ASSISTANT SECRETARY FOR

PLANNING AND EVALUATION March 8, 2022

(@ ASPE ISSUE BRIEF

ANTIPSYCHOTIC MIEDICATION PRESCRIBING IN LONG-TERM CARE FACILITIES
INCREASED IN THE EARLY MONTHS OF THE COVID-19 PANDEMIC

 

KEY POINTS

e Prescriptions dispensed for antipsychotics in nursing homes and assisted living facilities increased
since the beginning of the pandemic, with 20.8 million dispensed in 2020 compared to 20.5 million
in 2019. This represents a 1.5% increase in total prescriptions since the beginning of the pandemic
despite lower resident census levels in long-term care facilities (LTCFs).

e In 2020, the highest increase in the number of prescriptions dispensed occurred during the first
quarter of the pandemic, with an increase of 7.4% compared to the first quarter of 2019. After this
initial increase, the quarterly number of prescriptions for antipsychotic medications dropped close
to pre-pandemic levels, despite a declining nursing home resident census and likely a declining
LTCF resident census overall.

e The number of prescriptions dispensed for four out of the five most frequently prescribed
antipsychotics in LTCFs increased in both 2020 and 2021 compared to pre-pandemic levels.
Aripiprazole had the largest increase, of 14% in the first quarter of 2020 compared to 2019 levels.

 

INTRODUCTION

Residents of congregate long-term care settings, including nursing homes and assisted living facilities, were
disproportionately affected by the COVID-19 pandemic. Since the pandemic started in January 2020, 5% of
total cases and 31% of total deaths have occurred in long-term care facilities (LTCFs), representing more than
186,000 deaths of residents and staff.1 The beginning of the year 2020 marked the highest number of COVID-
19 cases and deaths in LTCFs. Facilities reported facing substantial hardships in procuring resources, and hiring
and keeping staff to help control outbreaks." Many facilities also reported added financial strains resulting
from costs of personal protective equipment, testing, and acquiring and retaining staff. In addition, the
lockdown and in-person visitation restrictions in LTCFs raised concerns about the impacts on resident
treatment, safety, and mental health.'

These acute difficulties that arose during the COVID-19 pandemic added to other long-standing challenges and
concerns related to the quality of care provided in LTCFs. Media outlets have reported on the increasing use of
antipsychotics by LTCFs to help manage the challenging behaviors of residents with behavioral and
psychological symptoms, a concerning trend even before the pandemic.* Antipsychotic drugs are used to treat
symptoms of psychiatric disorders such as schizophrenia and bipolar disorder, and have been shown to
improve daily functioning in individuals with these disorders. The Food and Drug Administration (FDA) has
issued a "black box" warning regarding the risks of atypical antipsychotic use among older adults with
dementia. A recent news report in the New York Times stated that, according to Medicare's public database of
nursing home ratings (Nursing Home Compare), Medicare insurance claims and resident assessment data, and
facility-by-facility data that a resident advocacy group got from Medicare via an open records request and
shared with the Times, at least 21% of nursing home residents (about 225,000 people) were using
antipsychotics as of the fourth quarter of 2020.

 

March 2022 ISSUE BRIEF 1
The Centers for Medicare & Medicaid Services (CMS), the government agency that oversees nursing homes,
tracks the use of antipsychotic medications as one of many statistics used to assess the quality of care in
nursing homes and seeks to discourage over-utilization of these drugs. On November 12, 2021, CMS released
State Survey Guidance stating that inappropriate use of antipsychotic medications continues to be an area of
concern related to quality of care, directing oversight efforts on identifying inappropriate use and emphasizing
non-pharmacologic practices.> CMS also worked with the Substance Abuse and Mental Health Services
Administration (SAMHSA) to issue guidance on inappropriate use of antipsychotics in older adults and people
with disabilities who live in the community.®

The purpose of this study is to examine trends in the prescribing of antipsychotics in LTCFs during the COVID-
19 pandemic. This brief presents results of a descriptive analysis using prescription claims data from January
2019 to June 2021.

METHODS

Prescription data were drawn from IQVIA's National Prescription Audit (NPA) database. NPA includes over 3
billion prescriptions per year, representing more than 92% of prescriptions dispensed at retail pharmacies
(chain, independent, and food store pharmacies), 72% of mail-order medications, and 78% of medications
used in LTCFs. Long-term care data in IQVIA tracks prescriptions dispensed through pharmacies that service
residential care facilities, institutional providers, and nursing home pharmacies. IQVIA's data include
prescriptions dispensed to nursing homes and assisted living providers nationwide. The IQVIA data did not
allow us to distinguish between prescriptions dispensed in these two settings, therefore, we refer to all
prescriptions dispensed in our sample more broadly as dispensed to LTCFs. In addition, these data include
claims for antipsychotic medications dispensed in these settings, regardless of payer. The NPA does not include
U.S. Department of Veterans Affairs (VA) nursing homes (i.e., nursing homes with which the VA contracts, state
veteran homes, and the VA Community Living Centers). Monthly data on prescriptions for antipsychotics
dispensed in LTCFs were analyzed to estimate how the number of antipsychotic prescriptions dispensed
differed between 2020 and 2021 compared to 2019. For 2021, prescription data was available through the
second quarter. Antipsychotic drugs were identified through IQVIA's Uniform System of Classifications.

LIMITATIONS

Controlling for Resident Census Changes

Accounting for changes in the nursing home and assisted living resident census during the study period would
have been ideal in order to determine changes in antipsychotic prescribing rates per capita of LTCF residents;
however, the IQVIA NPA data does not include data on the size of the LTCF resident population. We were also
unable to obtain this information from other sources because, although there is data available for the nursing
home census, there is no national yearly standardized data on the number of residents in assisted living
facilities. The IQVIA NPA data also does not allow us to distinguish prescriptions dispensed to nursing homes
from those dispensed to assisted living facilities, so it is not possible to separately examine changes in
prescriptions dispensed per capita to nursing home residents, only.

Despite not being able to account for total LTCF population census in our analyses, we believe our findings
likely underestimate the number of prescriptions per capita dispensed during our study period due to declines
in the resident census in congregate care settings during the COVID-19 pandemic. To understand this further,
we examined publicly available data from the Nursing Home Payroll-Based Journal (PBJ) files, which contains
nursing home census information for the period of this study. We then compared the nursing home census
with the total LTCF prescriptions dispensed from the first quarter of 2019 to the second quarter 2021
(Appendix Figure 1a and 1b). We found that nursing home resident census in fact decreased during our study

 

March 2022 ISSUE BRIEF 2
period despite increases in the number of total prescriptions dispensed in LTCFs. Between the fourth quarter
of 2019 and the first quarter of 2021, nursing home resident census decreased 16.9%, from 1.3 million
residents to 1.08 million residents, and remained well below pre-pandemic levels as of June 2021. While there
is no available data source to track the number of residents living in assisted living facilities, news stories and
anecdotal accounts from the industry reported that people were reluctant to go or send their family members,
friends, and significant others to congregate settings, and that some residents even moved out due to the fear
of outbreaks. It is therefore likely that the census for assisted living facilities also declined, or at least stayed
fairly constant during the COVID-19 pandemic. Given the likely decline in the combined census of nursing
home and assisted living facility residents during the study period, any observed increase in the number of
prescriptions dispensed likely underestimates increases in prescriptions per capita. Analyses that control more
accurately for LTCF resident census should be considered in future research to determine whether these
increases in prescriptions are higher than the existing trend observed prior to the pandemic.

Controlling for Medication Formulation or Duration

Another limitation of this study is that we did not examine medication formulation or the duration of
prescriptions, both of which could help discern which medications are being used chronically as opposed to for
acute agitation, potentially providing further insight into the appropriateness of antipsychotic use.

Representativeness of the IQVIA NPA Data

Although these data include the majority of long-term care and covers 78% of medications used in LTCFs, the
representativeness of these data for the entire long-term care market is not known.

RESULTS
Overall Trends in Antipsychotic Drug Prescriptions in LTCFs during COVID-19

Prescriptions for antipsychotic medications in LTCFs have been steadily increasing since 2016 (the earliest year
in our sample -- Appendix Figure 2). During the COVID-19 pandemic, total prescriptions for all antipsychotics in
LTCFs increased by 1.5%, from 20.5 million prescriptions dispensed in 2019 to 20.8 million in 2020

(Figure 1). We did not account for a likely decrease in LTCF resident census during this time, thus, the increase

in per capita prescriptions in 2020 and 2021 may have been higher.

Because antipsychotic prescribing levels show some evidence of seasonality with substantial variations
between quarters within the same year (Appendix Figure 2), we compared prescribing levels for
corresponding quarters across different years. We cannot explain the variations we found in prescribing across
different months. The first quarter of 2020 (the beginning of the COVID-19 pandemic) had the highest increase
of 7.4% compared to the first quarter of 2019. This increase in prescriptions is relatively high compared to
historical trends dating back to 2016 (Appendix Figure 3). After the first quarter of 2020, prescriptions
decreased and later stabilized close to 2019 levels through the end of 2020 and during the first two quarters of
2021, despite an overall decreasing trend in nursing home resident census.

 

March 2022 ISSUE BRIEF 3
 

Figure 1. Overall Antipsychotic Prescribing and Percent Difference of Total Prescribing:
January 2019-June 2021

 

  

2019 [2020 MM 2oz1

5.32M
oD -$__ : 5.25M
a 5.23M --™ 5.22M
5 5.21M
a
2 a
= ; 515M
5 >
¢ 5.12M
&

5.07M
Total Antipsychotics Dispensed (2
28M Total Antipsychotics Dispensed (

 

Quarterly % Difference of Total Prescription Dispensed Compared to 2019

7a

O-92% O.18%
-L37%

 

 

 

 

 

 

 

 

SOURCE: Internal ASPE analysis using IQVIA National Prescription Audit, 2015-2021.

 

Trends in the Five Most Prescribed Antipsychotic Medications in LTCFs during COVID-19

Figure 2 shows the most common antipsychotic drugs prescribed in LTCFs. These five medications represent
about 80% of all antipsychotics prescribed in our sample in 2019 and 2020. Quetiapine was the most
frequently prescribed drug, followed by risperidone, olanzapine, aripiprazole, and haloperidol, respectively.
Except for risperidone, total prescriptions for the four other medications increased by the end of 2020 and into
2021.

 

March 2022 ISSUE BRIEF 4
 

 

 

  
  
 

 

 

 

 

 

 

 

Figure 2. Share of Top 5 Prescribed Antipsychotics in LTCFs in 2019 and 2020
Prescrption Year
QUETIAPINE 2019 6.08M 'AiiIGRRIOTE
RISPERIDONE 10.3%
RISPERIDONE 2019 267M Lf OLANZAPINE
14.0%
Top 5 most
ANZAPINE 2019 2.87M Prescribed
Antipsychotics
ocd a aoe ALOPERIDOL
MEAT LIRSEA) saa = 7.5%
ARIPIPRAZOLE 2013 20m QUETIAPINE
29.7%
Others.
HALOPERIDOL 2019 153M says 20.7%
- a a Top 5 = 79% of total antipsychotic drug prescriptions
nuee Ee aa _ 2020 proportion for the top 5 were the same.
SOURCE: Internal ASPE analysis using IQVIA National Prescription Audit, 2015-2021.

 

Figure 3 shows the trends in the numbers of prescriptions dispensed for all five drugs separately. With the
exception of risperidone, prescriptions for the other four antipsychotics increased both in 2020, and in the first
two quarters of 2021, compared to 2019 levels.

Aripiprazole had the highest increase in the total number of prescriptions, with 2.26 million prescriptions
dispensed in 2020 compared to 2.10 million in 2019. Prescriptions for haloperidol and olanzapine also
increased in 2020 and 2021 compared to 2019. For each of these three medications, there were marked
increases in prescribing levels during the first quarter of 2020 compared to the first quarter of 2019.
Prescriptions for aripiprazole increased 13.8% in the first quarter of 2020 compared to the first quarter of
2019; and prescriptions for haloperidol and olanzapine increased 8% and 9.4%, respectively, in the first quarter
of 2020 compared to the first quarter of 2019.

Quetiapine and risperidone, by contrast, had similar or lower levels of prescriptions in 2020 compared to 2019,
with risperidone maintaining steady decreases in the number of prescriptions for most months in 2020 and
into 2021.

 

March 2022 ISSUE BRIEF 5

 
 

 

 

 

 

 

 

 

 

 

 

 

Figure 3. Trends in 5 Most Prescribed Antipsychotics, January 2019-June 2021
Aripiprazole Haloperidol
3 5a3k ee 3
a -<-$-$-- 5 . a 404Ks sight
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Olanzapine Quetiapine
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= 301K
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% Quarterly Change
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td 57% @ 2020
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SOURCE: Internal ASPE analysis using IQVIA National Prescription Audit, 2015-2021.

 

DISCUSSION

Antipsychotic medications may be prescribed in nursing homes as an intervention for behavioral and

psychological symptoms. When residents are aggressive, agitated, or intrusive, and redirection, distraction,

 

March 2022

ISSUE BRIEF

6

 
and other interventions are not effective, atypical antipsychotics' are one means of controlling harmful
behavior in support of resident and staff safety. In such situations, antipsychotic use is recommended only
after the patient is thoroughly evaluated for physical and mental health conditions, and when the benefit
outweighs the risks, which include increased mortality in people with dementia. However, inappropriate off-
label® and over-prescribing of these drugs to reduce behavioral and psychological symptoms of people living in
LTCFs, many of whom are older, frail, and have dementia, or the symptoms of dementia, has been a concern
for years, long before COVID-19.°"° Side effects from antipsychotics vary from mild sedation to more severe
adverse reactions, including blood clots, diabetes, dyskinesia, fall risk, irreversible cognitive decompensation,
pneumonia, severe nervous system problems, stroke, visual disturbances, and death." Older adults receiving
antipsychotics are more vulnerable to falls and cognitive impairment,*! and adults with dementia have an
increased risk of death, stroke, and other severe side effects associated with antipsychotic use.?? In addition,
the efficacy of off-label use of antipsychotic medications in this group is mixed.*®

This analysis sought to understand whether overall antipsychotic prescribing increased during the COVID-19
pandemic. Using a sample of 78% of medications dispensed in LTCFs, our analyses found that prescriptions for
antipsychotics in LTCFs increased by 1.5% during the beginning of the COVID-19 pandemic, from 20.5 million in
2019 to 20.8 million in 2020. This increase in prescriptions occurred despite a likely decline in total LTCF census
in 2020, which suggests that the total increase in per capita prescriptions may be higher. Further research is
needed to verify whether this trend holds after accounting for the entire LTCF resident census.

We also observed that the number of prescriptions dispensed in 2020 and 2021 varied across time and by the
specific medication used. We found that by the end of the first quarter of 2020, when the COVID-19 pandemic
had just started, overall prescribing had increased by 7.4% compared to the first quarter of 2019, an increase
that is historically high relative to prior years. During this time, LTCFs were experiencing a disproportionately
high number of infections and deaths from COVID-19 outbreaks, and there was still a fair amount of
uncertainty about the disease and infection control measures, in addition to a lack of personal protective
equipment, staffing shortages, and new federal requirements for isolation and limiting in-person visits.14>
These added challenges disrupted care in many facilities, likely affecting residents' physical, mental, and
behavioral health, which may have influenced changes in care practices, including medication prescribing. Our
study did not assess whether this increase in prescriptions was clinically justified, what caused the increase in
prescribing, and what effects it may have on residents' overall physical and mental health and well-being.

After the first quarter of 2020, the number of prescriptions returned to levels similar to 2019. However,
nursing home census -- and likely LTCF census overall -- was decreasing throughout 2020, so it is likely that the
number of antipsychotic prescriptions per capita in 2020 exceeded that in 2019. In the first two quarters of
2021, the number of prescriptions increased again and remained high compared to 2019 levels.*®

This study also examined differences in prescribing trends for the five most frequently prescribed antipsychotic
drugs during the COVID-19 pandemic. Aripiprazole had the highest absolute increase in the total number of
prescriptions in 2020 and 2021 compared to 2019. The reasons are unclear. Aripiprazole is used to treat the
symptoms of schizophrenia and has also been used in LTCFs to manage behavioral and psychological
symptoms of dementia (BPSD), possibly because it is perceived to have a milder side effect profile than other
antipsychotics,!"78 and may also be used to manage chronic conditions such as depression and bipolar
disorder. These factors may explain the higher rates of prescribing observed during the COVID-19 pandemic.
Risperidone is an atypical antipsychotic for people with certain mental disorders such as schizophrenia, bipolar
disorder, and autism spectrum disorders; it is not approved for BPSD. Risperidone, by contrast, maintained a
steady decrease in prescriptions for most months in 2020 and 2021 compared to 2019. Risperidone can cause
some serious side effects, the most concerning of which are motor side effects that mimic Parkinson's disease,
which may explain its more restrictive use relative to other antipsychotic options used by clinicians to treat

 

March 2022 ISSUE BRIEF 7
BPSD. Understanding the reasons for these divergent trends in the use of specific antipsychotic medications
during the COVID-19 pandemic is an important area for future research.

The observed growth in antipsychotic prescribing in LTCFs during the COVID-19 pandemic raises concerns, and
warrants further investigation to determine whether these changes represent a significant and meaningful
increase beyond the pre-existing trend of rising antipsychotic use over time; the reasons for higher levels of
antipsychotic prescribing over time more generally, the types of antipsychotics prescribed, as well as the
factors related specifically to the COVID-19 pandemic; and, how increasing rates of antipsychotic prescribing
have affected people living in nursing homes and assisted living facilities, especially people with dementia who
have a higher risk of adverse effects when receiving these medications. In addition, further research could
examine differences in antipsychotic prescribing patterns by resident characteristics (e.g., race/ethnicity,
disability, income, and the effect on health outcomes).

CONCLUSION

The COVID-19 pandemic created considerable challenges and hardships for LTCFs and the residents who live in
them. Our study showed that prescriptions of antipsychotic medications appear to have increased in 2020
relative to 2019, especially in the first few months of the pandemic. Given the known drop in nursing home
resident census -- and likely drop in overall LTCF census -- during 2020 and 2021, the increase in antipsychotic
prescriptions per resident may be even larger, raising questions about the short-term and long-term effects on
quality of care and health outcomes. Future studies could extend this work to focus specifically on the nursing
home population, with an emphasis on residents with dementia and other common comorbidities, to explore
the reasons for changes in antipsychotic prescribing, disparities in prescribing by facility and resident
characteristics, and impacts on resident care and health outcomes.

 

March 2022 ISSUE BRIEF 8
APPENDIX

 

Appendix Figure 1a and 1b. Number of Antipsychotic Prescriptions Dispensed in LTCFs
Increasing Despite Decreasing Nursing Home Census

Appendix Figure 1a: Total Antipsychotic Drugs Prescribed (Q1 of 2019 - Q2 of 2021)

Total Antypsychotic Drugs Prescribed
1

 

 

ee

5M ! Source: Payrall Based Journal Daily Nurse Staffing
| Database. Downloaded October 2021.

230m 130M 130M

130M ">... 30M

Nursing Home Resident Census

   

1.05M

1.08M

in BAe nina is pa ania na anon At anonat anon At ann 0, a9 4 sneq 49
evisUtL elo ye euis Us euts4s euey Wa evel Qe eucU Us eed US éuel ul fuel de

NOTE: Appendix Figure 1b shows total nursing home resident census from the first quarter of 2019 to the 2nd
quarter of 2021, using the CMS PBJ database. Under the COVID-19 Emergency Declaration Blanket Waivers for
Health Care Providers, CMS temporarily waived the requirement for nursing homes to submit PBJ data during the
first quarter of 2020 to allow facilities to focus on efforts on combating COVID-19 and to reduce administrative
burden on nursing homes. CMS stated that about 40% of nursing homes did not submit the data during the first
quarter of 2020. Due to this large volume of missing data submissions, we excluded first quarter data from this
analysis. Despite this omission, census remained low until the end of year 2020 and into 2021.

 

 

 

 

March 2022 ISSUE BRIEF 9
 

Appendix Figure 2. Historical Trend of Antipsychotic Prescribing (October 2016-June 2021)

March, 2020
Total Prescribed

March, 2021
Total Prescribed:
186M

      

 

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5 aon i January,2021
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1
Oct, 2016 177M
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Total Prescribed:
160M '
Peer i
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2 eee ee a pe 2 Tow oR ae se 2 8 ne
o8 22336 8 2 8 gee SET E RE RE TERE E ESE

 

 

SOURCE: Internal ASPE analysis using IQVIA National Prescription Audit, 2015-2021.

 

 

 

March 2022 ISSUE BRIEF 10
 

SOURCE: Internal ASPE analysis using IQVIA National Prescription Audit, 2015-2021.

 

Appendix Figure 3. Percent Change of All Antipsychotics Combined Compared to the Previous Year

O41 o2 O23 oa

  

-| ERP mG igs re! 0.49%...

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2016

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eh

 

 

REFERENCES

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Kaiser Family Foundation. (2021). State COVID-19 Data and Policy Actions. Accessed 15 September 2021
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March 2022 ISSUE BRIEF 12
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March 2022 ISSUE BRIEF

13
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Mailstop 447D
Washington, D.C. 20201

For more ASPE briefs and other publications, visit:
aspe.hhs.gov/reports

hel
ABOUT THE AUTHORS

lara Oliveira, Martin Blanco, M.A., M.P.H, and Mir M. Ali, Ph.D.
work in the Office of Behavioral Health, Disability, and Aging

Policy in the Office of the Assistant Secretary for Planning and
Evaluation.

SUGGESTED CITATION
Oliveira, |., Blanco, M., & Ali, M.M. Antipsychotic Medication
Prescribing in Long-Term Care Facilities Increased in the Early

Months of the COVID-19 Pandemic (Issue Brief). Washington, DC:
Office of the Assistant Secretary for Planning and Evaluation, U.S.

Department of Health and Human Services. March 8, 2022.

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March 2022

ISSUE BRIEF

14