Decomposing Racial and Ethnic Disparities in Nursing Home Influenza Vaccination

Abstract

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 longstay (!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 shortstay 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 R.v.A., M.M. L., and A. C. are employed by Sanofi Pasteur. S.G. reports grants from Seqirus and Sanofi, and consulting or speaker fees from Sanofi, Seqirus, Merck, and the Gerontological Society of America related to vaccines or nursing home care quality. No other authors report potential conflicts of interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.This Brown University collaborative research was supported by Sanofi Pasteur.

Addressing Racial and Ethnic Disparities in Nursing Homes

“…36 Current literature continues to report racial and ethnic disparities in influenza vaccination among nursing home residents, and facility characteristics play an important role in this inequality. 37 Although racial disparities in some quality measures, such as inappropriate use of antipsychotics, have decreased over time, 38 Black and Hispanic adults are still less likely than white adults to reside in high-quality (i.e., 4 or 5 stars) nursing homes, as measured by Overall Quality Star ratings. 39…”

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

“…These disparities occur when there are differences between socially disadvantaged (ie, Black and Hispanic) and more socially advantaged (ie, White) racial/ethnic groups, such that influenza vaccination uptake favors the more socially advantaged racial/ethnic group [ 10 ]. Although most prior literature has examined influenza vaccination disparities among Black and White NH residents [ 7–9 , 11–14 ], some evidence suggests that disparities in vaccination between Hispanic (regardless of race) and non-Hispanic White residents range between 3.4 and 12.7 percentage points [ 15 ]. As the Hispanic population is expected to represent ∼20% of older adults in the United States by 2050 [ 16 ], it is critical to mitigate existing racial/ethnic inequities in NH influenza vaccination now and prevent these disparities from widening in the future.…”

“…Prior studies have examined person-level (eg, age) and facility-level factors (eg, chain vs standalone facility) associated with influenza vaccination in NHs [ 14 , 17 , 18 ], as well as disparities in influenza vaccination between Hispanic and non-Hispanic White NH residents [ 7 , 12 , 15 ]. However, studies investigating racial/ethnic disparities were mainly conducted at the national level, leaving smaller-area geographic patterns of non-Hispanic White and Hispanic influenza vaccination disparities underexplored [ 7 , 19 ].…”

“…In addition, past studies have seldom examined short-stay (post–acute care) and long-stay (long-term care) NH residents separately. Length of stay is an important characteristic, as long-stay residents have distinct clinical features and care goals compared with short-stay residents [ 15 ]. Length of stay may also influence influenza vaccination receipt in NHs.…”

“…For example, short-stay residents could prefer to receive preventative care services, such as influenza vaccination, from an established outpatient provider rather than NH providers during short-term post–acute care. One study even found that racial/ethnic disparities in influenza vaccination were greater among short-stay residents [ 15 ].…”