Report Examines Extent of Disruption of Health Services for Patients With PD, Dementia in Ontario

In Canada, patients with Parkinson disease (PD), dementia and other neurological ailments sought health care services far less often during the COVID-19 pandemic, resulting in excess deaths during the first wave in 2020, according to a study published Friday.

Writing in JAMA Health Forum, the researchers said they wanted to take a broad look at the level and scope of the disruption for both in-person and virtual care for those with PD and dementia still living at home, and compare the findings to before the pandemic.

As in the United States, when the pandemic began spreading in March 2020, hospitals began discharging patients when they could to make room for infected patients, elective surgeries were canceled and outpatient physician services were curtailed, and nursing homes were catapulted into disarray as the virus spread within group living settings.

The researchers said they wanted to examine how different health care services intersect for these vulnerable populations, with an eye towards providing information to guide policy makers for the next pandemic.

The population-based repeated cross-sectional analysis looked at information from numerous databases for residents of Ontario, Canada from March 1 through the week of September 20, 2020, and compared it with the previous year (March 3 through the week of September 22, 2019). The main outcomes were weekly rates of emergency department visits, hospitalizations, nursing home admissions, home care, virtual and in-person physician visits, and all-cause mortality.

Information sources included the registry of all Ontarians eligible for provincial health insurance; hospital records; insurance claims; a home care database; a registry of all individuals residing in nursing homes in Ontario; and information from Ontario’s drug dispensation claims. All data sets were linked using unique encoded identifiers and analyzed at a nonprofit research institute.

Rates of health service use and mortality per 100 persons were calculated for each week of the pandemic period and compared with the earlier period. Poisson regression models calculated weekly rate ratios (RRs) with 95% confidence intervals (CIs) comparing pandemic weeks with historical levels.

By age, those persons with dementia (131,466) were the oldest (mean [SD] age, 80.1 [10.1] years), followed by those with PD (30,606; 73.7 [10.2] years).

Older adults without neurological disorders (2,363,742) were the youngest (74.0 [7.1] years).

All health services saw large declines at the start of the pandemic, with the biggest reductions happening in nursing home admissions as well as in emergency department (ED) visits.

For nursing homes, results were:

• Dementia RR, 0.10; 95% CI, 0.07-0.15
• PD RR, 0.03; 95% CI, 0.00-0.21
• Older adults RR, 0.11; 95% CI, 0.06-0.18

For ED visits, results were:

• Dementia RR, 0.45; 95% CI, 0.41-0.48
• PD RR, 0.40; 95% CI, 0.34-0.48
• Older adults RR, 0.45; 95% CI, 0.44-0.47).

Home care visits saw the smallest decline for services.

At the lowest point of the pandemic in 2020, visits to specialists, such as neurologists and geriatricians, plummeted. After the first wave, most health care services returned to historical levels, but physician visits shifted towards virtual care. At the end of the study, physician visits remained high, particularly family physician visits for those with dementia (RR, 1.10; 95% CI, 1.08-1.12) and PD (RR, 1.08; 95% CI, 1.04-1.13).

The authors said the quick shift to virtual care “has been championed as a success of pandemic planning in Ontario” but they cautioned that more work is needed to ensure that patients with dementia and PD are getting the care that they need.

All-cause mortality was elevated across all groups (+1092 dementia; +150 PD; +1481 older adults), with the largest relative effect happening in persons with dementia and PD. However, these effects had overlapping confidence intervals, the researchers said, and more research is needed to differentiate COVID-19-related deaths from deaths from other causes. They said it is possible that "individuals with dementia may have also had a higher mortality risk during the pandemic associated with decreased access to community support and hospital care."

Understanding who sought care and why will help judge the quality of care as well as the outcomes of service reductions in support programs, the authors said.

Reference

Bronskill SE, Maclagan LC, Maxwell CJ, et al. Trends in health service use for Canadian adults with dementia and parkinson disease during the first wave of the COVID-19 pandemic. JAMA Health Forum. 2022;3(1):e214599. doi:10.1001/jamahealthforum.2021.4599