American Journal of Public Health Research
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American Journal of Public Health Research. 2013, 1(2), 38-46
DOI: 10.12691/ajphr-1-2-1
Open AccessArticle

Does Frailty Modify the Effect of Race on Influenza Vaccination within Nursing Facilities in Michigan, 2005-2006?

Barbara Bardenheier, , Stefan Gravenstein, Carolyn Furlow, Faruque Ahmed and Carol J. Rowland Hogue

Pub. Date: March 15, 2013

Cite this paper:
Barbara Bardenheier, Stefan Gravenstein, Carolyn Furlow, Faruque Ahmed and Carol J. Rowland Hogue. Does Frailty Modify the Effect of Race on Influenza Vaccination within Nursing Facilities in Michigan, 2005-2006?. American Journal of Public Health Research. 2013; 1(2):38-46. doi: 10.12691/ajphr-1-2-1


Nursing home racial composition is associated with vaccine uptake; black residents are less well immunized than white residents. To determine if health status modifies the effect of race on receiving vaccination among nursing home residents, we used cross-sectional data from the Centers for Medicare & Medicaid Services for Michigan from October 1, 2005 through March 31, 2006 in 291 racially mixed nursing facilities (n=66,895 residents). Analyses included multilevel models, stratified by the proportion of black residents in the nursing home, to assess whether frailty, measured with the Cognitive Performance Scale (CPS), the Activities of Daily Living (ADL), and the Changes in Health, End-stage disease and Symptoms and Signs (CHESS), contributed to vaccination inequity (i.e., white-black difference) within nursing homes. In facilities with few (<5%) blacks, the median vaccination inequity increased when comparing non-frail to frail (CPS) residents: from 4.4 to 14.5 percentage points; ADL: 3.6 to 8.7; and CHESS: 4.1 to 9.4. Among residents of nursing homes with majority (> 50%) blacks, the inequity decreased with increasing frailty (CPS: 8.7 to 0.8; ADL: 9.3 to 2.1; and CHESS: 6.7 to 4.6). Frail residents of minority status within a facility were less likely to be vaccinated than either healthier minority status residents or majority status residents, frail or healthy.

vaccination nursing home frailty racial inequity

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[1]  Centers for Disease Control and Prevention. Prevention and Control of Influenza with Vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59(No.RR-8):1-62.
[2]  Bardenheier B, Wortley PM, Shefer A. Influenza vaccine among African-American and white nursing home residents: Is there a gap? J Am Geriatr Soc 2009;57:2164-2165.
[3]  Bardenheier B, Shefer A, Wortley P, et al. Trend in Influenza immunization coverage among residents of nursing homes certified by CMS, 2005-2010. 11 Mar 29; Washington, D.C.: National Immunization Conference, 2011.
[4]  Bardenheier B, Wortley PM, Ahmed F, Racial inequities in receipt of influenza vaccination among long-term care residents within and between facilities in Michigan. Med Care. 2011; 49:371-377.
[5]  Buchanan RJ, Martin RA, Zuniga M, et al. Nursing home residents with multiple sclerosis: comparisons of African American residents to white residents at admission. Mult Scler 2004;10:660-667.
[6]  Bardenheier B, Shefer A, Mckibben L, et al. Characteristics of long-term-care facility residents associated with receipt of influenza and pneumococcal vaccinations. Infect Control Hosp Epidemiol 2004;25:946-954.
[7]  Jackson ML, Nelson JC, Weiss NS, et al. Influenza vaccination and risk of community-acquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study. Lancet 2008;372:398-405.
[8]  Jackson LA, Nelson JC, Benson P et al. Functional status is a confounder of the association of influenza vaccine and risk of all cause mortality in seniors. Int J Epidemiol 2006;35:345-352.
[9]  Centers for Disease Control and Prevention. Link Plus. National Center for Chronic Disease Prevention and Health Promotion [serial online] 2008; Accessed July 2, 2009.
[10]  Institute of Medicine. Improving the Quality of Long-Term Care. Washington D.C.: National Academy Press, 2001.
[11]  Health Care Financing Administration. Minimum data set plus multistate nursing home case mix and quality demonstration training manual. Natick, MA: Eliot Press, 1991.
[12]  Morris JN, Fries BE, Mehr DR et al. MDS Cognitive Performance Scale. J Gerontol 1994;49:M174-M182.
[13]  Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci 1999;54:M546-M553.
[14]  Hirdes JP, Frijters DH, Teare GF. The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people. J Am Geriatr Soc 2003;51:96-100.
[15]  Bardenheier B, Wortley PM, Ahmed F, et al. Influenza immunization coverage among residents of long-term care facilities certified by CMS, 2005-2006: The newest MDS quality indicator. Journal of the American Medical Directors Association 2010;11:59-69.
[16]  Rothman K, Greenland S, Lash T. Modern Epidemiology. 3rd ed. New York, NY: Lippincott, Williams, & Wilkins, 2008.
[17]  Institute of Medicine. Unequal Treatment: Confronting racial and ethnic disparities in healthcare. In: Smedley B, Stith A, Nelson AR, eds. Washington, D.C.: The National Academies Press; 2002.
[18]  Crawley LM. Racial, cultural, and ethnic factors influencing end-of-life care. J Palliat Med 2005;8 Suppl 1:S58-S69.
[19]  Bardenheier B, Shefer A, Ahmed A, Remsburg R, Hogue CR, Gravenstein S. Do racial inequities in receipt of influenza vaccination among nursing home residents narrow if facility vaccination policies exist? Results of the National Nursing Home Survey, 2004. J Am Geriatr Soc 2011;59:687-93.
[20]  Use of Standing Orders Programs to Increase Adult Vaccination Rates. MMWR Morb Mortal Wkly Rep 2000 Mar 24;49(RR-1):15-26.
[21]  Deborah Reed-Danahay. Cultural Diversity and Health Care: The Nursing Home. Cultural Diversity in the United States. Westport, CT: Bergin & Garvey; 1997;291.
[22]  Daniels NA, Gouveia S, Null D, et al.. Acceptance of pneumococcal vaccine under standing orders by race and ethnicity. J Natl Med Assoc 2006;98:1089-1094.