Influenza Immunization in Nursing Homes: Who Does Not Get Immunized and Whose Status Is Unknown?

Decomposing Racial and Ethnic Disparities in Nursing Home Influenza Vaccination

OBJECTIVES

Quantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents.

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Short- and long-stay U.S. NH residents aged ≥65 years.

METHODS

We linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents.

RESULTS

Our study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity.

CONCLUSIONS AND IMPLICATIONS

The racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination.

Racial/Ethnic Differences in Receipt of Influenza and Pneumococcal Vaccination among Long-Stay Nursing Home Residents

OBJECTIVE/STUDY QUESTION

To examine racial/ethnic differences in influenza and pneumococcal vaccination receipt and nonreceipt among nursing home (NH) residents post implementation of federal vaccination policy. DATA SOURCES/STUDY SETTING/STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: An analysis of a merged national cross-sectional dataset containing resident assessment, facility, and community data for years 2010-2013 was conducted. Logistic regressions omitting and including facility fixed effects were used to examine the influence of race and ethnicity (black, Hispanic, white) and black concentration on vaccination status across and within NHs.

PRINCIPLE FINDINGS

Vaccination receipt of 107,874 residents in 742 NHs was examined. Blacks were less likely than whites to receive influenza and pneumococcal vaccinations (OR = 0.75; OR = 0.81, respectively, p-values <.001). The likelihood of not being offered the influenza vaccination was greater for blacks (OR=1.25, p = .004) and the likelihood of not being offered the pneumococcal vaccination was greater for Hispanics (OR = 1.65, p = .04) compared to whites. Fixed effects showed that within the same NH, Hispanics were more likely to receive both vaccinations compared to whites (OR=1.22, p = .004 (influenza); OR=1.34, p < .001 (pneumococcal)). Facilities highly concentrated with blacks accounted for large proportions of differences seen in vaccination receipt.

CONCLUSIONS

Racial/ethnic differences remain despite policy changes. Focused strategies aimed at NH personnel and racially segregated NHs are critical to improving vaccination delivery and eliminating disparities in care.

Racial/Ethnic Disparities in Influenza and Pneumococcal Vaccinations Among Nursing Home Residents: A Systematic Review

This systematic review analyzes research examining racial/ethnic disparities in influenza and pneumococcal vaccination coverage between White and racial/ethnic minority (Black and Hispanic) nursing home residents. A review of the literature for years 1966-2014 using Medline, Web of Science, and PubMed was conducted. The Epidemiological Appraisal Instrument was used to appraise the quality of the 13 included studies. Overall, articles were strong in reporting and data analysis, but weak in sample selection and measurement quality. Disparities between vaccination coverage among racial/ethnic minorities versus Whites ranged from 2% to 20% for influenza and 6% to 15% for pneumococcal vaccination. Researchers reported racial/ethnic minorities were more likely to refuse vaccinations and less likely to have vaccinations offered and their vaccination status tracked compared to Whites. Policies/strategies that focus on ensuring racial/ethnic minorities are offered influenza and pneumococcal vaccinations and their vaccination status are tracked in nursing homes are warranted. Updated evaluation on vaccination disparities is also needed.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Factors associated with resident influenza vaccination in a national sample of nursing homes

Influenza vaccination remains the cornerstone of influenza prevention, yet national goals for nursing home residents and staff vaccination have not been met. Few studies have examined associations between facility and resident characteristics; employee processes, such as staff vaccination policies; and resident influenza vaccination. In this national survey of nursing homes, employee processes were not associated with resident influenza vaccination; however, various facility and resident characteristics were.

Herpes Zoster Vaccine in the Long-Term Care Setting: A Clinical and Logistical Conundrum

Advancing age is associated with an increased risk of herpes zoster (shingles) infection and latent effects such as postherpetic neuralgia. The herpes zoster vaccine is recommended in those 60 years of age and older and has been shown to prevent both the primary disease and associated complications. While this recommendation applies to those living in long-term care facilities, there is little clinical evidence to support use in this population. Additionally, there are logistical barriers that may complicate the use of the vaccine. The article examines the evidence for vaccinating residents in long-term care facilities and discusses logistical barriers to vaccination. Pharmacists and providers may consider life expectancy and other factors when evaluating which patients should receive the vaccination.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

OBJECTIVES

To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Influenza vaccination and its impact on hospitalization events in nursing homes

OBJECTIVES

To examine trends of influenza vaccination in nursing homes before and after public reporting (objective-1), and to assess the effect of influenza vaccinations on hospitalization events (objective-2).

RESEARCH DESIGN

Nursing Home Compare (NHC) database was used to obtain influenza vaccination rates during the 2005-2006, 2006-2007, and 2007-2008 flu seasons (objective-1). The 2005-2007 Minimum Data Set for New York State (NYS) was obtained and linked with the NHC data (objective-2).

SETTINGS AND PARTICIPANTS

All nursing homes in the United States were included in the analysis of objective-1. All eligible NYS nursing homes and their residents, during 2005-2006 and 2006-2007 flu seasons, were included in the analysis of objective-2.

MEASUREMENTS

Nursing home was the unit of analysis. Influenza vaccination rates in nursing homes over the 3 flu seasons were compared nationwide. A first-differenced model was fit to examine the relationship between facility vaccination rates and hospitalization rates in NYS.

RESULTS

There was an increase in influenza vaccination rates in nursing homes over the 3 flu seasons, but this increase was no greater than that among community-dwelling elderly. In NYS facilities with high baseline vaccination rates, the effect of vaccination on reducing hospitalizations was small. In NYS facilities with a low baseline rate, a 10.0% increase in vaccination rate for long-term care residents was correlated with a 6.2% decline in baseline hospitalization rates. However, a 10.0% increase in vaccination rate for short-term care residents was correlated with a 4.6% increase in baseline hospitalization rates.

CONCLUSIONS

There is no clear evidence that public reporting improves vaccination rates in nursing homes. The effects of vaccination on hospitalization events in nursing homes are mixed.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Racial disparities in receipt of influenza and pneumococcus vaccinations among US nursing-home residents

OBJECTIVES

We examined racial disparities in receipt and documentation of influenza and pneumococcus vaccinations among nursing-home residents.

METHODS

We performed secondary analyses of data from a nationally representative survey of White (n = 11 448) and Black (n = 1174) nursing-home residents in 2004. Bivariate and multivariate analyses determined racial disparities in receipt of influenza vaccination in 2003 and 2004, receipt of pneumococcus vaccination ever, and having a documented history for each vaccination.

RESULTS

The overall vaccination rate was 76.2% for influenza and 48.5% for pneumococcus infection. Compared with Whites, Blacks showed a 13% lower vaccination rate and a 5% higher undocumentation rate for influenza, and a 15% lower vaccination rate and a 7% higher undocumentation rate for pneumococcus. For influenza, the odds ratio (OR) for Blacks being unvaccinated was 1.84 (P < or = .001), and the OR for Blacks having undocumented vaccination was 1.85 (P = .001). For pneumococcus infection, the OR for Blacks being unvaccinated was 1.70 (P < or = .001), and the OR for Blacks having undocumented vaccination was 1.95 (P < or = .001). Stratified analyses confirmed persistent racial disparities among subpopulations.

CONCLUSIONS

Racial disparities exist in vaccination coverage among US nursing-home residents. Targeted interventions to improve vaccination coverage for minority nursing-home residents are warranted.

Influenza immunization coverage among residents of long-term care facilities certified by CMS, 2005-2006: the newest MDs quality indicator

BACKGROUND

In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that long-term care (LTC) facilities certified by CMS offer each resident annual influenza vaccination. Subsequently, vaccination status was added to resident assessments collected beginning in the influenza season, 2005-2006. This is the first year immunization coverage can be reported based on a census of LTC residents.

OBJECTIVES

Report influenza immunization coverage for LTC residents by state, resident, and facility characteristics. Identify uses of the data and areas in need of improvement.

METHODS

Analysis of CMS' Minimum Data Set of 1,851,676 residents in nursing homes from October 1 through December 31 but who could have been discharged between January 1 and March 31 merged with data for 14,493 non-hospital-based facilities from the Online Survey and Certification Assessment Reporting System.

RESULTS

Overall, 83% of residents were offered the vaccine and 72% had received the vaccine. Almost 10% refused to receive the vaccine, 14% were not offered the vaccine, 1% were ineligible, and 3% were missing vaccination status. Vaccination coverage varied significantly among states (range: 49% to 87%). Fewer African Americans and Hispanics than whites were offered the vaccine (79% and 79% versus 84%, respectively) and received it (65% and 66% versus 73%, respectively); more African Americans refused the vaccine (12%) than residents of other races and/or ethnicities. Residents of Medicaid-certified-only facilities had higher levels of vaccination than residents of other facilities (82% versus < or =73%).

CONCLUSION

MDS immunization data can be used as surveillance to work with states to improve coverage. Further research to examine racial disparities in vaccination among LTC residents is needed.

Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study

BACKGROUND

Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease.

STUDY DESIGN

A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15.

SETTING & PARTICIPANTS

Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients.

PREDICTOR OR FACTOR

Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders.

OUTCOMES

Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine.

MEASUREMENTS

Patient vaccination, given at or outside the center.

RESULTS

Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively).

LIMITATIONS

Data are cross-sectional, and vaccinations outside the center were self-reported.

CONCLUSIONS

Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.