cohort studies comparing residential care facilities with nursing homes and/or communities,

Outcomes: To be included, we considered studies that reported the number of participants or person years and the number of deaths or hospitalizations in both groups (residential care facilities versus nursing home and/or communities). We excluded studies reporting mortality or a hospitalization for a specific medical condition.”

We hope that these changes meet your expectations.

Attachment

Submitted filename: Response to editor comments_15.05.23.docx

Click here for additional data file.^{(18KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0286527.r005

Decision Letter 2

Charlotte Beaudart

18 May 2023

Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review.

PONE-D-23-05379R2

Dear Dr. Boucaud-Maitre,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Charlotte Beaudart

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0286527.r006

Acceptance letter

Charlotte Beaudart

22 May 2023

PONE-D-23-05379R2

Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review.

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Supplementary Materials

S1 Checklist. PRISMA 2020 checklist.

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S1 Appendix. Search strategy.

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S1 Annex. Quality studies.

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Data Availability Statement

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PERMALINK

Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review

Denis Boucaud-Maitre

Luc Letenneur

Moustapha Dramé

Nadine Taubé-Teguo

Jean-François Dartigues

Hélène Amieva

Maturin Tabué-Teguo

Roles

Abstract

Introduction

Methods

Data source

Eligibility criteria

Population

Intervention

Comparison

Outcomes

Data extraction and management

Quality assessment

Statistical analysis

Results

Fig 1. Flow diagram of included studies.

Characteristics of the included studies

Risk of bias

1. Comparison of mortality between residential care facilities and nursing homes

Table 1. Studies comparing residential care facilities versus nursing homes on mortality.

2. Comparison of hospitalizations between residential care facilities and nursing homes

Table 2. Studies comparing hospitalizations between residential care facilities and nursing homes.

3. Comparison of mortality between residential care facilities and the community

Table 3. Studies comparing mortality of older adults living in residential care facilities and the community.

4. Comparison of hospitalizations of older adults living in residential care facilities and the community

Table 4. Studies comparing hospitalizations of older adults living in residential care facilities and the community.

Discussion

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Mickael Essouma

Roles

Author response to Decision Letter 0

Decision Letter 1

Charlotte Beaudart

Roles

Author response to Decision Letter 1

Decision Letter 2

Charlotte Beaudart

Roles

Acceptance letter

Charlotte Beaudart

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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