1. Reduction in Mortality Associated with Influenza and Pneumococcal Vaccination of Nursing Home Residents Sophia Kazakova 1, Dale Bratzler 2, Wato Nsa 2, Amy Curtis 1 Linda McKibben 1, Abigail Shefer 1, Lynn Steele 1, Chesley Richards 1, John Jernigan 1 Centers for Disease Control and Prevention 1 Oklahoma Foundation of Medical Quality 2

2. Background In the US 1.6 million residents live in more than 17,000 long term care facilities (LTCF) Incidence of invasive pneumococcal disease 4 times higher among LTCF residents compared to older adults in the community 1 90% of influenza related deaths in the US occur among the elderly 2 1 Kupronis et.al. J Am Geriatr Soc 2003;51:1520-1525. 2 Thompson et. Al. JAMA 2003;289:179

3. Documented Influenza and Pneumococcal Vaccination Among US Nursing Home Residents, 1995-1999 Buikema AR, Singleton JA, et al. [abstract] Centers for Disease Control and Prevention, 35th National Immunization Conference. % Vaccinated

4. Vaccine Efficacy Among Elderly General and LTCF elderly populations –Influenza 1 Reduces respiratory illness, pneumonia and death –Pneumococcal vaccine 2 Small sample size unable to examine facility-level characteristics 1 Gross PA, et al. Ann Int Med 1995;123:518-527 2 Jackson LA, et al. N Engl J Med 2003;348:1747-55, 2003

5. Study Objective To examine the impact of individual influenza and pneumococcal vaccination of Nursing Home residents on individual mortality controlling for individual and facility-level characteristics

6. The Immunization Standing Orders Project Centers for Disease Control and Prevention and Center for Medicare and Medicaid Services DC 14 States

7. Methods

8. Study Population –20 LTCF within each state Size, influenza program type, and QIO participation –100 residents randomly sampled from each facility November 2000 – January 2001 November 2001 – January 2002 Data Sources –Medical record review Influenza (October – December of the study year) Pneumococcal vaccination status (life-time history) –Minimum Data Set (MDS) Coexisting conditions, Activities of Daily Living –Medicare Claims and Enrollment Database Vital status and demographics

9. Methods (continued) Outcome –Individual Vital Status (dead/alive) 14 days or more after flu vaccination during influenza season (November – April) Predictor Variables –Individual influenza and pneumococcal vaccination Control Variables –Age, sex, race/ethnicity, diabetes, COPD, stroke, cancer, renal failure, atherosclerotic heart disease and CHF, dementia, ADL

10. Methods (continued) Multilevel multivariate statistical analysis –Two-level random intercept logistic regression modeling with logit link function –HLM 5; Hierarchical Linear Modeling; Scientific Software International, Inc. Lincolnwood, IL

11. 2000-2001 (Cohort One) 2001-2002 (Cohort Two) Original random sample22,31721,773 Nursing Homes277260 Exclusions: Coverage Survey or MDS data not available 2,904 (13%)2,907 (13%) Terminal illness, under Hospice Care, or HIV/AIDS 542 (2.4%)521 (2.4%) Vaccination Status Unknown5,130 (22.9%)3,411 (15.7%) Final Cohort Size 13,267 (59.4%) 13,891 (63.8%) Number of Nursing Homes 273259 Study Cohorts

12. Results

13. Results: Vaccination Rates 2000-2001 Cohort One (N=13,267) 2001-2002 Cohort One (N=13,891) Received Influenza Vaccine 61% Received Pneumococcal Vaccine 39%44%

14. Vaccination Status

15. Demographic Characteristics Cohort 2000-2001 Both Vaccines N = 6,130 Flu Only N = 5,160 Pneumo Only N = 1,007 Neither N = 1,063 Male, %27.7 29.328.929.4 White, % 79.7 80.3 81.583.4 Age Groups, % Under 65 years6.05.66.85.9 65 to 7411.912.614.116.9 75 to 84 34.8 34.636.836.3 85 years or older47.3 43.340.8

16. Co-Existing Conditions (%) Cohort 2000-2001 Both Vaccines Flu Only Pneumo OnlyNeither Heart disease 29.730.833.430.9 COPD 16.6 16.716.4 20.8 Diabetes 23.2 23.726.024.2 Renal failure4.45.15.36.7 Dementia 53.6 54.245.835.0 Cancer6.76.36.911.7 Stroke 24.5 23.622.618.3 Mean ADL11. 610.910.810.4

17. % Dead Cohort OneCohort Two Vaccination Both Vaccines 11.712.4 Influenza Only 14.115.2 Pneumo Only 15.417.02 None 19.521.1 Association Between Vaccination and All- Cause Mortality, 2000-2002

18. *Control Variables: diabetes, stroke, cancer, renal failure, heart disease, dementia, ADL score, sex, age Adjusted* RR (CI) Cohort OneCohort Two Received Both Vaccines0.55 (0.49 – 0.69)0.58 (0.521 – 0.67) Received Influenza Only0.75 (0.62 – 0.86)0.73 (0.648 – 0.87) Received Pneumo. Only0.81 (0.65 – 0.98)0.80 (0.676 – 0.9) Received None (Ref)

19. Facility-Level Vaccination Coverage In initial analysis, without exclusion of residents with unknown vaccination status – >80% coverage with influenza significantly and independently associated with decreased risk of mortality After exclusion, this association became insignificant

20. Summary The first prospective study of Nursing Home residents to demonstrate a significant protective effect of pneumococcal vaccination on mortality. Confirmed the important role of influenza vaccination in preventing the adverse outcome.

21. Limitations Facility selection non-randomized Vaccination status non-randomized Possibility of exclusion bias Possibility of misclassification bias in ascertaining vaccination status Possibility of unmeasured confounders

22. Health Policy Implications Unvaccinated residents are at increased risk for adverse outcomes Failure to vaccinate residents of long term care facilities is a patient safety issue Wider implementation of standing orders programs or other effective interventions to increase vaccination rates A better understanding of the barriers to vaccination in this setting is needed Poor documentation of vaccination status in NHs

23. Acknowledgments CDC –Jeremy Miller Oklahoma Foundation For Medical Quality –Jennifer O’Hagan CMS –Jackie Harley –Kathy Pirotte –Peter Houck

24. Category Skilled Nursing Facility/ Nursing Facility (dual certification) 52% Skilled Nursing Facility/ Nursing Facility (distinct part certified) 39% Skilled nursing facility 4% Nursing 4% Size small 26% medium 41% large 33% Ownership Government 12% For profit 53% Non-profit 34% Nursing Home Characteristics (n=249)

25. Results: Vaccination Rates 2000-2001 Cohort One (N=13,267) 2001-2002 Cohort One (N=13,891) Received Influenza Vaccine 84.7%75.9% Received Pneumococcal Vaccine 53.1%54.5%