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Comparison of Medication Prescribing Before and After the COVID-19 Pandemic Among Nursing Home Residents in Ontario, Canada

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  How are COVID-19 and related disruptions in care associated with changes in the dispensation of medications commonly used among nursing home residents?

Findings  In this population-based cohort study with an interrupted time-series analysis of all nursing home residents from the 630 facilities in Ontario, Canada, the emergence of the COVID-19 pandemic was associated with significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids and no meaningful changes in the use of antibiotics or selected cardiovascular medications.

Meaning  The finding of increased use of medications with the potential for adverse effects among nursing home residents during the initial wave of the pandemic warrants ongoing monitoring for prescribing appropriateness and related resident outcomes.

Abstract

Importance  COVID-19 has had devastating effects on the health and well-being of older adult residents and health care professionals in nursing homes. Uncertainty about the associated consequences of these adverse effects on the use of medications common to this care setting remains.

Objective  To examine the association between the COVID-19 pandemic and prescription medication changes among nursing home residents.

Design, Setting, and Participants  This population-based cohort study with an interrupted time-series analysis used linked health administrative data bases for residents of all nursing homes (N = 630) in Ontario, Canada. During the observation period, residents were divided into consecutive weekly cohorts. The first observation week was March 5 to 11, 2017; the last observation week was September 20 to 26, 2020.

Exposures  Onset of the COVID-19 pandemic on March 1, 2020.

Main Outcomes and Measures  Weekly proportion of residents dispensed antipsychotics, benzodiazepines, antidepressants, anticonvulsants, opioids, antibiotics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme (ACE) inhibitors. Autoregressive integrated moving average models with step and ramp intervention functions tested for level and slope changes in weekly medication use after the onset of the pandemic and were fit on prepandemic data for projected trends.

Results  Across study years, the annual cohort size ranged from 75 850 to 76 549 residents (mean [SD] age, 83.4 [10.8] years; mean proportion of women, 68.9%). A significant increased slope change in the weekly proportion of residents who were dispensed antipsychotics (parameter estimate [β] = 0.051; standard error [SE] = 0.010; P < .001), benzodiazepines (β = 0.026; SE = 0.003; P < .001), antidepressants (β = 0.046; SE = 0.013; P < .001), trazodone hydrochloride (β = 0.033; SE = 0.010; P < .001), anticonvulsants (β = 0.014; SE = 0.006; P = .03), and opioids (β = 0.038; SE = 0.007; P < .001) was observed. The absolute difference in observed vs estimated use in the last week of the pandemic period ranged from 0.48% (for anticonvulsants) to 1.52% (for antipsychotics). No significant level or slope changes were found for antibiotics, ARBs, or ACE inhibitors.

Conclusions and Relevance  In this population-based cohort study, statistically significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids followed the onset of the COVID-19 pandemic, although absolute differences were small. There were no significant changes for antibiotics, ARBs, or ACE inhibitors. Studies are needed to monitor whether changes in pharmacotherapy persist, regress, or accelerate during the course of the pandemic and how these changes affect resident-level outcomes.

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Article Information

Accepted for Publication: May 21, 2021.

Published: August 2, 2021. doi:10.1001/jamanetworkopen.2021.18441

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Campitelli MA et al. JAMA Network Open.

Corresponding Author: Colleen J. Maxwell, PhD, School of Pharmacy, University of Waterloo, 200 University Ave West, Waterloo, ON N2L 3G1, Canada (colleen.maxwell@uwaterloo.ca).

Author Contributions: Mr Campitelli had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Campitelli, Bronskill, Maclagan, Harris, Cotton, Tadrous, Gruneir, Maxwell.

Acquisition, analysis, or interpretation of data: Campitelli, Bronskill, Cotton, Tadrous, Gruneir, Hogan, Maxwell.

Drafting of the manuscript: Campitelli, Hogan, Maxwell.

Critical revision of the manuscript for important intellectual content: Campitelli, Bronskill, Maclagan, Harris, Cotton, Tadrous, Gruneir, Maxwell.

Statistical analysis: Campitelli, Maclagan, Harris, Cotton, Gruneir.

Obtained funding: Bronskill, Maxwell.

Administrative, technical, or material support: Harris.

Supervision: Bronskill, Tadrous, Maxwell.

Conflict of Interest Disclosures: Dr Bronskill reported receiving grants from the Canadian Institutes of Health Research (CIHR), nonfinancial support from ICES (formerly Institute for Clinical Evaluative Sciences), and grants from the Ontario Health Data Platform (OHDP) during the conduct of the study. Dr Tadrous reported receiving grants from the Ontario Ministry of Health (MOH) and the Ministry of Long-term Care (MLTC) during the conduct of the study. Dr Maxwell reported receiving grants from the CIHR, nonfinancial support from the ICES, and grants from the OHDP during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was funded by the CIHR through operating grant MOP-136854 (Exploring frailty and its role in the assessment of high-risk medications and risk of poor health outcomes in vulnerable populations), by ICES through an annual grant from the Ontario MOH and the MLTC; and by the OHDP, a Province of Ontario initiative to support Ontario’s ongoing response to COVID-19 and its related effects.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions, results and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by the ICES, the MOH or MLTC, OHDP, its partners, or the Province of Ontario is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the CIHI; however, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of CIHI.

Additional Contributions: We thank IQVIA Solutions Canada Inc. for use of their Drug Information Database.

Additional Information: The data set from this study is held securely in coded form at ICES. Although data sharing agreements prohibit ICES from making the data set publicly available, access may be granted to those who meet prespecified criteria for confidential access at https://www.ices.on.ca/DAS. Please contact the authors for any supplemental information related to the study such as the study protocol, analysis plan, or analytic code. The full data set creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely on coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

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