A new study published in JAMA finds that fewer than one in five US nursing home residents received evidenced-based treatment with monoclonal antibodies or oral antiviral drugs for COVID-19, despite being at high risk for poor outcomes. The rate had improved to one in four by late 2022.
Researchers from the University of Rochester and Harvard used the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network Nursing Home COVID-19 database to determine rates of monoclonal antibodies and oral antivirals among residents of all Medicare-certified nursing homes from May 31, 2021, to December 25, 2022.
Nursing home residents are at elevated risk for severe COVID-19 owing to a tendency toward older age, higher number of underlying illnesses, and living in a congregate-care setting with possible lower rates of compliance with public health efforts to mitigate viral spread.
41% of homes never used treatments
A total of 763,340 nursing home residents tested positive for COVID-19, and only 136,066 of them received a monoclonal antibody or oral antiviral drug among 15,092 nursing homes, for an overall treatment rate of 17.8% (95% confidence interval [CI], 17.4% to 18.3%). The moving average treatment rate peaked in November 2021 at 32.7% (95% CI, 30.5% to 34.8%), coinciding with a reduction in resident COVID-19 cases.
Treatment was less likely in for-profit nursing homes and those with higher proportions of non-White residents and Medicaid beneficiaries, with the latter two factors suggesting that structural barriers contributed to therapy underuse and disparities.
In the last 6 weeks of the study, the average treatment rate was 24.5% (95% CI, 23.2% to 25.7%). Oral antivirals replaced monoclonal antibodies as the dominant treatment in 2022, with nirmatrelvir-ritonavir (Paxlovid) making up 61.1% of all treatments in 2022, and molnupiravir constituting 18.2%. The proportion of nursing homes reporting ever using a treatment rose steadily, but by the end of 2022, 41.0% still reported no use.
After adjustment, factors associated with treatment use included more beds, higher overall quality rating, greater direct care hours per resident-day, having an affiliated geriatrician, higher staff and resident vaccination rates, and greater average resident age and acuity.
Treatment was less likely in for-profit nursing homes and those with higher proportions of non-White residents and Medicaid beneficiaries, with the latter two factors suggesting that structural barriers contributed to therapy underuse and disparities.
The researchers said that while oral antiviral use has been reported to be higher in nursing homes than the community, it still has been low and may not align with residents' higher risk levels.
Multiple barriers to antiviral use exist in nursing homes.
"Furthermore, multiple barriers to antiviral use exist in nursing homes, including treatment access, frequently changing authorizations and recommendations on the use of monoclonal antibodies (mAbs), patient and physician preferences, unfamiliarity with these medications, and treatment costs," they wrote.
