Estimating the Effect of Influenza Vaccination on Nursing Home Residents' Morbidity and Mortality

Effectiveness of annual influenza campaigns and vaccination in reducing influenza burden in nursing homes of Canton Vaud in Switzerland

BACKGROUND

Influenza infections pose significant risks for nursing home (NH) residents. Our aim was to evaluate the impact of the cantonal influenza campaign, and influenza vaccination coverage of residents and healthcare workers (HCWs) on influenza burden in NHs in a context of enhanced infection prevention and control measures (IPC) during the SARS-CoV-2 pandemic.

METHODS

We extracted data from epidemic reports provided by our unit to NHs over two consecutive winter seasons (2021-22 and 2022-23) and used linear regression to assess the impact of resident and HCW vaccination coverage, and participation in the campaign, on residents' cumulative influenza incidence and mortality.

RESULTS

Thirty-six NHs reported 155 influenza cases and 21 deaths during the two winter seasons corresponding to 6.2% of infected residents and a case fatality ratio of 13.5%. Median vaccination coverage was 83% for residents, 25.8% for HCWs, while 87% of NHs participated in the campaign. Resident vaccination was significantly associated with a decrease in odds of death (odds ratio (OR) 0.96, 95% confidence interval (CI): 0.93-0.99). There was no significant effect of HCW vaccination coverage on resident infections and deaths. Campaign participation was associated with decreased odds of infection and death among residents (OR: 0.17, 95% CI: 0.06-0.47 and OR: 0.06, 95% CI: 0.02-0.17 respectively).

CONCLUSION

Our analysis suggests that in a context of reinforced IPC measures, influenza still represents a significant burden for NH residents. The most effective measures in decreasing resident influenza burden in NHs was participation in the cantonal influenza vaccination campaign and resident vaccination.

Reducing unplanned hospital admissions from care homes: a systematic review

Background

Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost.

Objectives

Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings.

Data sources

We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked.

Methods

We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect.

Results

We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence.

Conclusions

Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation.

Limitations

Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible.

Future work

We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes.

Study registration

This study is registered as PROSPERO database CRD42021289418.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.

Mortality among Nursing Home Residents Enrolled in Hospice and Hospice Utilization Post-Hurricane Irma

Background: Nursing home (NH) residents are vulnerable to increased mortality after a natural disaster such as hurricanes but the specific vulnerability of NH residents on hospice and the impact on admission to hospice are unknown. Objectives: Exposure to Hurricane Irma (2017) was used to evaluate increased mortality among Florida NH residents by hospice status compared with the same time period in a nonhurricane year. Difference in hospice utilization rates poststorm for short- and long-stay NH residents was also examined. Setting/Subjects: Subject were all Florida NH residents of age 65 years and older utilizing fee-for-service Medicare claims data exposed to Hurricane Irma in 2017 compared with a control group of residents residing at the same NHs in 2015. Analysis: Mortality rates were calculated by hospice status, rates of hospice enrollment, and the corresponding odds ratios (ORs). Results: Hurricane exposure was associated with an increase in mortality 30 days poststorm (OR = 1.12, 95% confidence interval [CI]: 1.00-1.26) but not 90 days poststorm (OR = 1.02, 95% CI: 0.95-1.10) for residents on hospice. For the rate of hospice enrollment poststorm among residents previously not on hospice, there was an increase in odds of enrollment among long-stay residents in 30 days (OR = 1.15, 95% CI: 1.02-1.23) and 90 days (OR = 1.12, 95% CI: 1.05-1.20) but not short-stay residents within 30 (OR = 1.02, 95% CI: 0.91-1.15) and 90 days (OR = 1.07, 95% CI: 0.99-1.15). Conclusion: Mortality in NH residents on hospice care increased in the aftermath of Hurricane Irma. In addition, NH residents not on hospice were more likely to be referred to hospice in the 30 days after the storm.

Estimated Cardiorespiratory Hospitalizations Attributable to Influenza and Respiratory Syncytial Virus Among Long-term Care Facility Residents

IMPORTANCE

Older adults residing in long-term care facilities (LTCFs) are at a high risk of being infected with respiratory viruses, such as influenza and respiratory syncytial virus (RSV). Although these infections commonly have many cardiorespiratory sequelae, the national burden of influenza- and RSV-attributable cardiorespiratory events remains unknown for the multimorbid and vulnerable LTCF population.

OBJECTIVE

To estimate the incidence of cardiorespiratory hospitalizations that were attributable to influenza and RSV among LTCF residents and to quantify the economic burden of these hospitalizations on the US health care system by estimating their associated cost and length of stay.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used national Medicare Provider Analysis and Review inpatient claims and Minimum Data Set clinical assessments for 6 respiratory seasons (2011-2017). Long-stay residents of LTCFs were identified as those living in the facility for at least 100 days (index date), aged 65 years or older, and with 6 months of continuous enrollment in Medicare Part A were included. Follow-up occurred from the resident's index date until the first hospitalization, discharge from the LTCF, disenrollment from Medicare, death, or the end of the study. Residents could re-enter the sample; thus, long-stay episodes of care were identified. Data analysis was performed between January 1 and September 30, 2020.

EXPOSURES

Seasonal circulating pandemic 2009 influenza A(H1N1), human influenza A(H3N2), influenza B, and RSV.

MAIN OUTCOMES AND MEASURES

Cardiorespiratory hospitalizations (eg, asthma exacerbation, heart failure) were identified using primary diagnosis codes. Influenza- and RSV-attributable cardiorespiratory events were estimated using a negative binomial regression model adjusted for weekly circulating influenza and RSV testing data. Length of stay and costs of influenza- and RSV-attributable events were then estimated.

RESULTS

The study population comprised 2 909 106 LTCF residents with 3 138 962 long-stay episodes and 5 079 872 person-years of follow-up. Overall, 10 939 (95% CI, 9413-12 464) influenza- and RSV-attributable cardiorespiratory events occurred, with an incidence of 215 (95% CI, 185-245) events per 100 000 person-years. The cost of influenza- and RSV-attributable cardiorespiratory events was $91 055 393 (95% CI, $77 885 316-$104 225 470), and the length of stay was 56 858 (95% CI, 48 757-64 968) days.

CONCLUSIONS AND RELEVANCE

This study found that many cardiorespiratory hospitalizations among LTCF residents in the US were attributable to seasonal influenza and RSV. To minimize the burden these events place on the health care system and residents of LTCFs and to prevent virus transmission, additional preventive measures should be implemented.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability

Objectives

To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States.

Design

Retrospective cohort study from November 27, 2017 to November 27, 2019.

Setting and Participants

In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies.

Methods

We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies.

Results

A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states’ NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times.

Conclusions and Implications

As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

Geographic Variation in Pneumonia and Influenza in Long-Term Care Facilities: A National Study

There is large county-level geographic variation in pneumonia and influenza hospitalizations among short-stay and long-stay long-term care facility residents in the United States. Long-term care facilities in counties in the Southern and Midwestern regions had the highest rates of pneumonia and influenza from 2013 to 2015. Future research should identify reasons for these geographic differences.

Promoting Influenza Vaccination among Staff of Nursing Homes According to Behavioral Insights: Analyzing the Choice Architecture during a Nudge-Based Intervention

(1) Background: Influenza vaccination uptake in nursing home (NH) workers is uncommon. The aim of this study was to understand the choice architecture of influenza vaccination acceptance or refusal among them and to promote vaccination acceptance using the nudge approach. (2) Methods: In autumn 2019, a nudge intervention with a contextual qualitative analysis of choice architecture of vaccination was performed among the staff of eight Tuscan NHs. In summer 2020, a cross-sectional study including the staff of 111 NHs (8 in the nudge, 103 in the comparison group) was conducted to assess the impact of the nudge intervention in promoting vaccination uptake. (3) Results: Macro-categories of motivations for vaccination uptake that emerged from the qualitative analysis were risk perception, value dimension, and trust, while those regarding refusal were risk perception, distrust, value dimension, and reasons related to one’s health. Considering the cross-sectional study, influenza vaccination uptake in the 2018–2019 season was similar in the two groups (23.6% vs. 22.2% respectively, in the nudge and comparison group), but significantly different in the 2019–2020 season: 28% in the nudge vs. 20% in the comparison group. Also, the intention to get the vaccine in the 2020–2021 season was significantly different in the two groups: 37.9% in the nudge and 30.8% in the comparison group. (4) Conclusions: Nudge interventions-simple, fast, low cost-could be effective in promoting vaccination acceptance among NH workers and the analysis of choice architecture could be useful in improving tailored, new nudge interventions aimed at modifying irrational biased and cognitive errors.

Association Between Exposure to Hurricane Irma and Mortality and Hospitalization in Florida Nursing Home Residents

IMPORTANCE

Nursing home residents are at heightened risk for morbidity and mortality following an exposure to a disaster such as a hurricane or the COVID19 pandemic. Previous research has shown that nursing home resident mortality related to disasters is frequently underreported. There is a need to better understand the consequences of disasters on nursing home residents and to differentiate vulnerability based on patient characteristics.

OBJECTIVE

To evaluate mortality and morbidity associated with exposure to Hurricane Irma, a Category 4 storm that made landfall on September 10, 2017, in Cudjoe Key, Florida, among short-stay (<90-day residence) and long-stay (≥90-day residence) residents of nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study of Florida nursing home residents comparing residents exposed to Hurricane Irma in September 2017 to a control group of residents residing at the same nursing homes over the same time period in calendar year 2015. Data were analyzed from August 28, 2019, to July 22, 2020.

EXPOSURE

Residents who experienced Hurricane Irma were considered exposed; those who did not were considered unexposed.

MAIN OUTCOME AND MEASURES

Outcome variables included 30-day and 90-day mortality and first hospitalizations after the storm in both the short term and the long term.

RESULTS

A total of 61 564 residents who were present in 640 Florida nursing home facilities on September 7, 2017, were identified. A comparison cohort of 61 813 residents was evaluated in 2015. Both cohorts were mostly female (2015, 68%; 2017, 67%), mostly White (2015, 79%; 2017, 78%), and approximately 40% of the residents in each group were over the age of 85 years. Compared with the control group in 2015, an additional 262 more nursing home deaths were identified at 30 days and 433 more deaths at 90 days. The odds of a first hospitalization for those exposed (vs nonexposed) were 1.09 (95% CI, 1.05-1.13) within the first 30 days after the storm and 1.05 (95% CI, 1.02-1.08) at 90 days; the odds of mortality were 1.12 (95% CI, 1.05-1.18) at 30 days and 1.07 (95% CI, 1.03-1.11) at 90 days. Among long-stay residents, the odds of mortality for those exposed to Hurricane Irma were 1.18 (95% CI, 1.08-1.29) times those unexposed and the odds of hospitalization were 1.11 (95% CI, 1.04-1.18) times those unexposed in the post 30-day period.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters. These risks may be underreported by state and federal agencies. Long-stay residents, those who have resided in a nursing home for 90 days or more, may be most vulnerable to the consequences of hurricane disasters.

Five-Day vs 10-Day Postexposure Chemoprophylaxis With Oseltamivir to Prevent Hospital Transmission of Influenza: A Noninferiority Randomized Open-Label Study

Background

The efficacy and optimal duration of postexposure influenza prophylaxis with oseltamivir are undetermined in hospital settings, where immediate separation from index cases is not feasible.

Methods

In an open-label noninferiority randomized clinical trial in a single-center university hospital, the efficacy of 5-day vs 10-day postexposure prophylaxis with oseltamivir was compared in adult patients exposed to influenza who could not be immediately separated from index influenza cases. Influenza incidence was assessed for 10 days after discontinuing prophylaxis.

Results

Among 222 exposed patients (median age, 75 years; male 119; median Charlson Comorbidity Index, 5), 110 patients were assigned to 5 days of postexposure prophylaxis with oseltamivir, and 112 patients were assigned to the 10-day group. The median duration of exposure to influenza (interquartile range) was 2 (1-3) days. In the intention-to-treat analysis, the incidence of influenza was 2/110 (1.8%) in the 5-day group and 0/112 (0%) in the 10-day group (difference, 1.8 percentage points; 1-sided 95% CI, -1 to 4.9 percentage points; P = .77).

Conclusions

For patients exposed to influenza in a hospital setting and who were not immediately separated from index cases, postexposure prophylaxis with oseltamivir resulted in low incidence of nosocomial influenza transmission. Five-day postexposure prophylaxis was noninferior to 10-day regimen.

ClinicalTrialsgov Registration

NCT03899571.

Non-ventilator health care-associated pneumonia (NV-HAP): Long-term care

Nonventilator health care-associated pneumonia (NV-HAP) is costly and preventable with significant impact on patient morbidity and mortality. This chapter outlines the increased risk of NV-HAP among individuals residing in long-term care facilities and the incidence of pneumonia in this health care setting which accounts for up to 18% of all persons admitted to acute care hospital for pneumonia. A description of prevention strategies with detail on modifiable and Nonmodifiable risk factors for acquiring pneumonia are presented along with the need for a robust interdisciplinary team and approach for this vulnerable population. In addition, the lack of active surveillance and infection prevention expertise may result in the spread of pathogens that can cause NVHAP outbreaks.

Health Literacy, Vaccine Confidence and Influenza Vaccination Uptake among Nursing Home Staff: A Cross-Sectional Study Conducted in Tuscany

The aim of this cross-sectional study is to address whether health literacy (HL) and vaccine confidence are related with influenza vaccination uptake among staff of nursing homes (NHs). It was conducted in Tuscany (Italy) in autumn 2018, including the staff of 28 NHs. A questionnaire was used to collect individual data regarding influenza vaccination in 2016–2017 and 2017–2018 seasons; the intention to be vaccinated in 2018–2019; as well as demographic, educational, and health information. It included also the Italian Medical Term Recognition (IMETER) test to measure HL and eight Likert-type statements to calculate a Vaccine Confidence Index (VCI). The number of employees that fulfilled the questionnaire was 710. The percentage of influenza vaccination uptake was low: only 9.6% got vaccinated in 2016–2017 and 2017–2018 and intended to vaccinate in 2018–2019. The VCI score and the IMETER-adjusted scores were weakly correlated (Rho = 0.156). At the multinomial logistic regression analysis, the VCI was a positive predictor of vaccination uptake. In conclusion, vaccine confidence is the strongest predictor of influenza vaccination uptake among the staff of NHs. The development of an adequate vaccine literacy measurement tool could be useful to understand whether skills could be related to vaccine confidence.

Risk factors for pneumonia and influenza hospitalizations in long-term care facility residents: a retrospective cohort study

BACKGROUND

Older adults who reside in long-term care facilities (LTCFs) are at particularly high risk for infection, morbidity and mortality from pneumonia and influenza (P&I) compared to individuals of younger age and those living outside institutional settings. The risk factors for P&I hospitalizations that are specific to LTCFs remain poorly understood. Our objective was to evaluate the incidence of P&I hospitalization and associated person- and facility-level factors among post-acute (short-stay) and long-term (long-stay) care residents residing in LTCFs from 2013 to 2015.

METHODS

In this retrospective cohort study, we used Medicare administrative claims linked to Minimum Data Set and LTCF-level data to identify short-stay (< 100 days, index = admission date) and long-stay (100+ days, index = day 100) residents who were followed from the index date until the first of hospitalization, LTCF discharge, Medicare disenrollment, or death. We measured incidence rates (IRs) for P&I hospitalization per 100,000 person-days, and estimated associations with baseline demographics, geriatric syndromes, clinical characteristics, and medication use using Cox regression models.

RESULTS

We analyzed data from 1,118,054 short-stay and 593,443 long-stay residents. The crude 30-day IRs (95% CI) of hospitalizations with P&I in the principal position were 26.0 (25.4, 26.6) and 34.5 (33.6, 35.4) among short- and long-stay residents, respectively. The variables associated with P&I varied between short and long-stay residents, and common risk factors included: advanced age (85+ years), admission from an acute hospital, select cardiovascular and respiratory conditions, impaired functional status, and receipt of antibiotics or Beers criteria medications. Facility staffing and care quality measures were important risk factors among long-stay residents but not in short-stay residents.

CONCLUSIONS

Short-stay residents had lower crude 30- and 90-day incidence rates of P&I hospitalizations than long-stay LTCF residents. Differences in risk factors for P&I between short- and long-stay populations suggest the importance of considering distinct profiles of post-acute and long-term care residents in infection prevention and control strategies in LTCFs. These findings can help clinicians target interventions to subgroups of LTCF residents at highest P&I risk.

Hospital Influenza Admissions as a Harbinger for Nursing Home Influenza Cases

OBJECTIVES

To determine temporal associations of local measures of influenza morbidity and mortality by the Centers for Disease Control and Prevention (CDC) with influenza hospitalizations in nursing home residents.

DESIGN

Retrospective, longitudinal panel study.

SETTING AND PARTICIPANTS

Long-stay nursing home residents, aged 65 years or older in 823 nursing homes from 2011 to 2015.

MEASURES

CDC-reported rates of influenza and pneumonia mortality and laboratory-confirmed influenza hospitalizations. We compared the CDC measures to nursing home resident hospitalizations due to (1) all-cause, (2) a primary diagnosis of respiratory or circulatory illness, and (3) a primary diagnosis of pneumonia or influenza based on Medicare Part A Claims data.

RESULTS

Our final sample included 273,743 unique residents in 819 nursing homes in 108 cities. National laboratory-confirmed influenza-associated hospitalizations for the group aged 65 and older occurred 0 to 1 week prior to nursing home resident influenza-related hospitalizations (Spearman ρ = 0.54). CDC-reported influenza hospitalizations occurred 3 weeks prior to CDC-reported influenza deaths (ρ = 0.59). Nursing home resident influenza hospitalizations occurred 2 weeks before local CDC-reported pneumonia and influenza deaths occurred (ρ = 0.44).

CONCLUSIONS/IMPLICATIONS

Publicly reported CDC measures correlate well with nursing home hospitalizations for pneumonia and influenza. Rates of laboratory-confirmed influenza hospitalizations (as reported by the CDC) may be a useful surrogate for nursing home influenza outbreaks but should be considered along with local indicators of disease outbreaks. Early community signals could be clinically leveraged as a trigger for increased infection control measures in nursing homes.

Predicting intention to receive a seasonal influenza vaccination using Protection Motivation Theory

RATIONALE

Seasonal influenza vaccination rates are below the recommended targets, contributing to significant preventable harms. Protection Motivation Theory (PMT), a widely applied model of motivation to respond to threats, may provide some insights into strategies to increase the rate of vaccine uptake. Yet, previous research has omitted some of the proposed predictors of intention when applying this model to vaccination.

OBJECTIVE

The aim of the study is to assess the utility of the PMT in predicting intention to obtain the seasonal influenza vaccine. This study will be the first to examine the role of all six PMT constructs in predicting intention to receive the seasonal influenza vaccine.

METHOD

A cross-sectional study of 547 US residents was conducted using Amazon MTurk.

RESULTS

All constructs show significant bivariate correlations in the direction expected from the prior literature. Further examination of the theory within a linear regression model, however, found that perceived costs of vaccinating (i.e., response costs) did not uniquely account for variance in intention. All other components, perceived severity of and susceptibility to influenza, the perceived benefits of not vaccinating (i.e., maladaptive response rewards), the self-efficacy to vaccinate, and the perceived efficacy of vaccinating in preventing influenza (i.e., response efficacy) were unique predictors of intention. Overall, the PMT accounted for 62% of the variance in intention to vaccinate.

CONCLUSIONS

The study is the first to investigate influenza vaccination using all six theorised predictors of intention from the PMT. The findings highlight the importance of the simultaneous inclusion of all components of the model in assessing their potential utility as targets for intervention. Importantly, the results identify under-utilised constructs in the promotion of vaccine uptake, such as maladaptive response rewards, which should be considered targets for future intervention.

Long-term Care Facility Variation in the Incidence of Pneumonia and Influenza

Background

Pneumonia and influenza (P&I) increase morbidity and mortality among older adults, especially those residing in long-term care facilities (LTCFs). Facility-level characteristics may affect the risk of P&I beyond resident-level risk factors. However, the relationship between facility characteristics and P&I is poorly understood. To address this, we identified potentially modifiable facility-level characteristics that influence the incidence of P&I across LTCFs.

Methods

We conducted a retrospective cohort study using 2013-2015 Medicare claims linked to Minimum Data Set and LTCF-level data. Short-stay (<100 days) and long-stay (100+ days) LTCF residents were followed for the first occurrence of hospitalization, LTCF discharge, Medicare disenrollment, or death. We calculated LTCF risk-standardized incidence rates (RSIRs) per 100 person-years for P&I hospitalizations by adjusting for over 30 resident-level demographic and clinical covariates using hierarchical logistic regression.

Results

We included 1 767 241 short-stay (13 683 LTCFs) and 922 863 long-stay residents (14 495 LTCFs). LTCFs with lower RSIRs had more licensed independent practitioners (nurse practitioners or physician assistants) among short-stay (44.9% vs 41.6%, P < .001) and long-stay residents (47.4% vs 37.9%, P < .001), higher registered nurse hours/resident/day among short-stay and long-stay residents (mean [SD], 0.5 [0.7] vs 0.4 [0.4], P < .001), and fewer residents for whom antipsychotics were prescribed among short-stay (21.4% [11.6%] vs 23.6% [13.2%], P < .001) and long-stay residents (22.2% [14.3%] vs 25.5% [15.0%], P < .001).

Conclusions

LTCF characteristics may play an important role in preventing P&I hospitalizations. Hiring more registered nurses and licensed independent practitioners, increasing staffing hours, and higher-quality care practices may be modifiable means of reducing P&I in LTCFs.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study

Background

Influenza and pneumococcal vaccines have been proved to be effective and safe in preventing and controlling infection among elderly, reducing morbidity and mortality. However, some evidences raised health concerns related to these vaccinations. This study aims to identify prevalence and outcomes related to influenza and pneumococcal vaccinations in a large European population of frail old people living in nursing homes (NHs).

Methods

We conducted a survival analysis of NH residents participating to the Services and Health for Elderly in Long-TERm project, a prospective cohort study collecting information on residents admitted to 57 NH in eight countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands and Israel). Clinical and demographical data were collected using the international resident assessement instrument for long-term care facilities. Incident mortality was recorded during 1-year follow-up. A shared-frailty Cox regression model was used to assess the impact of vaccination status on mortality.

Results

Mean age of 3510 participants was 84.6 years (SD = 7.7). In total, 81.7 and 27.0% received influenza and pneumococcal vaccination, respectively. Overall, 727 (20.7%) residents died during the follow-up period. After adjusting for potential confounders, which included age, sex, number of diseases, depression, cognitive and functional status, influenza (HR = 0.80; 95% CI 0.66-0.97) and the combination of influenza and pneumococcal vaccination (HR = 0.72; 95% CI 0.57-0.91), but not pneumococcal vaccination alone (HR = 0.52; 95% CI 0.25-1.06), were associated with a statistically significant reduction in mortality in respect of no vaccinations.

Conclusion

In a population of older adult living in NH influenza and the combination of influenza and pneumococcal vaccination were associated with a reduction in all-cause mortality respect to no vaccination.

Influenza vaccination rates before and after admission to nursing homes in Germany

BACKGROUND

Influenza vaccination is highly recommended for nursing home residents. However, it is known that vaccination coverage is low in the general population.

AIMS

We aim to find out whether influenza vaccination coverage differs for nursing home residents between the year before and after admission and factors determining the chance to receive vaccination.

METHODS

Claims data of the health insurance fund DAK of at least 65-year-olds were used. The proportion of residents with influenza vaccination were compared in the year before and after the admission stratified by several covariates. A multivariate logistic regression analysis was conducted to obtain predictors for influenza vaccination after admission.

RESULTS

Vaccination coverage was overall higher in the year after admission (53.0%) than before (38.3%). Differences in vaccination coverage between most covariates evened out after admission. Differences remained for region of residence and number of comorbidities. The strongest predictor for receiving a vaccination after admission was the vaccination status before admission (OR 3.5; 95% CI 3.3-3.6) followed by region and number of comorbidities.

DISCUSSION

Overall, vaccination coverage of nursing home residents remains lower than recommended. Doctor-patient contacts whether due to care for comorbidities or as a continuation of the relation over the time of admission to the nursing home seem to assure vaccination for residents.

CONCLUSION

Clear and unambiguous evidence of vaccine safety and efficacy for different subgroups within the same age group as well as organizational efforts to increase vaccination within nursing homes would be recommended.

Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study

OBJECTIVE

The care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures.

DESIGN

Multicentre longitudinal cohort-study.

SETTING

57 nursing homes (NH) in 7EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel).

PARTICIPANTS

3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study.

MEASUREMENTS

We described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality.

RESULTS

During the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64-0.97) and obesity (HR 0.64; 95% C.I. 0.48-0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54-0.83), social activities (HR 0.63; 95% C.I. 0.51-0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55-0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63-0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03-1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27-2.42) were associated with higher mortality.

CONCLUSIONS

Health determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life.

Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management

New information on infectious diseases in older adults has become available in the past 20 years. In this review, in-depth discussions on the general problem of geriatric infectious diseases (epidemiology, pathogenesis, age-related host defenses, clinical manifestations, diagnostic approach); diagnosis and management of bacterial pneumonia, urinary tract infection, and Clostridium difficile infection; and the unique challenges of diagnosing and managing infections in a long-term care setting are presented.

A comparative analysis of vaccine administration in urban and non-urban skilled nursing facilities

Background

The U.S. population is aging at an unprecedented rate, resulting in an increased demand for skilled nursing facilities (SNFs) and long-term care. Residents of these facilities are at a high risk for pneumococcal disease or severe influenza-related illnesses and death. For these reasons, the Centers for Medicare and Medicaid Services use influenza and pneumococcal vaccination rates as a quality measure in the assessment of SNFs, as complications related to these infections increase morbidity and mortality rates.

Methods

Disparities have been reported amongst vaccination with increased rates in urban areas as compared to their non-urban counterparts. Statistical analyses were performed to compare influenza and pneumococcal vaccination in urban and non-urban SNFs to determine variables that may influence vaccination status.

Results

Of the 15,639 nursing homes included in the study, 10,107 were in urban areas, while 5532 were considered non-urban. We found the percent of eligible and willing residents with up-to-date influenza and pneumococcal vaccinations increased with overall five-star ratings of SNFs. Somewhat paradoxically, although urban SNFs had higher mean overall five-star ratings, they showed lower rates of influenza and pneumococcal vaccination compared to non-urban SNFs. Ordinary least squares regression analysis comparing overall ratings, type of ownership, and geographic location by region yielded statistically significant results in which the overall rating, ownership-type and certificate-type favored urban SNFs (p < 0.001).

Conclusions

This is the first systematic and comparative analysis to use the Nursing Home Compare database to assess vaccine administration of urban and non-urban SNFs. The findings of this study may be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0320-4) contains supplementary material, which is available to authorized users.

A cluster randomized controlled trial comparing relative effectiveness of two licensed influenza vaccines in US nursing homes: Design and rationale

BACKGROUND

Influenza, the most important viral infection affecting older adults, produces a substantial burden in health care costs, morbidity, and mortality. Influenza vaccination remains the mainstay in prevention and is associated with reduced rates of hospitalization, stroke, heart attack, and death in non-institutional older adult populations. Influenza vaccination produces considerably lower antibody response in the elderly compared to young adults. Four-fold higher vaccine antigen (high-dose) than in the standard adult vaccine (standard-dose) elicits higher serum antibody levels and antibody response in ambulatory elderly.

PURPOSE

To describe the design considerations of a large clinical trial of high-dose compared to standard-dose influenza vaccine in nursing homes and baseline characteristics of participating nursing homes and long-stay (more than 90 days) residents over 65 years of age.

METHODS

The high-dose influenza vaccine intervention trial is multifacility, cluster randomized controlled trial with a 2×2 factorial design that compares hospitalization rates, mortality, and functional decline among long-stay nursing home residents in facilities randomized to receive high-dose versus standard-dose influenza vaccine and also randomized with or without free staff vaccines provided by study organizers. Enrollment focused on nursing homes with a large long-stay resident population over 65 years of age. The primary outcome is the resident-level incidence of hospitalization with a primary diagnosis of pulmonary and influenza-like illness, based upon Medicare inpatient hospitalization claims. Secondary outcomes are all-cause mortality based upon the vital status indicator in the Medicare Vital Status file, all-cause hospitalization directly from the nursing home Minimum Data Set discharge records, and the probability of declining at least 4 points on the 28-point Activities of Daily Living Scale.

RESULTS

Between February and September 2013, the high-dose influenza vaccine trial recruited and randomized 823 nursing homes. The analysis sample includes 53,035 long-stay nursing home residents over 65 years of age, representing 57.7% of the participating facilities' population. Residents are mainly women (72.2%), white (75.5%), with a mean age of 83 years. Common conditions include hypertension (79.2%), depression (55.1%), and diabetes mellitus (34.4%). The prevalence of circulatory and pulmonary disorders includes heart failure (20.5%), stroke (20.1%), and asthma/chronic obstructive pulmonary disease (20.2%).

CONCLUSIONS

This high-dose influenza vaccine trial uniquely offers a paradigm for future studies of clinical and programmatic interventions within the framework of efforts designed to test the impact of changes in usual treatment practices adopted by health care systems.

TRIAL REGISTRATION

NCT01815268.