Changes in End-of-Life Symptom Management Prescribing among Long-Term Care Residents during COVID-19

Deena Fremont; Rhiannon L Roberts; Colleen Webber; Anna E Clarke; Christina Milani; Sarina R Isenberg; Shirley H Bush; Daniel Kobewka; Luke Turcotte; Michelle Howard; Kaitlyn Boese; Amit Arya; Benoit Robert; Aynharan Sinnarajah; Jessica E Simon; Jenny Lau; Danial Qureshi; James Downar; Peter Tanuseputro

doi:10.1016/j.jamda.2024.01.024

Changes in End-of-Life Symptom Management Prescribing among Long-Term Care Residents during COVID-19

J Am Med Dir Assoc. 2024 Mar 2:104955. doi: 10.1016/j.jamda.2024.01.024. Online ahead of print.

Authors

Deena Fremont¹, Rhiannon L Roberts², Colleen Webber², Anna E Clarke³, Christina Milani¹, Sarina R Isenberg⁴, Shirley H Bush⁵, Daniel Kobewka², Luke Turcotte⁶, Michelle Howard⁷, Kaitlyn Boese⁸, Amit Arya⁹, Benoit Robert¹⁰, Aynharan Sinnarajah¹¹, Jessica E Simon¹², Jenny Lau¹³, Danial Qureshi¹, James Downar⁵, Peter Tanuseputro¹⁴

Affiliations

¹ Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
² Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
³ ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
⁴ Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
⁵ Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
⁶ Department of Health Sciences, Brock University, St Catharines, Ontario, Canada.
⁷ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
⁸ Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
⁹ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Kensington Research Institute, Toronto, Ontario, Canada.
¹⁰ Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada.
¹¹ Department of Medicine, Queen's University, Kingston, Ontario, Canada.
¹² Department of Oncology, Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
¹³ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.
¹⁴ Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Electronic address: peter.tanuseputro@mail.utoronto.ca.

PMID: 38438112
DOI: 10.1016/j.jamda.2024.01.024

Abstract

Objective: To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic.

Design: Retrospective cohort study using routinely collected health administrative data in Ontario, Canada.

Setting and participants: We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021).

Methods: For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles.

Results: We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%).

Conclusions and implications: LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak.

Keywords: Administrative health data; COVID-19; end-of-life; health system measures; long-term care; medications.