Nursing Home Resident and Facility Characteristics Associated with Pneumococcal Vaccination, National Nursing Home Survey, 1995-1999 Barbara Bardenheier,

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Nursing Home Resident and Facility Characteristics Associated with Pneumococcal Vaccination, National Nursing Home Survey, Barbara Bardenheier, MPH, MA Abigail Shefer, MD Ronald Tiggle, PhD Jill Marsteller, PhD, MPP Robin Remsburg, PhD

BACKGROUND Nursing Home-Acquired Pneumonia is associated with substantial morbidity, healthcare expenses, and mortality rates as high as 44% among nursing home residents.* Pneumococcal vaccination coverage is low in nursing homes. Advisory Committee for Immunization Practices (ACIP) recommends the pneumococcal vaccine for persons aged > 65 years.  In 1997 recommended pneumococcal immunization status be assessed for nursing home residents. *Muder et.al, Comprehensive Therapy, 2000.

OBJECTIVES Examine change in national pneumococcal immunization coverage from 1995 to 1999 among nursing home residents. Assess ACIP recommendations for the pneumococcal vaccine among those aged > 65 years in nursing homes.  Determine if those with high-risk medical diagnoses associated with complications for pneumococcal disease have higher immunization rate.

METHODS National Nursing Home Survey (NNHS)  Two-stage cross sectional sample survey of nursing homes with > 3 beds that offer routine nursing and personal care services.  First stage is probability sample of US homes stratified by bed size and certification status (certified or not certified by Medicare/Medicaid).  Second stage is selection of 6 current residents. Interviews

METHODS Study Population  1995: 1,409 homes and 7,374 residents  1997: 1,488 homes and 7,399 residents  1999: 1,423 homes and 7,383 residents Proportion of residents with missing information each year is < 6%.

METHODS Survey Instrument:  Facility characteristics: Ownership, affiliation with chain, certification status, facility size, MSA, region, program for pneumococcal immunizations  Resident Characteristics: Age, Race, Sex, Level of Care, ADLs, high-risk medical diagnoses, payment source, length of stay, pneumococcal and influenza vaccination status

METHODS Outcome Measure:  “Has…(the resident) EVER had a pneumococcal vaccine, that is a pneumonia vaccination?”  Status coded Yes/No/Unknown Statistical Analysis  Used SUDAAN to adjust data for complex survey design to represent the U.S. population of those > 65 living in nursing homes.  Multinomial logistic regression

RESULTS Vaccination Coverage Pneumococcal Coverage 1995 % 1997 % 1999 % Yes No Unknown Increase in pneumococcal coverage significant at p <

CHARACTERISTICS 1995 % 1997 % 1999 % Ownership Proprietary Non-Profit Government Affiliation with Chain? Yes Certification Status* Medicare & Medicaid Medicare only Medicaid only Not certified for either Proportion of Residents by Facility Characteristics, NNHS * P <.05

CHARACTERISTICS1995 % 1997 % 1999 % Facility Size Small (<60 beds) Med ( beds) Large (>120 beds) Facility Program for Pneumococcal Immunizations?* Yes Region Northeast Midwest South West Proportion of Residents by Facility Characteristics, NNHS * P <.05

CHARACTERISTICS 1995 % 1997 % 1999 % Race* White African-American Other Level of Care Residential Intermediate Skilled Received Influenza Vaccine* Yes No Unknown Proportion by Residents Characteristics, NNHS * P <.05

CHARACTERISTICS 1995 % 1997 % 1999 % High-Risk Medical Diagnosis* Yes Eating Assistance* Yes Primary Payment Source* Private Insurance Own Funds Medicare Medicaid Other Proportion by Resident Characteristics, NNHS * P <.05

FACILITY CHARACTERISTICS 1995 OR (95% CI) 1997 OR (95% CI) 1999 OR (95% CI) Ownership Proprietary vs Govt1.8 (1.2, 2.8) 2.3 (1.4, 3.6) Non-Profit vs Govt1.3 (0.8, 2.1)0.9 (0.6, 1.4)1.8 (1.2, 2.9) Affiliation with Chain? Yes vs No1.3 (1.1, 1.7)1.1 (0.9, 1.5)1.3 (1.0, 1.6) Certification Status Medicare vs Medicare & Medicaid1.0 (0.5, 2.1)0.7 (0.4, 1.5)1.0 (0.4, 2.3) Medicaid vs Medicare & Medicaid1.1 (0.8, 1.6)1.2 (0.8, 1.8)1.9 (1.3, 2.8) Neither vs Medicare & Medicaid1.1 (0.5, 2.4)1.5 (0.7, 3.4)2.7 (1.4, 5.4) Facility Program for Pneumococcal Immunizations? No vs Yes-4.2 (3.0, 5.9)5.6 (3.6, 8.7) NNHS Multivariable Results: Factors Associated with Being Unimmunized with Pneumococcal Vaccine NOTE: Adjusted for NS variables: MSA, Facility Size, Sex, Age, Eating Assistance, Primary Payment Source, and Length of Stay

FACILITY CHARACTERISTICS 1995 OR (95% CI) 1997 OR (95% CI) 1999 OR (95% CI) Region Midwest vs Northeast1.3 (0.9, 1.8)1.1 (0.8, 1.6)1.4 (1.1, 1.9) South vs Northeast1.3 (0.9, 1.8)1.1 (0.8, 1.5)1.8 (1.3, 2.5) West vs Northeast1.8 (1.2, 2.8)1.2 (0.8, 1.9)1.5 (1.0, 2.2) RESIDENT CHARACTERISTICS Race African-American vs White1.1 (0.9, 1.5)1.2 (0.9, 1.6)1.6 (1.2, 2.1) Other vs White1.1 (0.6, 2.0)0.8 (0.4, 1.5)0.8 (0.5, 1.2) Level of Care Intermediate vs Residential0.7 (0.4, 1.4)0.5 (0.3, 0.8)1.8 (1.1, 3.0) Skilled vs Residential0.8 (0.4, 1.4)0.5 (0.3, 0.8)1.5 (0.9, 2.6) NOTE: Adjusted for NS variables: MSA, Facility Size, Sex, Age, Eating Assistance, Primary Payment Source, and Length of Stay NNHS Multivariable Results: Factors Associated with Being Unimmunized with Pneumococcal Vaccine

RESIDENT CHARACTERISTICS 1995 OR (95% CI) 1997 OR (95% CI) 1999 OR (95% CI) High-Risk Medical Diagnosis? Yes vs No1.0 (0.8, 1.1) 1.2 (1.1, 1.4) Received Influenza Vaccine No vs Yes- 9.5 (7.0, 12.9)8.8 (6.9, 11.1) Unk vs Yes -1.5 (1.0, 2.2)0.9 (0.6, 1.3) Interaction Terms No Facility Program for Pneumococcal Immunizations Received Flu VaccineReferent-- No Flu Vaccine5.6 (4.3, 7.3)-- Unknown Flu Vaccine Status 23.6 (15.1, 36.9) -- NOTE: Adjusted for NS variables: MSA, Facility Size, Sex, Age, Eating Assistance, Primary Payment Source, and Length of Stay NNHS Multivariable Results: Factors Associated with Being Unimmunized with Pneumococcal Vaccine

RESULTS Analysis examining unknown immunization status vs receipt of pneumococcal vaccination  Results similar with few exceptions  Each year those with unknown flu status >20 times higher odds of unknown pneumo status  Each year those living in every region other than NE had significantly higher odds of having unknown pneumo status

DISCUSSION Although increase in coverage was significant, rates far short of national goal set for 2000 Use of multiple strategies and standing orders for immunizations have been associated with increase in coverage National Quality Forum included pneumococcal vaccination as 1 of 11 standards for assessing quality of care in nursing homes* *The National Quality Forum. National Voluntary Consensus Standards for Nursing Home Care. Available at:

LIMITATIONS Large proportion of residents with unknown pneumococcal immunization status  Inconsistency in recording immunization status in medical chart is possible problem No information about type of immunization program  2004 NNHS will have this information

IMPLICATIONS Addition of immunization to MDS as quality indicator. Future research to understand why this intervention is not being provided and to find ways to implement strategies to improve immunization coverage in nursing homes.