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. Author manuscript; available in PMC: 2025 Sep 25.
Published in final edited form as: J Appl Gerontol. 2025 Apr 14;45(1):17–25. doi: 10.1177/07334648251332388

COVID-19 Factors Associated with Medication Changes Among Nursing Home Residents with Dementia

Alison C Rataj 1, Kate L Lapane 2, Brian R Ott 3, Jonggyu Baek 4, Shiwei Liang 5, Matthew Alcusky 6,*
PMCID: PMC12459643  NIHMSID: NIHMS2067904  PMID: 40228502

Abstract

This study examined associations of COVID-19 mortality rates, staffing, and resident behavior with changes in antidementia and psychotropic medication initiation among nursing home (NH) residents with dementia. A nationally representative survey of Directors of Nursing was analyzed to assess changes in medication initiation at the peak of the pandemic. NHs with higher COVID-19 mortality rates were less likely to report increases in antidementia medication initiation. COVID-19 mortality rates were not associated with significant increases or decreases in psychotropic initiation. NH’s that reported increased resident behavioral problems during the pandemic had higher odds of psychotropic initiation. In summary, NHs most affected by COVID-19 deaths were less likely than NHs with a milder pandemic experience to increase initiation of antidementia medications. Increased behavioral symptoms, possibly due to consequences of COVID-19, were associated with more psychotropic drug use. More research is needed to understand factors influencing prescribing practices during public health emergencies.

Introduction

The SARS-CoV-2 (COVID-19) pandemic caused major morbidity and mortality among nursing home residents in the United States. While less than 1% of the total U.S. population lived in nursing homes (NH), approximately 25% (~200,000) of documented COVID-19 deaths occurred among NH residents and staff (Chidambaram, 2023). Due to the pandemic, NH residents with dementia became more susceptible to poor outcomes related to increased risk of infection, routine care changes, and increased social isolation (Gilstrap et al., 2022; Liu et al., 2021). A major cause of widespread infection rates and mortality of COVID-19 within NHs was asymptomatic transmission between residents and staff (Giri et al., 2021). Staff experienced difficulties in managing and administering medications due to cumbersome personal protection equipment and time constraints (Brand & Chou, 2020).

During the pandemic, some facilities increased the use of antipsychotics (Howard et al., 2020; Stall et al., 2021), antidepressants (Stall et al., 2021), benzodiazepines (Stevenson et al., 2022), anticonvulsants (Campitelli et al., 2021), and opioids (Campitelli et al., 2021). Increased prescribing of these medications may have been a response to an increase in behavioral and psychological symptoms (Coe et al., 2023) due to social isolation and quarantine (Cagnin et al., 2020). Conversely the use of antidementia drugs, which are generally not considered effective in managing behavioral symptoms of dementia, declined during the pandemic in Europe and North America (Ju et al., 2021). Due to infection control protocols, clinicians may not have been able to use nonpharmacological strategies to address common resident behaviors because of diminished resources (Stall et al., 2021).

The COVID-19 pandemic, and corresponding infection- and prevention-control practices intensified demands of staff leading to burnout (Denny-Brown et al., 2020). Additional precautions to reduce airborne and contact exposure created barriers for staff in meeting the needs of residents (Denny-Brown et al., 2020). COVID-19 prompted many staff to leave their jobs due to illness, high risk of exposure, or family obligations (Cantor et al., 2020). Notably, research found an association between increased antipsychotic use during the COVID-19 pandemic and decreased certified nursing assistant hours (Yan et al., 2023). To our knowledge, no studies have examined the association with antidementia medication prescribing and staffing during the COVID-19 pandemic.

To better understand the association between the burden of COVID-19 in U.S. NHs and changes in medication prescribing this study sought to 1) quantify changes in psychotropic and antidementia medication initiation during the pandemic; 2) examine the association between NH COVID-19 mortality rates and prescribing changes; 3) explore if staffing is associated with prescribing changes; and 4) investigate the relationship between resident behaviors and changes in prescribing. We hypothesized that NHs with higher rates of COVID-19 deaths would evidence decreases in initiation of antidementia medications because nursing homes were likely not focused on initiating treatments while dealing with peak COVID-19 burden. We posited that NHs with higher rates of COVID-19 deaths would evidence increases in initiation of psychotropic medications (Campitelli et al., 2021; Howard et al., 2020; Stall et al., 2021) during the pandemic. We also hypothesized that NHs that had higher rates of staff shortages and burnout would mitigate intensified demands (Denny-Brown et al., 2020) by increased initiation of psychotropic medications to control rising problem behaviors, as worsening of emotional and behavioral disorders could be caused by the restrictive measures of the pandemic (Uriguen et al., 2022).

Methods

Data Sources

Data were used from the nationally representative Dementia Treatment Survey (Lapane et al., 2024), which collected information on factors influencing pharmacologic and non-pharmacologic management of dementia among older adults residing in U.S. NHs. Multimodal (mail, web) data collection began in March 2022 and concluded in May 2022 (Lapane et al., 2024). Data from NH Compare (2022), which provides quality ratings for Medicare and/or Medicaid-certified NHs, and the Centers for Medicare and Medicaid Services (CMS) COVID-19 NH data (2024) files, which include information on rates of COVID-19 cases, hospitalizations, and deaths, were used. Data on NH characteristics were also drawn from the Provider of Service (POS, 2022) file, and individual-level data were aggregated to the NH level from the Medicare beneficiary enrollment information (Master Beneficiary Summary File), and NH assessment data (Minimum Data Set, MDS 3.0). The University of Massachusetts Chan Medical School Institutional Review Board approved this study.

Study Population

The Dementia Treatment Survey used a sampling frame of 14,455 US NHs with ≥30 beds (Lapane et al., 2024). The survey was a self-administered questionnaire that was intended to be completed by the Directors of Nursing (DoN). In their role, DoN’s oversee and organize nurses to promote high-quality, effective care and are involved in all aspects of nursing services (Siegel et al., 2018). DoN’s unique perspective exposed them to the preparedness, management, and control of care during the pandemic while simultaneously dealing with staffing issues and concerns about resident and staff safety (Phelan et al., 2022). The research team created an 8-page survey which was reviewed by survey experts on the team and several local DoNs provided revisions which were implemented before fielding the survey (Lapane et al., 2024).

To ensure adequate representation of NHs with dedicated dementia units, the sample was stratified by existence of a dedicated dementia care unit and oversampled NHs with dementia units, leading to a sample where 40% of NHs had and 60% did not have a dementia unit. A stratified random sample of 1,293 NHs received the survey. Due to a prior 2022 national survey that was conducted by Lapane et al. (2024), NHs that were sampled in the previous study were omitted and were replaced with NHs that had the same occupancy rates (30–99 beds, 100+ beds), quality rating (1, 2–4, 5 stars), and presence of a dementia unit. Among the eligible sample, 340 DoN’s (26.6% response rate) responded to the survey. This study excluded NHs if federal provider identification was not available (n=5), DoN’s did not work at the NH prior to the pandemic (n=92), non-response to survey items (n=2), or data was missing from CMS sources (n=8). This led to a final sample of 233 DoN’s (weighted N=9,624). See Supplemental Figure 1 for a sample selection flowchart.

Measures

Outcomes

Medication initiation was operationalized using two questions from the Dementia Treatment Survey. The survey included a matrix that asked, “Compared to before the pandemic, at the peak of the pandemic in your NH how often did the following medication decisions occur for residents with dementia?” and included two items: 1) Initiation of new antidementia medications; and 2) Initiation of psychotropic medications for resident behavioral problems. Indicators were ranked using a Likert scale (1= much less often to 5= much more often). To examine our hypotheses regarding COVID-19’s impact on prescribing we created four binary outcomes, two contrasting less/about the same versus more initiation, and two contrasting less versus more/about the same initiation.

Exposures

Consistent with our outcomes, which were defined at the peak of the pandemic, we operationalized a NH’s peak monthly COVID-19 death rate during the period of May 2020 through December 2022 using the CMS COVID-19 Nursing Home data file. The monthly COVID-19 death rate was calculated using the monthly number of residents with a suspected or laboratory positive case of COVID-19 who died in a NH or another location per 1,000 residents as reported by the NH. NHs were arranged into two groups using a median split (i.e., NHs that had ≥ 60.2 monthly deaths per 1,000 residents were in the top half; NHs that had < 60.2 monthly deaths per 1,000 residents were in the bottom half).

To explore the association between NH staffing and changes in resident behaviors from before the pandemic to its peak, we used data from the Dementia Treatment Survey. Changes in concern about staff burnout was based on responses to the question, “Compared to before the pandemic, at the peak of the pandemic in your nursing home how concerned were you about direct care staff burnout?” The responses on a five-point Likert scale were collapsed into two exposure categories (less often/about the same vs. more often). Direct care staff turnover was a binary variable based on responses to the question, “At the peak of the pandemic in your nursing home, did your nursing home experience significant direct care staff turnover?” An index was created to assess change in externalized behavior among residents. The question, “Compared to before the pandemic, at the peak of the pandemic in your nursing home how often did residents with dementia exhibit the following?” was answered using five-point scale responses (1 = much less likely to 5 = much more likely) for three types of behaviors: verbal and physical aggression, resisting care behaviors, and motor disturbances such as pacing. To create the index, scale points were collapsed for each behavior (1 = less likely to 3 = more likely), summed, and the average was calculated.

Covariates

NH characteristics were used in analyses to adjust for potential confounding of the relationship between the exposures and outcomes. Variables including the size of the NH (i.e., medium, large; Cioltan et al., 2017; Kleijer et al., 2014) and quality rating (range: 1–5) were drawn from the 2022 CMS NH Compare dataset. Proportions of residents who were dually eligible for Medicare and Medicaid (Hughes et al., 2000), Hispanic, Black, and diagnosed with ADRD were calculated from individual-level records in the 2018 MBSF and MDS 3.0 file (Chen et al., 2021; Gorges & Konetzka, 2021; Li et al., 2020). Provider of Service files included ownership type (i.e., for-profit, government, non-profit; Cioltan et al., 2017; Frankenthal et al., 2016) and presence of a dementia care unit in 2022. Covariates that were continuous (i.e., proportion of residents who were dually eligible for Medicare and Medicaid, Hispanic, Black, and diagnosed with ADRD) were first grouped into quartiles. Associations of quartiles of these variables with the outcome were examined to evaluate if the four quartiles of each variable could be collapsed. We reviewed the degree of associations for all four quartiles where the bottom quartile was the reference group, to assess whether relationships were homogenous. We found associations were homogeneous for the top three quartiles, so these were collapsed to create dichotomous variables (i.e., top three quartiles versus bottom quartile). Notably, more than one-quarter of NHs had no Hispanic residents, so rather than dichotomizing at the first quartile, the proportion of Hispanic residents was grouped as tertiles and then collapsed to compare the top two tertiles versus the bottom quartile.

Analytic Strategy

To generate nationally representative estimates of NHs with ≥ 30 beds, we used weights to take into consideration the stratified sampling design and non-response (Lapane et al., 2024). We calculated survey weights after adjusting the stratified sample sizes for nursing homes found to be closed or no longer providing nursing home care. Multicollinearity was assessed and ruled out overlapping exposure and outcomes variables using Pearson correlation matrix (see Supplemental Table 1). All analyses were performed using SAS survey procedures in version 9.4 (SAS Institute, Inc., Cary, NC).

We first described NH characteristics using frequencies and percentages. We then used bivariate and multivariable logistic regression to quantify the associations between exposures and outcomes while adjusting for NH characteristics. To increase the precision of contrasts in the context of limited sample sizes, we opted to use binary rather than multinomial logistic regression.

Results

Among all DoN respondents, 16.7% reported either much less or a little less initiation of antidementia medications from pre-pandemic to the pandemic’s peak (10.6% from NHs with higher COVID-19 death rates and 6.1% from NHs with lower death rates); 10.3% reported either much less or a little less initiation of psychotropic medications (5.9% from NHs with higher COVID-19 death rates and 4.4% from NHs with lower COVID-19) (see Figure 1). Comparatively, 13.6% of all DoNs reported either much more or a little more initiation of antidementia medications from pre-pandemic to the pandemic’s peak (3.2% from NHs with higher COVID-19 death rates and 10.4% from NHs with lower COVID-19 death rates); while 30.9% reported either much more or a little more initiation of psychotropics (14.3% from NHs with higher COVID-19 death rates and 16.8% from NHs with lower COVID-19 death rates).

Figure 1: Initiation of Antidementia and Psychotropic Medicationsa in Nursing Homes with Higher and Lower COVID-19 mortality rateb.

Figure 1:

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NOTES. N=233, weighted N = 9,624. aWeighted percentages. bCovid-19 mortality rate was calculated using the monthly number of residents with a suspected or laboratory positive case of COVID-19 who died in a nursing home or another location per 1,000 residents as reported by the nursing home; Median = 60.2 monthly deaths.

On average, NHs experienced about 94.6 (SD = 624.8) deaths per 1,000 residents during their identified peak pandemic month. Most NHs experienced more concern about staff burnout (88%) and turnover (68%). About 55% of DoN’s reported increased external behavior exhibited by residents. About three-quarters (77%) of NHs received a 3 NH Compare star rating, more than half (58%) were medium sized, and about 16% had an Alzheimer’s unit. Proportions of Hispanic residents (M = 1.1, SD = 0.2) and Black residents (M = 9.1, SD = 1.0) were notably low among US NH’s (see Table 1).

Table 1:

Characteristics of nursing homes during pandemic

Variable
COVID-19 mortality rate a, M(SD) 94.6 (624.8)
Concern about staff burnout, %
 Less/about the same concern 1201 (12.5)
 More concern 8422 (87.5)
NH experienced direct care staff turnover, % 6612 (68.7)
Increased external behaviors exhibited by residents, %
 Less/about the same external behavior exhibited 4300 (44.7)
 More external behavior exhibited 5323 (55.3)
Covariates
NH Compare Star Rating, %
 1–2 stars 945 (9.8)
 3 stars 7361 (76.5)
 4–5 stars 1318 (13.7)
Facility size, %
 Medium (30 – 99 beds) 5592 (58.1)
 Large (≥100 beds) 4031 (41.9)
Proportion of dual residents, M (SD) 44.2 (1.2)
Proportion of Hispanic residents, M (SD) 1.1 (0.2)
Proportion of Black residents, M (SD) 9.0 (1.0)
Proportion of residents with ADRDb diagnosis, M (SD) 56.0 (1.0)
Presence of Alzheimer’s Unit, % 1513 (15.7)
Nursing Home Ownership, %
 For-profit 6588 (69.7)
 Government 415 (4.4)
 Non-profit 2444 (25.9)
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NOTES. N=233, weighted N=9,624.

a

Covid-19 mortality rate was calculated using the monthly number of residents with a suspected or laboratory positive case of COVID-19 who died in a facility or another location per 1,000 residents as reported by the facility.

b

Alzheimer’s Diagnosis and Related Dementias (ADRD).

Antidementia Medications

Table 2 presents crude and adjusted regression models across exposures and outcomes of both medication classes. DoNs in NHs with higher COVID-19 death rates at the peak of the pandemic were not statistically different in reporting a decrease in antidementia medication initiation when compared to DoNs in NHs with lower COVID-19 death rates (adjusted [aOR]decrease: 2.26, 95% CI: 0.91–5.63). Changes in DoN concern about direct care staff burnout, turnover, and resident externalizing behaviors had weak or imprecise associations with decreases in antidementia drug initiation.

Table 2:

Associations between COVID-19 deaths, staff burnout, staff turnover, and externalized resident behaviors with decreases in antidementia and psychotropic drug initiation at the peak of the pandemic.

Antidementia Medications Psychotropic Medications
Decreased initiation Increased initiation Decreased initiation Increased initiation
Covid-19 deathsa (top vs. bottom 50%)
 Crudeb 1.93 (0.86–4.35) 0.27 (0.10–0.73) 1.39 (0.52–3.73) 0.81 (0.43–1.52)
 Adjustedcd 2.26 (0.91–5.63) 0.21 (0.07–0.66) 1.53 (0.47–4.99) 0.71 (0.33–1.52)
More concern about direct care staff burnoute
 Crudeb 1.47 (0.40–5.36) 0.80 (0.23–2.77) 0.49 (0.14–1.66) 1.23 (0.45–3.36)
 Adjustedcd 1.15 (0.27–4.90) 0.85 (0.25–2.93) 0.55 (0.11–2.79) 0.93 (0.35–2.49)
More direct care staff turnoverf
 Crudeb 1.81 (0.74–4.41) 1.92 (0.67–5.47) 1.27 (0.43–3.77) 1.67 (0.82–3.40)
 Adjustedcd 1.51 (0.58–3.91) 2.06 (0.63–6.78) 1.37 (0.40–4.66) 0.98 (0.40–2.40)
Increased external behaviors exhibited by residentsg
 Crudeb 2.07 (0.84–5.11) 2.17 (0.83–5.64) 0.42 (0.19–0.94) 9.15 (3.45–24.15)
 Adjustedcd 2.12 (0.79–5.71) 2.70 (1.05–6.92) 0.45 (0.17–1.19) 11.18 (4.01–31.15)
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NOTES. N=233, weighted N=9,624.

a

Covid-19 mortality rate was calculated using the monthly number of residents with a suspected or laboratory positive case of COVID-19 who died in a facility or another location per 1,000 residents as reported by the facility; Lower deaths reference group; Median = 60.2 monthly deaths.

b

Reported as odds ratio with 95% confidence intervals.

c

Reported as adjusted odds ratio with 95% confidence intervals.

d

Adjusted models included the following covariates: NH Compare Star Rating, facility size, proportion of residents who are dually eligible, proportion of Hispanic residents, proportion of Black residents, proportion of residents with ADRD diagnosis, presence of dementia care unit, and nursing home ownership.

e

Less/about the same concern for direct care staff burnout reference group.

f

NH did not experience direct care staff turnover at peak of pandemic reference group.

g

Increased external behaviors exhibited by residents was operationalized by averaging three behaviors (i.e., verbal and physical aggression, resisting care behaviors, motor disturbances).

We also examined associations with increases in antidementia drug initiation from pre-pandemic to the pandemic peak. An increase in initiation was less likely in NHs with higher COVID-19 death rates (aORincrease = 0.21, 95% CI = 0.07–0.66) when compared to NHs with lower COVID-19 death rates.

Psychotropic Medications

DoNs from NHs with higher COVID-19 death rates at the peak of the pandemic reported similar decreases in psychotropic medication initiation (aORdecrease=1.53, 95% CI: 0.47–4.99). Estimates of changes in concern about staff burnout, direct care staff turnover, and resident externalizing behaviors had weak or imprecise associations with decreases in psychotropic drug initiation.

NH COVID-19 death rates were not associated with an increase in initiation of psychotropic medication (aORincrease= 0.71; 95% CI: 0.33–1.52). DoNs reporting increased externalized resident behaviors were significantly more likely to report an increase in psychotropic drug initiation (aORincrease=11.18, 95% CI: 4.01–31.15). More direct care staff turnover and increased concern about burnout were not associated with increases in psychotropic drug initiation. Supplemental Table 2 presents adjusted models with covariate estimates.

Discussion

The COVID-19 pandemic exacted a considerable toll on NH residents and staff. The burden of COVID-19 deaths was not borne evenly among NHs in our study, with peak monthly death rates ranging from a low of 0 to a maximum of 500 deaths per 1,000 residents from May 2020 to December 2022. Consistent with our hypothesis, DoNs from NHs with higher COVID-19 death rates were less likely to report an increase in initiation of antidementia medications from the pre-pandemic period to the pandemic peak. This may suggest that NHs that experienced increased burden from COVID-19 were more likely than NHs that had a milder pandemic experience to reduce initiating antidementia medications. Contrary to our hypothesis, DoNs from NHs with higher COVID-19 death rates did not show differences in reporting an increase or a decrease in psychotropic initiation. As expected, NHs that reported an increase in externalized behaviors were more likely to report an increase in initiation of psychotropics. No associations were found between staffing and antidementia or psychotropic prescribing.

Our results indicate that NHs with higher levels of COVID-19 mortality may have reduced antidementia medication initiation during the pandemic. Shortages and delays in the supply of pharmaceutical products due to decreased production, supply chain issues, and stockpiling may have contributed to less initiation (European Commission, 2020). Also, initiating antidementia medication involves decisions among the prescriber, family, residents, and specialists (Lapane et al., 2024) and includes a resident assessment (e.g., cognition, function; Fillit et al., 2006). Given safety measures to reduce the spread of COVID-19 this process may have occurred at a slower pace, if at all, leading to less initiation of antidementia medications in NHs more affected by COVID-19. Initiation of antidementia medications may have declined as patients with dementia had a higher mortality rate from COVID-19 as compared to those without dementia (i.e., depletion of candidates for initiation; Liu et al., 2020).

It is notable that a greater burden of COVID-19 deaths was not associated with increased psychotropic drug initiation. Our findings indicated that increased behavioral changes, a possible result of the pandemic, were associated with more psychotropic drug use. Psychotropic prescribing may have increased due to agitation and psychosis secondary to COVID-19 restrictions (e.g., social isolation, pause of in-person family visits; Howard et al., 2020). Increased externalizing behaviors coupled with infection control barriers to implement nonpharmacological options, may have led to increased initiation of psychotropic medications during the pandemic.

Because prior studies have demonstrated an inverse relationship between staffing and antipsychotic use (Mattingly, 2015), we hypothesized that staff shortages and burnout would be exacerbated by COVID-19. Our findings show that direct care staff turnover was not clearly associated with changes in antidementia and psychotropic drug initiation, and that changes in staff burnout were generally associated with lower odds of increasing the use of both medication classes, together point to potential resiliency within NHs. NH staff during the COVID-19 pandemic have discussed feelings of burnout, while simultaneously expressing concern for residents and motivation to provide the best quality of care (White et al., 2020) which may have served as a bulwark against changes in prescribing practices. Moreover, while variable across states and NHs, short-term interventions (e.g., hazard pay, paid sick leave) may have helped reduce burdens on staff and improved retention (White et al., 2024).

Strengths and Limitations

This study used data from the first nationally representative survey of DoNs and provides salient estimates of changes in prescribing associated with COVID-19 related burdens on NHs. A major strength is the use of multiple data sources, including the official CMS COVID-19 mortality rates. The survey results are subject to non-response bias; however, our response rate is like other provider surveys (Derrett et al., 2019; Dubé et al., 2023), and we used weights that accounted for nonresponse. The data reported through the survey are the perceptions of the DoNs, which may deviate from other measures of prescribing; our survey items sought to capture changes in care from the pre-pandemic to pandemic period, and DoNs are well-positioned to comment directionally on changes in the approach to clinical care undertaken in their NHs. Due to our small sample size and cross-sectional design, we cannot draw causal inferences.

Conclusions and Implications

Given that some antidementia medications (i.e., acetylcholinesterase inhibitors) show potentially beneficial effects to combat COVID-19 (Simões et al., 2023) and reduce mortality (Shahim et al., 2024; Truong et al., 2022; Xu et al., 2021) it is troubling that our study uncovered a potential decrease in initiation, specifically for NHs that experienced higher rates of COVID-19 mortality. Recent declines in the use of antidementia medications in NHs (Ott et al., 2023) suggest that prescribing practices may not be aligned with clinical guidelines (Rataj et al., 2024) and changing perceptions of the clinical benefit of antidementia medications among NH providers may play a role (Lapane et al., 2024). Concerns have been raised that due to interruptions in staffing, support, and services, the COVID-19 pandemic may have deterred policy advancements (CMS, 2020) that sought to reduce the inappropriate use of psychotropic medications within NHs (Campitelli et al., 2021; Stall et al., 2021). We did not find evidence of an increase in psychotropic drug use due to the burden of COVID-19 on NHs, but our results indicate that to the extent externalized behaviors increased because of COVID-19, this led to increased psychotropic prescribing. While our study did not find robust associations between staff turnover, burnout, and prescribing changes in either medication class, strategies employed by NHs (e.g., infection control and prevention, hazard pay) to support staff may have reduced this effect.

Supplementary Material

1

Acknowledgement:

We thank the University of Massachusetts Boston Center for Survey Research for conducting the Dementia Treatment Survey.

Funding Statement:

This work was funded through the National Institute on Aging, Grant Number: 5R01AG068450–03.

Footnotes

Ethics Approval:

This study was approved by the Institutional Review Board at the University of Massachusetts Chan Medical School (IRB ID: H00020097) on April 24, 2020, and the study modification to incorporate the survey component (IRB ID: MODCR00000157) was approved on March 31, 2022.

Consent to Participate:

For survey data collected from nursing home administrators, completion of the survey was considered as consent to participate. All contacts with potential survey respondents informed them that this was a research study conducted with support of the National Institutes of Health, that participation was voluntary, and that if respondents did not want to answer a question, they could skip it and move on. For administrative data from CMS, a waiver of informed consent was issued by the UMass Chan Medical School IRB.

Consent for Publication:

No individual data is reported for this study.

Declaration of Conflicting Interest:

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Contributor Information

Alison C. Rataj, University of Massachusetts Chan Medical School (Department of Population and Quantitative Health Sciences), Worcester (MA), United States..

Kate L. Lapane, University of Massachusetts Chan Medical School (Department of Population and Quantitative Health Sciences), Worcester (MA), United States..

Brian R. Ott, Brown University (Alpert Medical School, Department of Neurology), Providence (RI), United States.

Jonggyu Baek, University of Massachusetts Chan Medical School (Department of Population and Quantitative Health Sciences), Worcester (MA), United States.

Shiwei Liang, University of Massachusetts Chan Medical School (Department of Population and Quantitative Health Sciences), Worcester (MA), United States.

Matthew Alcusky, University of Massachusetts Chan Medical School (Department of Population and Quantitative Health Sciences), Worcester (MA), United States.

Data Availability:

Administrative data was obtained through a data use agreement with the Centers for Medicare and Medicaid and due to confidentiality and legal agreements these data are not available to be shared. Requests for access to the survey data collected by the study team will be considered and can be made to the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS2067904-supplement-1.pdf (170.7KB, pdf)

Data Availability Statement

Administrative data was obtained through a data use agreement with the Centers for Medicare and Medicaid and due to confidentiality and legal agreements these data are not available to be shared. Requests for access to the survey data collected by the study team will be considered and can be made to the corresponding author.

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