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Background

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

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Background

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Presentation Transcript

  1. Reduction in Mortality Associated with Influenza and Pneumococcal Vaccination of Nursing Home Residents Sophia Kazakova1, Dale Bratzler2, Wato Nsa2, Amy Curtis1 Linda McKibben1, Abigail Shefer1, Lynn Steele1, Chesley Richards1, John Jernigan1 Centers for Disease Control and Prevention1 Oklahoma Foundation of Medical Quality2

  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 community1 • 90% of influenza related deaths in the US occur among the elderly2 1Kupronis et.al. J Am Geriatr Soc 2003;51:1520-1525. 2Thompson et. Al. JAMA 2003;289:179

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

  4. Vaccine Efficacy Among Elderly • General and LTCF elderly populations • Influenza1 • Reduces respiratory illness, pneumonia and death • Pneumococcal vaccine2 • Small sample size • unable to examine facility-level characteristics 1Gross 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. DC The Immunization Standing Orders ProjectCenters for Disease Control and Prevention and Center for Medicare and Medicaid Services 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. Study Cohorts

  12. Results

  13. Results: Vaccination Rates

  14. Vaccination Status

  15. Demographic Characteristics Cohort 2000-2001

  16. Co-Existing Conditions (%) Cohort 2000-2001

  17. Association Between Vaccination and All-Cause Mortality, 2000-2002

  18. Association Between Vaccination and All-Cause Mortality, 2000-2002 *Control Variables: diabetes, stroke, cancer, renal failure, heart disease, dementia, ADL score, sex, age

  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 • CMS • Jackie Harley • Kathy Pirotte • Peter Houck • CDC • Jeremy Miller • Oklahoma Foundation For Medical Quality • Jennifer O’Hagan

  24. Nursing Home Characteristics (n=249)

  25. Results: Vaccination Rates

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