key: cord-0286110-wvq0wxbo authors: Moyo, P.; Bosco, E.; Bardenheier, B. H.; Rivera-Hernandez, M.; van Aalst, R.; Chit, A.; Gravenstein, S.; Zullo, A. R. title: Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes date: 2021-10-07 journal: nan DOI: 10.1101/2021.10.06.21264537 sha: 24cd1b40c227805e72a2fefbb722e0e1aba6dd97 doc_id: 286110 cord_uid: wvq0wxbo ABSTRACT 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 groups. We examined three NH-level outcomes: percentage of residents assessed and appropriately provided the influenza vaccine, receiving influenza vaccine, and refusing influenza vaccine. 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). Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.7%, P<0.0001), or high (3.1%, P<0.0001) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.1%, P<0.0001), or high (-4.6% P<0.0001) MA compared with NHs with the lowest prevalence of MA. Among 753,616 short-stay residents in 12,205 NHs, there was no association between MA concentration and influenza vaccination receipt but vaccine refusal was greater in NHs with higher MA prevalence (high or moderate vs. low MA: 5.2%, P<0.0001). Conclusion: The relationship between MA concentration and influenza vaccination measures varied among post-acute and long-term NH residents. As MA takes a larger role in the Medicare program, and more MA beneficiaries enter NHs, there is need to consider how managed care can be leveraged to improve the delivery of preventive services such as influenza vaccinations in NH settings. payment models, coordinated care, and outreach programs urging high-risk members to 86 get vaccinated may encourage screening and preventive care use to prevent costly 87 medical services. [16] 88 NH MA Concentration. We determined a beneficiary's status of MA coverage at the time of 135 NH admission using Medicare enrollment data. We calculated the percentage of residents 136 in each NH who were enrolled in MA. We used the rank procedure to create a dummy 137 variable categorizing NHs into tertiles (low, moderate, high) based on their percentage of 138 MA enrollees. Covariates. Our analysis accounted for NH variables that capture the demographic (age, 155 sex, race/ethnicity) composition of residents and their physical and clinical attributes (e.g., 156 acuity index, activities of daily living scale, cognitive function scale) as well as facility 157 structural (e.g., for-profit ownership, bed count, occupancy rates, rurality, payer mix) and 158 quality (overall star rating) characteristics. These were selected based on prior literature 159 and substantive knowledge. The overall star rating is a composite score (ranging from 1 to 160 5) that takes into account a NH's performance on staffing, health inspections, and care 161 quality measures. We included the Herfindahl-Hirschman index, which measures the 162 concentration of NH beds in a county, as a covariate to account for variation in NH 163 availability. Additionally, we controlled for the county-level MA penetration rate since MA 164 markets vary substantially. MA penetration is defined as the share of Medicare 165 beneficiaries enrolled in MA plans per county. We used MA penetration data from 166 September 2014 which is the month prior to the start of our observation period. [ (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Resident and facility characteristics varied by the prevalence of MA beneficiaries in NHs. 201 As the prevalence of MA-enrolled residents increased, the beneficiaries tended to be older 202 in age, and more racially and ethnically diverse. NHs with the highest prevalence of MA 203 enrollees were more often larger, part of a chain system, and located in urban settings. 204 The resident acuity index varied minimally across categories of MA prevalence. However, 205 NHs with increasing MA prevalence had residents with more limitations in activities of daily 206 living, greater cognitive impairment, but lower levels of serious mental illness than NHs 207 with lower MA prevalence. The majority (89.2%) of NHs with low MA prevalence had a 208 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table S2 ). We found much lower levels of assessment and appropriate 242 provision of influenza vaccines (82.8% vs. 95.5% overall) than among long-stay NH 243 residents ( Figure S1 ). There was greater variation in vaccination rates, ranging from 62.7% 244 to 72.3% across MA categories, in contrast to the narrow range from 81.0% to 81.7% 245 among long-stay residents. One in 5 short-stay residents in NHs with high MA prevalence 246 refused influenza vaccination compared with about 1 in 20 of those in NHs with low MA 247 prevalence. After adjustment, there was no association between MA prevalence and 248 influenza vaccine receipt. However, vaccine refusal was higher as the prevalence of MA 249 increased: high vs low MA, 5.15% [4.08%, 6.23%] ( Table 3) . See supplementary Table S3 250 for covariate estimates and P values for the short-stay analysis. 251 This study investigated influenza vaccination receipt and nonreceipt among older adults in 261 NHs, and their variation on the basis of the concentration of residents enrolled in MA. 262 Several findings stood out in our analysis. First, although nearly all long-stay residents 263 were appropriately assessed (95.5%), influenza vaccination rates were lower (81.3%) 264 largely due to high refusal rates (13.4%) when the vaccine was offered. Second, although 265 crude estimates were similar, in adjusted models we found that as the concentration of MA 266 enrollees increased so did receipt of influenza vaccination among long-stay residents. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; acute and long-term care, [33] and high risk of morbidity and mortality due to respiratory 284 infections in NH residents and older adults generally. [34, 35] The COVID-19 pandemic 285 adds further imperative to explore levers (e.g., care coordination and initiatives to promote 286 preventive care) at the MA plan level to improve NH influenza vaccination coverage. 287 While improving uptake of the annual influenza vaccine is a perennial challenge, [2] the 289 imminence of a vaccine for COVID-19 means that it will be even more critical to ensure 290 high vaccination rates among NH residents -a population that has experienced 291 disproportionately high rates of COVID-19 cases and deaths. NH residents have 292 accounted for approximately 25% of the documented deaths due to COVID-19 although 293 less than 0.5% of the total U.S population (~1.5 million people) live in NHs. [36] Our 294 findings indicate that a notable proportion of NH residents decline the influenza vaccine 295 when offered with more refusals in nursing with higher percentages of Black residents and 296 among short-stay compared with long-stay Medicare beneficiaries. Culturally appropriate 297 education campaigns to raise awareness, counter misinformation, and encourage NH 298 residents to accept influenza and COVID-19 vaccinations are needed to more effectively 299 mitigate the transmission of these infections. 300 Since the composition of residents in a NH often includes a mix of post-acute short-stay 302 and long-stay residents, [37] effective influenza mitigation strategies should also target 303 improving the assessment and appropriate provision of the vaccine to short-stay 304 residents. [30] This may require NHs to maintain vaccine supplies over a longer period 305 during influenza season. Although discrepancies in data collection to determine 306 vaccination status are likely greater among short-stay than long-stay residents, we found 307 that not being offered the influenza vaccine was more common for short-stay residents 308 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; than long-stay residents. This presents a low-barrier opportunity for NHs to improve their 309 influenza vaccination performance by extending their efforts to offer and vaccinate short-310 stay residents. Such targeted efforts could be especially beneficial for NHs with large 311 proportions of short-stay residents. In addition, our results suggest actions to improve 312 overall NH Compare star ratings (targeting 4 or 5 starts) could contribute to better 313 vaccination rates. While the quality domain of star ratings includes NH vaccination 314 coverage, this is unlikely to fully explain the strong independent associations of the overall 315 star rating with vaccination rates in multivariable analyses. 316 This study has limitations. First, vaccination status may be misclassified, especially for 318 short-stay residents who are less frequently assessed. Second, this is a cohort study 319 focusing on a single influenza season (2014) (2015) . Nonetheless, the findings provide 320 foundational evidence that point to the relevance of further investigation through 321 longitudinal and more recent data. Third, we relied on resident acuity and comorbidity 322 measures from the CASPER database rather than MDS clinical assessments. However, 323 by using CASPER variables we avoided making assumptions that would be required to 324 handle missing data particularly for short-stay residents who more frequently have missing 325 information on MDS-derived variables. Also, our findings may not generalize to 326 beneficiaries younger than 65 years, residing in the community, or with insurance 327 coverage other than Medicare. 328 329 In conclusion, this study found that higher concentration of MA beneficiaries in NHs is 330 associated with increased rates of influenza vaccination receipt among long-stay residents. 331 There was no evidence that MA concentration affected influenza vaccination rates among 332 short-stay residents. Vaccine refusal when offered was lower (among long-stay) and 333 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; greater (among short-stay) as the prevalence of MA beneficiaries increased. As the MA 334 program continues to grow and more MA-enrolled beneficiaries enter NHs, concerted 335 efforts by MA plans and NHs will be essential to improve influenza vaccination rates and 336 reduce vaccine refusals. This importance is magnified in the COVID-19 era when 337 mitigating the transmission of respiratory infections is of critical importance for the health of 338 NH residents and staff. 339 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Trends in Influenza and Pneumococcal Vaccination Among US Nursing Home Residents Persistence of Racial Inequities in Receipt of Influenza Vaccination among Nursing Home Residents in the United States Influenza Season Nursing Home Vaccination Coverage Dashboard COVID-19 Preparedness in Nursing Homes in the Midst of the Pandemic COVID-19 Preparedness in US Home Health Care Agencies Flu Vaccination Urged During COVID-19 Pandemic Kaiser Family Foundation. A dozen facts about Medicare Advantage Dx for a careful approach to moving dual-eligible beneficiaries into managed care plans Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees How successful is Medicare Advantage? How Much Favorable Selection Is Left in Medicare Advantage? High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare Adjusted Mortality Rates Are Lower For Medicare Advantage Than Traditional Medicare, But The Rates Converge Over Time Steps to reduce favorable risk selection in medicare advantage largely succeeded, boding All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. well for health insurance exchanges Anthem Blue Cross. Anthem encourages high-risk members to get a flu shot. 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The copyright holder for this preprint this version posted The burden of respiratory infections among older adults in longterm care: a systematic review Nursing Home Care in Crisis in the Wake of COVID-19 Nursing Homes That Increased The Proportion Of Medicare Days Saw Gains In Quality Outcomes For Long-Stay Residents No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity