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Variation in Psychotropic and Non-Psychotropic Prescribing in Nursing Homes: A Multi-Level EMR-Based Retrospective
Darly Dash1, Ahmad Rahim1,2, Henry Yu-Hin Siu3
1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
Journal of the American Geriatrics Society
|February 19, 2026
Summary
Nursing home residents show significant variation in antipsychotic and other medication prescribing across units and homes. This prescribing variation is not explained by resident characteristics, highlighting a need for further research into unit- and home-level factors.
Area of Science:
- Geriatric Pharmacy
- Health Services Research
- Pharmacoeconomics
Background:
- Antipsychotic medications are frequently prescribed in nursing homes (NHs), often against guidelines.
- While NH-level prescribing variation is documented, unit- and organization-level differences, and variation for other drug classes, are less understood.
- This study investigates prescribing variation for multiple medication classes across NH units, homes, and organizations in Ontario, Canada.
Purpose of the Study:
- To examine and quantify prescribing variation for antipsychotics, antidepressants, statins, cardiovascular disease (CVD) medications, and trazodone.
- To assess this variation at the unit, home, and organization levels within the Canadian nursing home setting.
- To determine if resident characteristics explain observed prescribing differences.
Main Methods:
- Retrospective cohort study utilizing electronic medical record (EMR) data from April 1, 2022, to March 31, 2023.
- Inclusion of 16,896 NH residents across 179 homes and five organizations.
- Multi-level logistic regression models adjusted for resident factors, with random intercepts for units, homes, and organizations.
Main Results:
- Prescribing rates: 39% antipsychotics, 65.5% antidepressants, 33% statins, 65% CVD medications, 38% trazodone.
- Substantial prescribing variation observed across all studied medications at both home and unit levels.
- Trazodone showed the highest variation (home-level MOR: 2.06, unit-level MOR: 1.87). Organization-level variation was not significant. Resident factors did not account for unit/home differences.
Conclusions:
- Prescribing variation in NHs extends beyond antipsychotics to other common medications.
- Unit-level variation provides new insights and targets for quality improvement, not captured by previous home-level analyses.
- Further research is needed on unit- and home-level factors like staffing, culture, and clinical decision-making to explain prescribing disparities.
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