Influenza vaccine supply, 2005–2006: did we come up short?

<p>Abstract</p> <p>Background</p> <p>Although total influenza vaccine doses available in the 2005/2006 influenza season were over 80 million, CDC received many reports of delayed and diminished vaccine shipments in October to November of 2005. To better understand the supply problems, CDC and partners surveyed several health care professional groups.</p> <p>Methods</p> <p>Surveys were sent to representative samples of influenza vaccine providers including pediatricians, internists, federally qualified health centers, visiting nurse organizations, and all 64 state and other health departments receiving federal immunization funds directly. In November and December, 2005, providers were asked questions about their experience in ordering influenza vaccine, sources where orders were placed, proportion of orders received, and referral of patients to other vaccination sites.</p> <p>Results</p> <p>The number of providers surveyed (median: 154; range: 64 – 308) and response rates (median: 62%; range: 51% – 77%) varied among groups. Less than half of the providers in most groups placed a single order that was accepted (median: 31%; range: 8% – 53%), and most placed multiple orders. Only 57% of federally qualified health centers and 60% of internists reported they received at least 40% of their orders by the middle of December; the other provider groups received a greater proportion of their orders. Most internists (80%) and federally qualified health centers (54%) reported that they had referred priority group patients to other locations to receive the influenza vaccine due to inadequate supplies. Vaccine providers who ordered only from Chiron received a lower proportion of their orders than providers that ordered from another source or ordered from multiple sources.</p> <p>Conclusion</p> <p>Most of the providers surveyed received only part of their orders by the middle of December. Disruptions in receipt of influenza vaccine during the fall of 2005 were due primarily to shortfalls in vaccine from Chiron and also due to delays and partial shipments from other distributors.</p

Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

BACKGROUND: More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. METHODS: We analyzed 2014–2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination. RESULTS: There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (−3.10 pp, 95% CL: −3.53 pp, −2.68 pp), or high (−4.63 pp, 95% CL: −5.11 pp, −4.15 pp) MA compared with NHs with the lowest prevalence of MA. CONCLUSION: A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings

Geographic Variation in Influenza Vaccination Disparities Between Hispanic and Non-Hispanic White US Nursing Home Residents

BACKGROUND: Disparities in influenza vaccination exist between Hispanic and non-Hispanic White US nursing home (NH) residents, but the geographic areas with the largest disparities remain unknown. We examined how these racial/ethnic disparities differ across states and hospital referral regions (HRRs). METHODS: This retrospective cohort study included >14 million short-stay and long-stay US NH resident-seasons over 7 influenza seasons from October 1, 2011, to March 31, 2018, where residents could contribute to 1 or more seasons. Residents were aged ≥65 years and enrolled in Medicare fee-for-service. We used the Medicare Beneficiary Summary File to ascertain race/ethnicity and Minimum Data Set assessments for influenza vaccination. We calculated age- and sex-standardized percentage point (pp) differences in the proportions vaccinated between non-Hispanic White and Hispanic (any race) resident-seasons. Positive pp differences were considered disparities, where the proportion of non-Hispanic White residents vaccinated was greater than the proportion of Hispanic residents vaccinated. States and HRRs with ≥100 resident-seasons per age–sex stratum per racial/ethnic group were included in analyses. RESULTS: Among 7 442 241 short-stay resident-seasons (94.1% non-Hispanic White, 5.9% Hispanic), the median standardized disparities in influenza vaccination were 4.3 pp (minimum, maximum: 0.3, 19.2; n = 22 states) and 2.8 pp (minimum, maximum: −3.6, 10.3; n = 49 HRRs). Among 6 758 616 long-stay resident-seasons (93.7% non-Hispanic White, 6.5% Hispanic), the median standardized differences were −0.1 pp (minimum, maximum: −4.1, 11.4; n = 18 states) and −1.8 pp (minimum, maximum: −6.5, 7.6; n = 34 HRRs). CONCLUSIONS: Wide geographic variation in influenza vaccination disparities existed across US states and HRRs. Localized interventions targeted toward areas with high disparities may be a more effective strategy to promote health equity than one-size-fits-all national interventions

Persistence of Racial Inequities in Receipt of Influenza Vaccination among Nursing Home Residents in the United States

BACKGROUND: We sought to determine if the racial differences in influenza vaccination among nursing home (NH) residents during the 2008-09 influenza season persisted in 2018-19. METHODS: We conducted a cross-sectional study of NHs certified by the U.S. Centers for Medicare & Medicaid Services during the 2018-19 influenza season in U.S. states with ≥ 1% black NH residents and a white-black gap in influenza vaccination of NH residents (N=2,233,392) of at least one percentage point (N=40 states). NH Residents during October 1, 2018 through March 31, 2019 aged ≥ 18 years and self-identified as black or white race were included. Residents' influenza vaccination status (vaccinated, refused, and not offered) was assessed. Multilevel modeling was used to estimate facility-level vaccination status and inequities by state. RESULTS: The white-black gap in influenza vaccination was 9.9 percentage points. In adjusted analyses, racial inequities in vaccination were more prominent at the facility- than at the state-level. Black residents disproportionately lived in NHs with majority blacks, which generally had the lowest vaccination. Inequities were most concentrated in the Midwestern region, also the most segregated. Not being offered the vaccine was negligible by difference in absolute percentage points among whites (2.6%) and blacks (4.8%) whereas refusals were higher among black (28.7%) than white residents (21.0%). CONCLUSIONS: The increase in the white-black vaccination gap among NH residents is occurring at the facility-level, in more states, especially those with the most segregation. Standing orders for vaccinations, previously reported to narrow the racial gap in vaccination among NH residents, should be considered

Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis

BACKGROUND: Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis. METHODS AND FINDINGS: This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up. CONCLUSION: Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions

Relationships between Community Virus Activity and Cardiorespiratory Rehospitalizations From Post-Acute Care

OBJECTIVES: Quantify the relationship between increasing influenza and respiratory syncytial virus (RSV) community viral activity and cardiorespiratory rehospitalizations among older adults discharged to skilled nursing facilities (SNFs). DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: Adults aged ≥65 years who were hospitalized and then discharged to a US SNF between 2012 and 2015. METHODS: We linked Medicare Provider Analysis and Review claims to Minimum Data Set version 3.0 assessments, PRISM Climate Group data, and the Centers for Disease Control and Prevention viral testing data. All data were aggregated to US Department of Health and Human Services regions. Negative binomial regression models quantified the relationship between increasing viral activity for RSV and 3 influenza strains (H1N1pdm09, H3N2, and B) and cardiorespiratory rehospitalizations from SNFs. Incidence rate ratios described the relationship between a 5% increase in circulating virus and the rates of rehospitalization for cardiorespiratory outcomes. Analyses were repeated using the same model, but influenza and RSV were considered "in season" or "out of season" based on a 10% positive testing threshold. RESULTS: Cardiorespiratory rehospitalization rates increased by approximately 1% for every 5% increase in circulating influenza A(H3N2), influenza B, and RSV, but decreased by 1% for every 5% increase in circulating influenza A(H1N1pdm09). When respiratory viruses were in season (vs out of season), cardiorespiratory rehospitalization rates increased by approximately 6% for influenza A(H3N2), 3% for influenza B, and 5% for RSV, but decreased by 6% for influenza A(H1N1pdm09). CONCLUSIONS AND IMPLICATIONS: The respiratory season is a particularly important period to implement interventions that reduce cardiorespiratory hospitalizations among SNF residents. Decreasing viral transmission in SNFs through practices such as influenza vaccination for residents and staff, use of personal protective equipment, improved environmental cleaning measures, screening and testing of residents and staff, surveillance of viral activity, and quarantining infected individuals may be potential strategies to limit viral infections and associated cardiorespiratory rehospitalizations

Decomposing Racial and Ethnic Disparities in Nursing Home Influenza Vaccination

OBJECTIVES: Quantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents. DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: Short- and long-stay U.S. NH residents aged ≥65 years. METHODS: We linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents. RESULTS: Our study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity. CONCLUSIONS AND IMPLICATIONS: The racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination

Geographic variation in influenza vaccination among U.S. nursing home residents:A national study

OBJECTIVES: Estimates of influenza vaccine use are not available at the county level for U.S. nursing home (NH) residents but are critically necessary to guide the implementation of quality improvement programs aimed at increasing vaccination. Furthermore, estimates that account for differences in resident characteristics between counties are unavailable. We estimated risk‐standardized vaccination rates (RSVRs) among short‐ and long‐stay NH residents by U.S. county and identified drivers of geographic variation. METHODS: We conducted a retrospective cohort study utilizing 100% of 2013–2015 fee‐for‐service Medicare claims, Minimum Data Set assessments, Certification and Survey Provider Enhanced Reports, and Long‐Term Care: Facts on Care in the U.S. We separately evaluated short‐stay (<100 days) and long‐stay (≥100 days) residents aged 65 and older across the 2013–2014 and 2014–2015 influenza seasons. We estimated RSVRs via hierarchical logistic regression adjusting for 32 resident‐level covariates. We then used multivariable linear regression models to assess associations between county‐level NHs predictors and RSVRs. RESULTS: The study cohort consisted of 2,817,217 residents in 14,658 NHs across 2798 counties. Short‐stay residents had lower RSVRs than long‐stay residents (2013–2014: median [interquartile range], 69.6% [62.8–74.5] vs 84.0% [80.8–86.4]), and there was wide variation within each population (range, 11.4–89.8 vs 49.1–92.6). Several modifiable facility‐level characteristics were associated with increased RSVRs, including higher registered nurse to total nurse ratio and higher total staffing for licensed practical nurses, speech‐language pathologists, and social workers. Characteristics associated with lower RSVRs included higher percentage of residents restrained, with a pressure ulcer, and NH‐level hospitalizations per resident‐year. CONCLUSIONS: Substantial county‐level variation in influenza vaccine use exists among short‐ and long‐stay NH residents. Quality improvement interventions to improve vaccination rates can leverage these results to target NHs located in counties with lower risk‐standardized vaccine use

Impact of vaccine economic programs on physician referral of children to public vaccine clinics: a pre-post comparison

BACKGROUND: The Vaccines for Children (VFC) Program is a major vaccine entitlement program with limited long-term evaluation. The objectives of this study are to evaluate the effect of VFC on physician reported referral of children to public health clinics and on doses administered in the public sector. METHODS: Minnesota and Pennsylvania primary care physicians (n = 164), completed surveys before (e.g., 1993) and after (2003) VFC, rating their likelihood on a scale of 0 (very unlikely) to 10 (very likely) of referring a child to the health department for immunization. RESULTS: The percentage of respondents likely to refer was 60% for an uninsured child, 14% for a child with Medicaid, and 3% for a child with insurance that pays for immunization. Half (55%) of the physicians who did not participate in VFC were likely to refer a Medicaid-insured child, as compared with 6% of those who participated (P < 0.001). Physician likelihood to refer an uninsured child for vaccination, measured on a scale of 0 to 10 where 10 is very likely, decreased by a mean difference of 1.9 (P < 0.001) from pre- to post-VFC. The likelihood to refer a Medicaid-insured child decreased by a mean of 1.2 (P = 0.001). CONCLUSION: Reported out-referral to public clinics decreased over time. In light of increasing immunizations rates, this suggests that more vaccines were being administered in private provider offices