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Reduction in Mortality Associated with Influenza and Pneumococcal Vaccination of Nursing Home Residents

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Reduction in Mortality Associated with Influenza and Pneumococcal Vaccination of Nursing Home Residents Sophia Kazakova1, Dale Bratzler2, Wato Nsa2, Amy Curtis1 Linda ... – PowerPoint PPT presentation

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Title: Reduction in Mortality Associated with Influenza and Pneumococcal Vaccination of Nursing Home Residents


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
2003511520-1525. 2Thompson et. Al. JAMA
2003289179
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 1995123518-527 2
Jackson LA, et al. N Engl J Med 20033481747-55,
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
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
2000-2001 (Cohort One) 2001-2002 (Cohort Two)
Original random sample 22,317 21,773
Nursing Homes 277 260
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 Unknown 5,130 (22.9) 3,411 (15.7)
Final Cohort Size 13,267 (59.4) 13,891 (63.8)
Number of Nursing Homes 273 259
12
Results
13
Results Vaccination Rates
2000-2001 Cohort One (N13,267) 2001-2002 Cohort One (N13,891)
Received Influenza Vaccine 61 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 29.3 28.9 29.4
White, 79.7 80.3 81.5 83.4
Age Groups,
Under 65 years 6.0 5.6 6.8 5.9
65 to 74 11.9 12.6 14.1 16.9
75 to 84 34.8 34.6 36.8 36.3
85 years or older 47.3 47.3 43.3 40.8
16
Co-Existing Conditions () Cohort 2000-2001
Both Vaccines Flu Only Pneumo Only Neither
Heart disease 29.7 30.8 33.4 30.9
COPD 16.6 16.7 16.4 20.8
Diabetes 23.2 23.7 26.0 24.2
Renal failure 4.4 5.1 5.3 6.7
Dementia 53.6 54.2 45.8 35.0
Cancer 6.7 6.3 6.9 11.7
Stroke 24.5 23.6 22.6 18.3
Mean ADL 11. 6 10.9 10.8 10.4
17
Association Between Vaccination and All-Cause
Mortality, 2000-2002
Dead Dead
Cohort One Cohort Two
Vaccination
Both Vaccines 11.7 12.4
Influenza Only 14.1 15.2
Pneumo Only 15.4 17.02
None 19.5 21.1
18
Association Between Vaccination and All-Cause
Mortality, 2000-2002
Adjusted RR (CI) Adjusted RR (CI)
Cohort One Cohort Two
Received Both Vaccines 0.55 (0.49 0.69) 0.58 (0.521 0.67) 0.58 (0.521 0.67)
Received Influenza Only 0.75 (0.62 0.86) 0.73 (0.648 0.87) 0.73 (0.648 0.87)
Received Pneumo. Only 0.81 (0.65 0.98) 0.80 (0.676 0.9) 0.80 (0.676 0.9)
Received None (Ref)
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
  • gt80 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 OHagan

24
Nursing Home Characteristics (n249)
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
25
Results Vaccination Rates
2000-2001 Cohort One (N13,267) 2001-2002 Cohort One (N13,891)
Received Influenza Vaccine 84.7 75.9
Received Pneumococcal Vaccine 53.1 54.5
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