nchs july 11, 2006. influenza immunization in nursing homes: who does not get immunized and whose...
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NCHS July 11, 2006
NCHS July 11, 2006
Influenza Immunization in Nursing Homes: Who Does Not Get Immunized and Whose Status is Unknown
Jill A. Marsteller, PhD, MPP, Ronald Tiggle, PhD, Robin Remsburg, PhD, Abigail Shefer, MD and Barbara Bardenheier, MPH, MA
National Center for Health Statistics and the National Immunization Program
of the Centers for Disease Control and Prevention
NCHS July 11, 2006
Context
Some 32,400 influenza-related deaths among those >65 annually between 1990 and 1999
Particular risk for exposure in nursing homes
But… Fifteen percent of nursing home residents
were unimmunized for influenza in 1999 Nineteen percent had unknown
immunization status
NCHS July 11, 2006
Objectives
To analyze, in a nationally representative sample (the NNHS)
… both the resident AND facility characteristics associated with
… not receiving influenza immunization
… AND with unknown influenza immunization status
NCHS July 11, 2006
Methods
Influenza immunization among nursing home residents >65 from the 1999 National Nursing Home Survey
7,194 residents living in 1,423 facilities Multinomial logistic regression
Three-level outcome ‘Received immunization’ is referent group Used SAS and SUDAAN
NCHS July 11, 2006
Dependent Variable
“During the past 12 months, has [the resident] had an influenza vaccination at this facility or any other location?” The measure has three response categories: “yes,” “no,” or “unknown.”
Facility staff check all relevant records when responding
A survey response of unknown is marked if there is no evidence in any records of the
resident’s immunization status if the record states that status is unknown
NCHS July 11, 2006
Independent Variables Resident
characteristics pneumococcal
immunization age length of nursing
home stay primary payment
source level of care high-risk diagnosis
Facility characteristics number of beds Medicare/Medicaid certification ownership membership in a chain metropolitan statistical area geographic region assesses immunization status
upon admission organized immunization program records immunization status in
the medical record requires staff to be immunized
NCHS July 11, 2006
Significant Variables for No Immunization v. Yes Characteristics Referent ORs (95% CI)
Age >85 65-74 1.37 (1.09-1.73)*
75-84 1.16 (0.98-1.37)
Level of Care Skilled Residential 2.33 (1.54-3.53)*
Intermediate 1.07 (0.87-1.32)
Length of Stay >6 months <6 months 3.59 (3.01-4.30)*
Pneumococcal Immunization Yes No 8.24 (6.50-10.44)*
Unknown 3.16 (2.46-4.07)*
Certification Both Medicare & Medicaid
Medicare-only 0.79 (0.39-1.62)
Medicaid-only 0.53 (0.36-0.77)*
Non-certified 0.56 (0.28-1.11)
Screens for immunization at admission Yes No 1.40 (1.10-1.78)*
Organized vaccination program Yes No 0.45 (0.22-0.92)*
Records immunization status in medical record Yes No 1.90 (1.01-3.58)*
Controlling for: chain, MSA/non-MSA, ownership, region, staff vaccinations, bedsize, primary payment source, race, high risk diagnosis, and eating assistance
NCHS July 11, 2006
Significant Variables for UK Immunization v. YesCharacteristics Referent ORs (95% CI)
Length of Stay >6 months <6 months 4.38 (3.63-5.28)*
Eating Assistance Yes No 1.25 (1.06-1.48)*
Pneumococcal Immunization Yes No 0.83 (0.53-1.31)
Unknown 18.87 (14.43-24.69)*
Primary Payment Source Medicaid Medicare 1.55 (1.18-2.03)*
Private Insur. 1.54 (1.11-2.13)*
Own funds 1.11 (0.87-1.42)
All other 1.41 (0.82-2.44)
Certification Both Medicare & Medicaid
Medicare-only 0.68 (0.33-1.42)
Medicaid-only 0.58 (0.37-0.92)*
Non-certified 0.24 (0.09-0.66)*
Screens for immunization at admission Yes No 1.41 (1.03-1.93)*
Records immunization status in medical record Yes No 2.17 (1.05-4.47)*
Controlling for: age, level of care, chain, region, ownership, MSA/non-MSA, staff vaccinations, organized immunization program, bedsize, race, and high-risk diagnosis
NCHS July 11, 2006
Unknowns are Different Two binary logistic regressions test whether
unknowns are distinguishable from other categories Yes v. Unknown,Wald F=36.97, p<0.0001
Unknowns more likely: length of stay <6 months, unknown pneumonia vaccination, no eating assistance
Live in facilities with dual Medicare and Medicaid certification, no screening, no recording
No v. Unknown, Wald F=15.78, p<0.0001 Unknowns less likely residential care, immunized for
pneumonia, in facilities with >100 beds Unknowns more likely unknown pneumonia
vaccination, Medicare as payment source
(Long, 1997).
NCHS July 11, 2006
Discussion
Both resident and facility characteristics are associated with not being immunized and unknown immunization status
Important covariates are pneumococcal immunization status, length of stay, facility certification, screening and recording
Notably unimportant are staff vaccination policies and high-risk status of residents
Residents with unknown vaccination are statistically different from the immunized and the unimmunized
NCHS July 11, 2006
Conclusions
About 34 percent of residents did not receive immunizations in the last 12 months or had an unknown status
Results suggest Targeted education for residents, staff Facility screening for and recording immunization
Residents with unknown immunization are Too different from both those who do and do not
receive vaccinations to justify lumping categories Should be analyzed separately Current policy of not immunizing unknowns may
be appropriate
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