Darly Dash

Background: Antipsychotic medications remain widely used in nursing homes (NHs) despite guidelines discouraging potentially inappropriate use. While home‐level variation is known, less is understood at the unit and organization levels, or across other psychotropic and non‐psychotropic drugs. We examined prescribing variation across NHs in Ontario, Canada. We examined prescribing variation for psychotropic and non‐psychotropic drugs across NH units, homes, and organizations in Ontario, Canada. Methods: We conducted a retrospective cohort study of NH residents using EMR data from April 1, 2022, to March 31, 2023. Outcomes included whether residents were prescribed any antipsychotic, antidepressant, statins, cardiovascular disease (CVD) medications, and trazodone for at least 1 day during the follow‐up period. Multi‐level logistic regression models adjusted for resident characteristics and included random intercepts for units, homes, and organizations. Results: Among 16,896 NH residents across 179 homes and five organizations, 39% were prescribed antipsychotics, 65.5% antidepressants, 33% statins, 65% CVD medications, and 38% trazodone. Substantial variation was observed across all medications. For antipsychotics, the home‐level median odds ratio (MOR) was 1.65 (95% CrI: 1.52–1.78) and unit‐level MOR was 1.24 (95% CrI: 1.10–1.33). Trazodone exhibited the highest variation (home‐level MOR: 2.06, 95% CrI 1.75–2.37; unit‐level MOR: 1.87, 95% CrI 1.76–1.97). No significant variation was found at the organization level. Resident characteristics, like aggression and dementia, were associated with prescribing but did not explain unit and home‐level differences. Conclusions: Prescribing variation extends beyond antipsychotics to other common pharmacotherapies. Unit‐level variation reveals additional unexplained variation not captured in previous home‐level studies, providing new targets for research and quality improvement interventions. Future research should explore potential unit‐ and home‐level contributors, such as staffing, practice culture, clinician decision‐making, and policies.

Background: Medical care of complex nursing home (NH) residents in Canada is primarily managed by physicians. While physician commitment to NH practice is assumed to impact care quality, its influence on resident outcomes is inconsistent. This study quantifies commitment among NH physicians in Ontario, Canada, and its association with the quality of care among NH residents. Methods: We conducted a retrospective cross‐sectional study using multiple linked health administrative databases in 2022. We describe the practice patterns of the most responsible physician (MRP) of NH residents. We assessed three measures of commitment, including the proportion of NH practice based on residents, years in NH practice, and the number of NHs a physician worked in. Pearson‐scaled Poisson and negative binomial regression models examined the relationship between commitment and resident outcomes, including medication prescriptions, emergency department (ED) visits, hospitalizations, and death. Results: Our study identified 1368 NH MRPs practicing in 628 NHs and caring for 84,914 residents in Ontario. One hundred and fourteen (8.3%) had a ≥ 80% practice commitment to NH. The MRP cohort was generally male, had less than full‐time practice, worked in more urban settings, and practiced in various settings beyond NH. We observed mixed associations between measures of commitment and resident outcomes, with some evidence suggesting that higher commitment could be beneficial. Residents receiving care from an MRP with ≥ 80% practice commitment had a reduced rate of ED visits (RR 0.90; 95% CI 0.83–0.99). Conclusions: Our work is the first to explore the impact of commitment in NH MRPs on resident care quality in Ontario, Canada. While commitment may be a factor, it is not the sole determinant of care quality. Further research is needed to refine how commitment is defined and measured and to consider additional factors beyond the physician, such as infrastructure, NH staff, and team collaboration, in how they influence care quality.

Introduction: The delivery of medical services by primary care physicians (PCPs) in long-term care (LTC) homes lacks consistency. There is no Canadian standard for PCP commitment in the LTC home setting, which can influence the quality of care delivered and resident health outcomes. The PCP’s commitment to LTC practice is theorised as the proportion of a physician’s practice dedicated to LTC, the number of residents for whom they provide care and the time spent on individual resident encounters. We aim to establish consensus on expectations concerning PCP commitment in Canadian LTC homes. Methods and analysis: We describe a protocol for a two-round modified e-Delphi study assessing the consensus of an expert panel, guided by the RAND methodological guidance for conducting Delphi panels and the ACcurate COnsensus Reporting Document (ACCORD) guideline for healthcare-based consensus studies. We will recruit pan-Canadian experts who demonstrate extensive knowledge and experience in medical care delivery and medical practice models in the Canadian LTC sector. A literature review will generate a candidate list of statements constituting PCP commitment. The first round evaluates the relevance and feasibility of candidate statements through an online questionnaire. Panellists may also write open-ended, qualitative responses to add rationales, suggest alternatives and share new ideas. We will then host a virtual synchronous meeting to have an in-depth discussion about the results from round one. A second questionnaire will be distributed to evaluate the remaining statements that have not reached consensus, and any new statements added based on the same criteria. Ethics and dissemination: The Hamilton Integrated Research Ethics Board (Project ID #17321) approved our study. The findings will be disseminated through manuscripts, presentations, and the lead author’s thesis. Trial registration number: The ISRCTN Registry: #35125526.

Background: The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC. Methods: We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability. Results: There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41–1.65) and 1.62 (95% CrI: 1.46–1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42–1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period. Interpretation: Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.