Racial inequities in receipt of influenza immunization among U.S. nursing home residents Open Access

Bardenheier, Barbara Helen (2011)

Permanent URL: https://etd.library.emory.edu/concern/etds/w0892b193?locale=en
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Abstract


Abstract
Racial inequities in receipt of influenza immunization among U.S. nursing home
residents
By Barbara Bardenheier

Two national studies reported a White-Black (W-B) difference in vaccination
coverage of 8 percentage points among nursing home residents. In Michigan during the
2005-2006 influenza season, the W-B difference in vaccination exceeded 20 percentage
points; the racial gap increased between facilities as proportions of Black residents in the
facility increased. Studies among community-dwelling seniors have shown that less frail
persons may seek the vaccine more; however, studies report inconsistent findings in the
association of frailty and vaccination among nursing home residents within facilities. Use of
standing order programs (SOPs) is an evidence-based approach to increase vaccination
coverage among residents. Further, Blacks are less likely than Whites to live in nursing
homes with SOPs. These findings lead to three questions that examine the relationship
between race and receipt of the influenza vaccine among nursing home residents.
1. Does frailty contribute to racial differences in reported receipt, refusal, or not
being offered the influenza vaccine within nursing facilities in Michigan?
2. What factors contribute to the racial gap in vaccine offering between nursing
facilities in Michigan?
3. Do racial composition of the facility, influential authorities and barriers to SOPs
jointly contribute to the racial gap in receipt of vaccine between nursing facilities?
In Michigan, frail residents of whichever race was in the minority in nursing homes had the
highest adjusted probabilities of not being offered the vaccine. Facility characteristics that
contributed to the variability in offering vaccine between homes include levels of staff
resources, proportions of Blacks in the facility, and levels of severely ill patients. Facilities
with larger proportions of Black residents were associated with perceived barriers (e.g.,
financial, legal, liability) to implementing SOPs. The states' Quality Improvement
Organization and certification surveyor may play an important role in addressing
misperceptions about staff's authority to vaccinate under SOPs and in educating physicians
about the benefits of SOPs for influenza vaccination among nursing home residents.

Table of Contents



Table of Contents

Table of Contents .................................................................................................................................. vii

List of Tables ............................................................................................................................. xi

List of Figures ..........................................................................................................................xiii

List of Abbreviations ............................................................................................................ xiv
Glossary .................................................................................................................................................... xv


INTRODUCTION ..................................................................................................................................... 1

Dissertation Aims ..................................................................................................................... 4

Chapter 1 Influenza vaccination in nursing homes ........................................................... 5


Efficacy and effectiveness of the vaccine......................................................................... 5


Duration of immunity and protection .............................................................................. 5


Vaccine delays and shortages .............................................................................................. 5

Long-term care settings ............................................................................................................. 6


Aging population ...................................................................................................................... 6


Healthcare workforce for long-term care ....................................................................... 6

Funding of nursing homes ........................................................................................................ 6


Medicare ...................................................................................................................................... 6


Medicaid ....................................................................................................................................... 8


Private Pay ................................................................................................................................10

Influenza and pneumonia in long-term care settings .............................................12


Influenza and Pneumonia among nursing home residents ...................................12


Chronic condition risk factors for influenza and pneumonia................................12

Transferring long-term care facility residents to hospitals for acute care .......13

Residents returning to the facilities .................................................................................13
Chapter 2 Vaccination requirements, recommendations and policies .................15

Vaccination requirements......................................................................................................15


State immunization laws .....................................................................................................15


State immunization laws for long-term care residents ...........................................15


State immunization laws for healthcare workers of long-term care facilities16

Vaccination recommendations ............................................................................................16


ACIP recommendations .......................................................................................................16


Healthy People 2010 immunization coverage goals .................................................16


CMS requirements for certification .................................................................................16


NQF adds immunization as quality indicator ..............................................................17


Summary of what should be done in nursing facilities ............................................17
Existing vaccination policies in nursing facilities


Standing order protocols for immunizations ..............................................................18


Written vaccination policies ..............................................................................................19


Verbal consent allowed ........................................................................................................19


Centralized tracking systems for immunizations ......................................................20


Immunization of healthcare workers .............................................................................21





Facility recommendations of immunization for its healthcare workers ..........21


Facility requires immunization of its healthcare workers .....................................22


Summary and critique of existing policies....................................................................22
Chapter 3 Racial inequities in receipt of healthcare .......................................................23

Definition and scope of racial disparities in healthcare ...........................................23
Racial inequities in access to long-term care ...............................................................23
Racial inequities in access to 'upper-tier' facilities ....................................................25

Lack of expert assistance in long-term care choices .................................................25

Evidence of extant segregation in nursing homes ......................................................26

Refusal of healthcare among minorities .........................................................................27


Summary of potential issues currently in nursing facilities ..................................27
Chapter 4 Racial inequities in receipt of vaccine ..............................................................29

National W-B difference first reported 2004 NNHS ..................................................29

National W-B difference confirmed 2005-2006 CMS ...............................................29




W-B vaccination difference varied by state and nursing facility ........................31

Standing order protocols (SOPs) associated with vaccination ...........................35


Does the national W-B gap narrow in homes with SOPs? .....................................35

Looking within a state for answers ...................................................................................35


Michigan: racial distribution among facilities ............................................................36


Michigan: vaccination coverage .......................................................................................36


Michigan: inequities in receipt of vaccine within nursing homes .......................37


Michigan: inequities in receipt of vaccine between nursing homes ...................40

Next steps: .......................................................................................................................................42


Does frailty contribute to the W-B vaccination gap within facilities ..................42


Barriers to implementing SOPs .........................................................................................42
Influential authorities making vaccination decisions in nursing homes ..........43
Relationship among barriers to SOPs, influential authorities, and racial
composition of the facility with use of SOPs and vaccination coverage ..........43


Examining factors associated with W-B gap between facilities ...........................44
Chapter 5 Methods ............................................................................................................................45
W-B vaccination gap within and between nursing homes in Michigan ........45


Study design .............................................................................................................................45


Cross-sectional ........................................................................................................................45


Study population ....................................................................................................................45


Study eligibility........................................................................................................................45


Data collection (sources) ....................................................................................................46


Facility data ..............................................................................................................................46


Description of OSCAR .......................................................................................................46


Strengths and weaknesses of OSCAR .........................................................................46


Facility characteristics examined ...........................................................................47


Administrative characteristics ..................................................................................47


Case-mix (severity of illness) ....................................................................................49


Deficiencies .......................................................................................................................49


Staffing resources ..........................................................................................................50


Funding characteristics ...............................................................................................50


Resident data............................................................................................................................50





Description of MDS ............................................................................................................51


Reliability/Validity of the MDS .....................................................................................52


Outcome Measure: Immunization status in MDS ...................................................52


Exposure Measure: Race/ethnicity in MDS ..............................................................56


Resident level independent variables ........................................................................57

Resident level independent variables 64


Socio-economic status: Covariate or confounder of race? ..........................57


Resident level confounders .....................................................................................58


County data ...............................................................................................................................58
CMS-CDC Standing Orders Project: Barriers to SOPs, influential authorities,
and racial composition of the nursing facility, 2000-2002...................................60


Study design .............................................................................................................................60


Intervention: Implement standing order programs in nursing homes .............60


Quality Improvement Organization's role in intervention .....................................60


Study Population ....................................................................................................................61


Intervention states .............................................................................................................61


Control states .......................................................................................................................61


Four sources of data collected ...........................................................................................62


Survey Instrument .................................................................................................................62


Data Collection .........................................................................................................................63

Facility Administrative Data (OSCAR) ...........................................................................63


Resident Data (MDS) ............................................................................................................63


Medical Chart abstraction ...................................................................................................64


Immunization status .............................................................................................................64
Chapter 6 Does frailty drive the racial gap in influenza vaccination within
nursing facilities in Michigan, 2005-2006?
..........................................................................66

Abstract ......................................................................................................................................66

Introduction ..............................................................................................................................68

Methods ......................................................................................................................................70

Resident characteristics .................................................................................................70

Facility characteristics ....................................................................................................73

Statistical analyses ............................................................................................................75

Results .......................................................................................................................................76

Discussion..................................................................................................................................82

Limitations ................................................................................................................................87

Conclusions ...............................................................................................................................88
Chapter 7 What factors contribute to the racial gap in vaccine offering among
nursing facilities in Michigan, 2005-2006?
....................................................................... 107

Abstract ................................................................................................................................... 107

Introduction ........................................................................................................................... 109

Methods ................................................................................................................................... 111

Resident characteristics .............................................................................................. 112

Facility characteristics ................................................................................................. 113

County characteristics .................................................................................................. 114

Analysis ................................................................................................................................... 115

Results .................................................................................................................................... 117

Discussion............................................................................................................................... 118




Limitations ............................................................................................................................. 123

Conclusions ............................................................................................................................ 123
Chapter 8 Influential authorities for vaccination policies and barriers to
implementing standing orders for influenza vaccination among nursing

facilities in 14 states, 1999-2002 ........................................................................................... 134

Abstract ................................................................................................................................... 134

Introduction ........................................................................................................................... 136

Methods ................................................................................................................................... 137

Data sources .......................................................................................................................... 138

Survey instrument and data collection .................................................................. 138

Other facility level characteristics ........................................................................... 140

Analysis ................................................................................................................................... 141

Results .................................................................................................................................... 146

Discussion............................................................................................................................... 151

Limitations ............................................................................................................................. 154

Conclusions ............................................................................................................................ 156
Chapter 9 Dissertation in context: Conclusions and public health
contributions ..................................................................................................................................... 169

Conclusions ............................................................................................................................ 169

Limitations ............................................................................................................................. 171

Contributions ........................................................................................................................ 172
Appendix 1: Multilevel model examining race and vaccination ...................................... 174
Appendix 2: Multilevel factor analysis ...................................................................................... 177
Appendix 3: Results of exploratory factor analysis .............................................................. 179
Reference List ...................................................................................................................................... 184

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