1. AbstractResults A Comparative Analysis of Vaccine Administration in Urban and Non-urban Skilled Nursing Facilities Yuan Pu 1, Veronika Dolar 2, and Azad L. Gucwa 1 Department of Biomedical Sciences 1, Department of Economics 2 Long Island University at Post, Brookville, NY Introduction Methods References Conclusion The U.S. population is aging at an unprecedented rate, resulting in an increased demand for skilled nursing facilities and long-term care. Residents of these facilities are at an increased risk for pneumococcal disease, severe influenza-related illnesses and death. For this reason, the Centers for Medicare and Medicaid Services use pneumococcal and influenza vaccination rates as a quality measure in determining Five-Star Quality Ratings of nursing homes. Disparities have been reported amongst vaccination rates in urban and non-urban populations. Thus, the purpose of this study was to compare influenza and pneumococcal vaccination in urban and non-urban nursing homes. Independent t-tests were performed to compare the mean percent of residents who had received the vaccines. Linear mixed binary logistic regression models controlling for urban locales were performed to determine which covariates were associated with vaccination rates. Of the 15,639 nursing homes included in the study, 10,107 were in urban areas, while 5,532 were deemed non-urban. Urban nursing homes showed lower rates of influenza and pneumococcal vaccination. T-test analysis comparing the overall rating, type of ownership, and geographic location yielded statistically significant results (p < 0.001) in which the overall rating, ownership-type and certificate-type favored urban nursing homes. Stata mixed model logistic regression analysis indicated urban nursing homes with a higher overall rating had a lower percent of eligible and willing residents with an up-to-date influenza and pneumococcal vaccination. These results can be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities. Skilled nursing facilities, also called nursing homes, are for residents who require continuous monitoring and medical assistance each day. People age 65 and older are expected to comprise 20% of the total U.S. population by 2015 1. This increase will undoubtedly result in a concurrent increase in the demand for skilled nursing facilities and long-term care. Nursing homes are rated by an overall Five-star Quality Rating System determined by the Centers for Medicare and Medicaid. This system is based on health inspections, quality measures and staffing, and provide a simplified and direct way for consumers to making informed decisions about these facilities 2. One quality measure included in these ratings is the percent of long stay residents who were appropriately administered the seasonal influenza or pneumococcal vaccines. Acute respiratory illnesses due to influenza and pneumococcal pneumonia are common in individuals residing in skilled nursing facilities. In addition, residents in these institutions are especially vulnerable to severe complications, and influenza or pneumonia-related death. Thus, the Centers for Disease Control and Prevention (CDC) have recommended vaccine administration for adults 65 years of age and older, and residents of nursing homes and other long-term care facilities, in an effort to reduce influenza and pneumonia-related morbidity and mortality 3. Differences between urban and non-urban vaccination rates have previously been reported 4. Additionally, others have cited differences in overall rating between urban and non-urban nursing homes, in which urban nursing homes were more likely to earn a rating greater or equal to 4-stars 5. Since these vaccinations are an important quality measure, the seasonal influenza and pneumococcal vaccination would be expected to influence the overall rating of nursing homes. The purpose of the study reported here is to determine if nursing homes also differ in the rate of vaccine administration in nursing homes located in urban versus non-urban areas. FIGURE 1. Map depicting U.S. Census Bureau regions. Regional divisions as determined by the U.S. Census Bureau. Northeast, Midwest, South, and West regions were used in this study. Source: U.S. Census Bureau We used Microsoft® Office, and Stata statistic analysis software for our study. A researchable database was created from two sources: 2013 CMS nursing home data and the 2010 Census Urban and Rural Classification and Urban Area Criteria for U.S. counties by state. U.S. Medicaid and Medicare nursing homes were individually categorized by geographic locale (urban, non-urban). Related independent t-tests and paired t- tests were performed. Linear mixed binary logistic regression models controlling for urban locales were performed to determine which covariates were associated with vaccination rates. Influenza vaccinationPneumococcal vaccination Coef.p valueCoef.p value Urban-2.250.00***-1.450.00*** Overall ratings1.210.00***1.560.00*** Geographic locate-0.770.00***-0.720.00*** Ownership-type1.070.00**1.120.00*** Church-related0.200.580.420.37 Certificate-type0.420.03**0.010.95 FIGURE 2. Five-star rating mean of urban (n=10,107) and non-urban (n=5,532) nursing homes (95% CI). Representation of the mean five-star ratings for the nursing homes used in this study. The overall five-star rating for urban nursing homes was 3.5, and the overall five-star rating for non-urban nursing homes was 3.4. The difference in these means were determined to be significant (p < 0.001). FIGURE 3. A greater proportion of long-term residents receive the vaccines in urban nursing homes. Urban nursing homes showed lower rates of influenza and pneumococcal vaccination (p < 0.001). TABLE 1. Mean percent of long-term residents assessed and appropriately given the seasonal influenza (IV) and pneumococcal vaccine (PV). Paired t-tests were performed for influenza and pneumococcal assessment and vaccination based on five-star ratings. Significant (p < 0.05) results were found for 1, 4 and 5-star nursing homes (Table 1). This data suggests nursing homes with these star values would treat seasonal influenza and pneumococcal as separate procedures. TABLE 2. Linear mixed binary logistic regression to determine effect of location, ownership-type and certificate-type on vaccination rate. Mixed model logistic regression showed that the overall rating, type of ownership, and geographic location yielded statistically significant results (***p < 0.001) in which the overall rating, ownership-type and certificate-type (only for influenza vaccines, **p < 0.05) favored urban nursing homes. Nursing homes located in south or west remained significant (***p<0.001) related to decreased odds of vaccination. Ownership seems play an important role in vaccination. The results for church-related nursing homes are not significant. ** p<0.05; *** p<0.001 This is the first comparative analysis to use the Nursing Home Compare database to assess vaccine administration of urban and non-urban nursing homes. Stata mixed model logistic regression analysis indicated urban nursing homes with a higher overall rating had a lower percent of eligible and willing residents with an up-to-date influenza and pneumococcal vaccination. Our results suggest that amongst all variables investigated, vaccination rates were most dependent on ownership-type in non- urban nursing homes is most dependent on ownership-type. In non-urban areas, there were more government-owned nursing homes (Figure 4). The results of this study can be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities. FIGURE 4: Ownership proportions of urban and non-urban nursing homes in this study. 1: Ortman J. M. Velkoff V. A., & Hogan H. (2014). An Aging Nation: The Older Population in the United States. Current Population Reports, 25- 1140. 2: The official site government site for Medicare (2014). “Nursing Home Compare.” 3: Centers for Disease Control and Prevention. (2014). “Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions?”. 4. Bennett, K. J., Pumkam, C., & Probst, J. C. (2011). Rural–urban differences in the location of influenza vaccine administration. Vaccine, 29(35), 5970-5977. 5: Lutfiyya M. N., Gessert C. E., & Lipsky M. S. (2013). Nursing home quality: a comparative analysis using CMS Nursing Home Compare data to examine differences between rural and nonrural facilities. Journal of the American Medical Directors Association, 14(8), 593-598.