Hospitalizations and Deaths Due to Respiratory Illnesses During Influenza Seasons: A Comparison of Community Residents, Senior Housing Residents, and Nursing Home Residents

Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review

Residential care facility may provide a transition between living at home and a nursing home for dependent older people or an alternative to nursing homes. The objective of this review was to compare mortality and hospitalizations of older adults living in residential care facilities with those living in nursing homes or in the community. We searched Medline, Scopus and Web of Science from inception to December 2022. Fifteen cohort studies with 6 months to 10 years of follow-up were included. The unadjusted relative risk (RR) of mortality was superior in nursing homes than in residential care facilities in 6 of 7 studies (from 1.3 to 1.68). Conversely, the unadjusted relative risk of hospitalizations was higher in residential care facilities in 6 studies (from 1.3 to 3.37). Studies conducted on persons with dementia found mixed results, the only study adjusted for co-morbidities observing no difference on these two endpoints. Compared with home, unadjusted relative risks were higher in residential care facilities for mortality in 4 studies (from 1.34 à 10.1) and hospitalizations in 3 studies (from 1.12 to 1.62). Conversely, the only study that followed older adults initially living at home over a 10-year period found a reduced risk of heavy hospital use (RR = 0.68) for those who temporarily resided in a residential care facilities. There is insufficient evidence to determine whether residential care facilities might be an alternative to nursing homes for older people with similar clinical characteristics (co-morbidities and dementia). Nevertheless, given the high rate of hospitalizations observed in residential care facilities, the medical needs of residents should be better explored.

Secondary attack rates from asymptomatic and symptomatic influenza virus shedders in hospitals: Results from the TransFLUas influenza transmission study

Objective:

Nosocomial transmission of influenza is a major concern for infection control. We aimed to dissect transmission dynamics of influenza, including asymptomatic transmission events, in acute care.

Design:

Prospective surveillance study during 2 influenza seasons.

Setting:

Tertiary-care hospital.

Participants:

Volunteer sample of inpatients on medical wards and healthcare workers (HCWs).

Methods:

Participants provided daily illness diaries and nasal swabs for influenza A and B detection and whole-genome sequencing for phylogenetic analyses. Contacts between study participants were tracked. Secondary influenza attack rates were calculated based on spatial and temporal proximity and phylogenetic evidence for transmission.

Results:

In total, 152 HCWs and 542 inpatients were included; 16 HCWs (10.5%) and 19 inpatients (3.5%) tested positive for influenza on 109 study days. Study participants had symptoms of disease on most of the days they tested positive for influenza (83.1% and 91.9% for HCWs and inpatients, respectively). Also, 11(15.5%) of 71 influenza-positive swabs among HCWs and 3 (7.9%) of 38 influenza-positive swabs among inpatients were collected on days without symptoms; 2 (12.5%) of 16 HCWs and 2 (10.5%) of 19 inpatients remained fully asymptomatic. The secondary attack rate was low: we recorded 1 transmission event over 159 contact days (0.6%) that originated from a symptomatic case. No transmission event occurred in 61 monitored days of contacts with asymptomatic influenza-positive individuals.

Conclusions:

Influenza in acute care is common, and individuals regularly shed influenza virus without harboring symptoms. Nevertheless, both symptomatic and asymptomatic transmission events proved rare. We suggest that healthcare-associated influenza prevention strategies that are based on preseason vaccination and barrier precautions for symptomatic individuals seem to be effective.

Absenteeism and presenteeism in healthcare workers due to respiratory illness

OBJECTIVE

To assess influenza symptoms, adherence to mask use recommendations, absenteesm and presenteeism in acute care healthcare workers (HCWs) during influenza epidemics.

METHODS

The TransFLUas influenza transmission study in acute healthcare prospectively followed HCWs prospectively over 2 consecutive influenza seasons. Symptom diaries asking for respiratory symptoms and adherence with mask use recommendations were recorded on a daily basis, and study participants provided midturbinate nasal swabs for influenza testing.

RESULTS

In total, 152 HCWs (65.8% nurses and 13.2% physicians) were included: 89.1% of study participants reported at least 1 influenza symptom during their study season and 77.8% suffered from respiratory symptoms. Also, 28.3% of HCW missed at least 1 working day during the study period: 82.6% of these days were missed because of symptoms of influenza illness. Of all participating HCWs, 67.9% worked with symptoms of influenza infection on 8.8% of study days. On 0.3% of study days, symptomatic HCWs were shedding influenza virus while at work. Among HCWs with respiratory symptoms, 74.1% adhered to the policy to wear a mask at work on 59.1% of days with respiratory symptoms.

CONCLUSIONS

Respiratory disease is frequent among HCWs and imposes a significant economic burden on hospitals due to the number of working days lost. Presenteesm with respiratory illness, including influenza, is also frequent and poses a risk for patients and staff.

TRIAL REGISTRATION

NCT02478905 (clinicaltrials.gov).

Psychological impact of COVID-19 on hospital workers in nursing care hospitals

Aim

This study aimed to explore coronavirus disease‐related psychological stress in hospital workers in nursing care hospitals during the coronavirus disease epidemic.

Design

Cross‐sectional observational study.

Methods

A questionnaire survey was administered to hospital workers at three nursing care hospitals.

Results

Fifty‐four workers at three nursing care hospitals (9, 29 and 16 works) responded to our survey. Twenty‐four workers (50%) scored ≥5 on the Generalized Anxiety Disorder Scale, indicating the presence of anxiety. For the Patient Health Questionnaire‐9, six employees (11.1%) scored ≥10 scores, indicating the presence of depression. Workers who lived with other people with chronic underlying diseases showed significantly higher incidence of the presence of anxiety and depression. In binary logistic regression analysis, when living with persons with chronic underlying diseases, the risk of the presence of depression increased. Also, there was a higher incidence of depression in occupational therapists compared with physical therapists and nurses.

Barriers to seasonal influenza vaccine uptake among health care workers in long-term care facilities: A cross-sectional analysis

Objectives The vaccination of health care workers (HCWs) against influenza is recommended by numerous public health authorities. Despite these recommendations, the rate of vaccine uptake is poor, particularly among those working in long-term care. The current study aimed to use the theoretical domains framework to identify the barriers associated with influenza vaccine uptake among HCWs in long-term care facilities. Design The study employed a cross-sectional survey design. Methods HCWs (n = 372) at 21 long-term care facilities in the west of Ireland completed a paper-based questionnaire, which assessed the socio-demographic and psychosocial determinants associated with HCW influenza vaccine uptake. Results Findings indicated that a logistic regression using the theoretical domains framework demonstrated a strong ability to correctly classify whether or not HCWs received the influenza vaccine. Significant predictors of receiving the vaccine were past vaccination (OR = 16.16, 95% CI = 5.52-47.34), Goals (OR = 3.15, 95% CI = 1.63-6.06), Intentions (OR = 2.42, 95% CI = 1.23-4.77), Social influences (OR = 0.39, 95% CI = 0.18-0.84), and Reinforcement (OR = 0.46, 95% CI = 0.21-0.98). Conclusions This research identified the key psychological determinants associated with HCW vaccine uptake. Interventions that target the theoretical domains, Goals, Intentions, Social influences, and Reinforcement, may enhance vaccine uptake among HCW in long-term care facilities. Statement of contribution What is already known on this subject? Seasonal influenza vaccine uptake among health care workers in long-term care settings is suboptimal. Many socio-demographic, psychosocial, and organizational barriers to vaccination have been identified. However, few studies have explored the barriers to vaccination among health care workers in long-term care settings within a behaviour change theory framework. What does this study add? This is the first study to apply the theoretical domains framework to vaccination behaviour. Health care worker vaccine uptake was associated with having previously received the vaccine and the domains Goals, Intentions, Social influences, and Reinforcement. The findings suggest that interventions that target these domains may increase vaccine uptake among health care workers in long-term care facilities. Possible interventions could include vaccination action planning and promoting vaccination as a positive act rather than a professional responsibility.

Risk factors for pneumonia and influenza hospitalizations in long-term care facility residents: a retrospective cohort study

BACKGROUND

Older adults who reside in long-term care facilities (LTCFs) are at particularly high risk for infection, morbidity and mortality from pneumonia and influenza (P&I) compared to individuals of younger age and those living outside institutional settings. The risk factors for P&I hospitalizations that are specific to LTCFs remain poorly understood. Our objective was to evaluate the incidence of P&I hospitalization and associated person- and facility-level factors among post-acute (short-stay) and long-term (long-stay) care residents residing in LTCFs from 2013 to 2015.

METHODS

In this retrospective cohort study, we used Medicare administrative claims linked to Minimum Data Set and LTCF-level data to identify short-stay (< 100 days, index = admission date) and long-stay (100+ days, index = day 100) residents who were followed from the index date until the first of hospitalization, LTCF discharge, Medicare disenrollment, or death. We measured incidence rates (IRs) for P&I hospitalization per 100,000 person-days, and estimated associations with baseline demographics, geriatric syndromes, clinical characteristics, and medication use using Cox regression models.

RESULTS

We analyzed data from 1,118,054 short-stay and 593,443 long-stay residents. The crude 30-day IRs (95% CI) of hospitalizations with P&I in the principal position were 26.0 (25.4, 26.6) and 34.5 (33.6, 35.4) among short- and long-stay residents, respectively. The variables associated with P&I varied between short and long-stay residents, and common risk factors included: advanced age (85+ years), admission from an acute hospital, select cardiovascular and respiratory conditions, impaired functional status, and receipt of antibiotics or Beers criteria medications. Facility staffing and care quality measures were important risk factors among long-stay residents but not in short-stay residents.

CONCLUSIONS

Short-stay residents had lower crude 30- and 90-day incidence rates of P&I hospitalizations than long-stay LTCF residents. Differences in risk factors for P&I between short- and long-stay populations suggest the importance of considering distinct profiles of post-acute and long-term care residents in infection prevention and control strategies in LTCFs. These findings can help clinicians target interventions to subgroups of LTCF residents at highest P&I risk.

Who Are High Users of Hospitals in Canada? Findings From a Population-Based Study

Background

Dying people and older people have often been thought of as high users of hospitals, but current population-based evidence is needed to confirm or refute this claim.

Purpose

Quantitative population-based study designed to identify and describe hospital patients who are high users.

Methods

Data for all 2014–2015 Canadian hospital patients (excluding Quebec) were analyzed to identify and describe high users through descriptive-comparative and regression analysis tests.

Results

Only a small proportion of patients are high users in relation to multiple admissions or 30+ inpatient days of care, and with considerable diversity among them and relatively few of these advanced in age or dying in hospital.

Conclusions

Relatively few patients are high users of hospitals. These people are most often under age 65, so they have the potential to be ill and high users for many years. Flagging would enable individualized care planning to reduce illness exacerbations or slow disease progression and address other risk factors for long or repeat hospitalizations.

Perceived threat of Alzheimer's disease and related dementias among older Chinese Americans in subsidized housing: Through a cultural lens

PURPOSES

Low socioeconomic status and limited social support may put older residents in subsidized housing at high risk for developing fears of Alzheimer's disease or related dementias. This study examined the perceived threat of Alzheimer's disease or related dementias among older Chinese Americans in subsidized housing facilities in Phoenix, Arizona of the United States, and focused on the effect of cultural beliefs (i.e., beliefs toward Alzheimer's disease or related dementias, and beliefs toward intergenerational support) on the perceived threat of Alzheimer's disease or related dementias.

METHOD

Analyses were based upon a survey of 207 Chinese American older adults (M_age = 75.37, SD = 7.47) living in subsidized housing facilities in the Phoenix metropolitan area. Standardized survey questionnaires were delivered through face-to-face interviews.

RESULTS

Multivariate analyses suggest that fatalism related beliefs about Alzheimer's disease or related dementias, rather than stigmatization, were related to higher levels of concerns for developing Alzheimer's disease or related dementias, while beliefs in intergenerational support were related to lower levels of perceived threat of Alzheimer's disease or related dementias. However, the protective effect of beliefs in intergenerational support tended to diminish in those living with higher levels of depressive symptoms.

DISCUSSION

Cultural beliefs can entail both risks and strengths when low-income Chinese American elders attempt to comprehend the implications of Alzheimer's disease or related dementias. Health education or intervention programs need to address their fatalism beliefs toward Alzheimer's disease or related dementias, and facilitate the accessibility of intergenerational support for this group.

Preventing Respiratory Viral Transmission in Long-Term Care: Knowledge, Attitudes, and Practices of Healthcare Personnel

OBJECTIVE

To examine knowledge and attitudes about influenza vaccination and infection prevention practices among healthcare personnel (HCP) in a long-term-care (LTC) setting.

DESIGN

Knowledge, attitudes, and practices (KAP) survey.

SETTING

An LTC facility in St Louis, Missouri.

PARTICIPANTS

All HCP working at the LTC facility were eligible to participate, regardless of department or position. Of 170 full- and part-time HCP working at the facility, 73 completed the survey, a 42.9% response rate.

RESULTS

Most HCP agreed that respiratory viral infections were serious and that hand hygiene and face mask use were protective. However, only 46% could describe the correct transmission-based precautions for an influenza patient. Correctly answering infection prevention knowledge questions did not vary by years of experience but did vary for HCP with more direct patient contact versus less patient contact. Furthermore, 42% of respondents reported working while sick, and 56% reported that their coworkers did. In addition, 54% reported that facility policies made staying home while ill difficult. Some respondents expressed concerns about the safety (22%) and effectiveness (27%) of the influenza vaccine, and 28% of respondents stated that they would not get the influenza vaccine if it was not required.

CONCLUSIONS

This survey of staff in an LTC facility identified several areas for policy improvement, particularly sick leave, as well as potential targets for interventions to improve infection prevention knowledge and to address HCP concerns about influenza vaccination to improve HCP vaccination rates in LTCs.

Infect Control Hosp Epidemiol 2017;38:1449–1456

Trends in Influenza and Pneumococcal Vaccination Among US Nursing Home Residents, 2006-2014

BACKGROUND

Institutionalized adults are at increased risk of morbidity and mortality from influenza and pneumococcal infection. Influenza and pneumococcal vaccination have been shown to be effective in reducing hospitalization and deaths due to pneumonia and influenza in this population.

OBJECTIVE

To assess trends in influenza vaccination coverage among US nursing home residents from the 2005-2006 through 2014-2015 influenza seasons and trends in pneumococcal vaccination coverage from 2006 to 2014 among US nursing home residents, by state and demographic characteristics.

METHODS

Data were analyzed from the Centers for Medicare and Medicaid Services' (CMS's) Minimum Data Set (MDS). Influenza and pneumococcal vaccination status were assessed for all residents of CMS-certified nursing homes using data reported to the MDS by all certified facilities.

RESULTS

Influenza vaccination coverage increased from 71.4% in the 2005-2006 influenza season to 75.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage increased from 67.4% in 2006 to 78.4% in 2014. Vaccination coverage varied by state, with influenza vaccination coverage ranging from 50.0% to 89.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage ranging from 55.0% to 89.7% in 2014. Non-Hispanic black and Hispanic residents had lower coverage compared with non-Hispanic white residents for both vaccines, and these differences persisted over time.

CONCLUSION

Influenza and pneumococcal vaccination among US nursing home residents remains suboptimal. Nursing home staff can employ strategies such as provider reminders and standing orders to facilitate offering vaccination to all residents along with culturally appropriate vaccine promotion to increase vaccination coverage among this vulnerable population.

A Novel Dynamic Model for Health Economic Analysis of Influenza Vaccination in the Elderly

Introduction

New vaccines are being developed to improve the efficacy of seasonal influenza immunization in elderly persons aged ≥65 years. These products require clinical and economic evaluation to aid policy decisions.

Methods

To address this need, a two-part model has been developed, which we have applied to examine the potential clinical and economic impact of vaccinating elderly persons with adjuvanted trivalent inactivated influenza vaccine (aTIV) relative to conventional trivalent (TIV) and quadrivalent (QIV) vaccines. We compared outcomes in the US population for (1) aTIV in persons aged ≥65 years and QIV in all other age cohorts; (2) QIV in all cohorts; (3) TIV in all cohorts. Low, average, and high intensity seasons with low, average, and high vaccine match scenarios were compared. Probabilistic sensitivity analysis was conducted within each discrete scenario to explore the impact of variation in model inputs on potential outcomes.

Results

Assuming current vaccination coverage rates in the US population with (a) 25% better efficacy of adjuvanted versus non-adjuvanted vaccine against any strain and (b) 35% better efficacy of non-adjuvanted vaccine against matched B versus mismatched B strains, use of aTIV in persons aged ≥65 years and QIV in persons <65 years could reduce influenza cases by 11,166–1,329,200, hospitalizations by 1365–43,674, and deaths by 421–11,320 versus use of QIV in all cohorts. These outcomes are reflected in a corresponding increase in quality-adjusted life-years (QALYs) of 3003–94,084. If the prevalence of mismatched influenza B was >54.5% of all circulating strains, use of QIV in all cohorts would offset the clinical benefits of aTIV. Elderly aTIV or QIV vaccination was associated with improved outcomes over non-adjuvanted TIV in many of the scenarios, particularly in low match seasons of any intensity. Total cost savings (including direct and indirect healthcare costs plus productivity impacts) with aTIV in the elderly versus QIV in the whole population ranged from $27 million (low intensity, low match) to $934 million (high intensity, high match). Univariate sensitivity analysis of relative vaccine prices in the average intensity, average match scenario indicated that aTIV could be marginally cost saving relative to QIV at the currently published Medicare price for influenza vaccines offering enhanced efficacy in the elderly. Elderly vaccination with aTIV was associated with a higher overall cost compared with TIV in only two scenarios (low intensity with average or high match); the incremental cost/QALY relative to TIV was $9980 in the average match scenario and $28,800 in the high match scenario.

Conclusions

Vaccination of persons aged ≥65 years with aTIV has the potential to provide clinical and economic benefit relative to QIV and TIV. The new model allows the assessment of various alternative strategies for available influenza vaccines.

Funding

Novartis Vaccines.

Electronic supplementary material

The online version of this article (doi:10.1007/s40121-015-0076-8) contains supplementary material, which is available to authorized users.

Building-level analyses to prospectively detect influenza outbreaks in long-term care facilities: New York City, 2013-2014

BACKGROUND

Timely outbreak detection is necessary to successfully control influenza in long-term care facilities (LTCFs) and other institutions. To supplement nosocomial outbreak reports, calls from infection control staff, and active laboratory surveillance, the New York City (NYC) Department of Health and Mental Hygiene implemented an automated building-level analysis to proactively identify LTCFs with laboratory-confirmed influenza activity.

METHODS

Geocoded addresses of LTCFs in NYC were compared with geocoded residential addresses for all case-patients with laboratory-confirmed influenza reported through passive surveillance. An automated daily analysis used the geocoded building identification number, approximate text matching, and key-word searches to identify influenza in residents of LTCFs for review and follow-up by surveillance coordinators. Our aim was to determine whether the building analysis improved prospective outbreak detection during the 2013-2014 influenza season.

RESULTS

Of 119 outbreaks identified in LTCFs, 109 (92%) were ever detected by the building analysis, and 55 (46%) were first detected by the building analysis. Of the 5,953 LTCF staff and residents who received antiviral prophylaxis during the 2013-2014 season, 929 (16%) were at LTCFs where outbreaks were initially detected by the building analysis.

CONCLUSIONS

A novel building-level analysis improved influenza outbreak identification in LTCFs in NYC, prompting timely infection control measures.

Characteristics and determinants of survival in oldest old nursing home residents admitted to hospital with an acute illness compared to their younger counterparts

BACKGROUND AND OBJECTIVES

The clinical problems and needs of our oldest old (≥85 years) are often substantially different from those of younger patients, and are arguably different from younger elderly patients (age 65-84). With the increasing number of frail oldest olds residing in Nursing Homes (NH), we aim to identify differences in prognostic indicators and outcomes in this age group compared to younger NH residents.

METHODS

We retrospectively identified all consecutive admissions from NHs to an Acute Medical Assessment Unit between January 2005 and December 2007. Admission prognostic indicators and outcomes at follow-up were compared between younger (<85) and older (≥85) age groups. Using multiple regression methods controlling for potential confounders, we compared in-hospital mortality and long-term survival after discharge between the groups.

RESULTS

Three hundred and sixteen patients (mean age 84.3, SD 8.34 years) were included (68 % females). Admission characteristics were mostly similar between age groups. In-hospital mortality rates were not significantly different between groups, even after adjusting for possible confounders. Oldest old patients had a significantly greater hazard of dying after discharge (HR 1.37; 1.03-1.83) compared to the younger group after removing explanatory variables with more than 5 % missing data.

CONCLUSION

Whilst the admission characteristics are similar between younger and older patients from NHs, there is evidence to suggest worse long-term survival prospects for oldest old patients.

Racial/Ethnic Disparities in Preventive Care Practice Among U.S. Nursing Home Residents

Objective: To assess racial/ethnic disparities in preventive care practices among U.S. nursing home residents. Method: To implement the Institute of Medicine definition of health care disparity, we used the rank-and-replace adjustment method to assess the disparity in receipt of eight preventive care services among residents and evaluate trends in disparities. The sampling design (stratification and clustering) was accounted for using Stata 11. Results: The 2004 National Nursing Home Surveys data show White residents were more likely to have pain management, scheduled toilet plan/bladder retraining, influenza vaccination, and pneumococcal vaccination than Black residents. White residents were also more likely to have scheduled toilet plan/bladder retraining than residents of Other race/ethnicity. Significant Black–White disparities in receipt of influenza vaccination and pneumococcal vaccination were found. Time trend analysis showed that disparities were neither exacerbated nor reduced. Conclusion: Persistent racial/ethnic disparities in preventive care among nursing home residents exist. We urge the development and implementation of targeted interventions to improve the quality of preventive care in nursing homes.

Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada

OBJECTIVES

We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings.

METHODS

We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates.

RESULTS

Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable.

CONCLUSIONS

We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

Influenza immunization coverage of residents and employees of long-term care facilities in New York State, 2000-2010

We describe influenza immunization coverage trends from the New York State (NYS) Department of Health long-term care facility (LTCF) reports. Overall median immunization coverage levels for NYS LTCF residents and employees were 84.0% (range: 81.6%-86.0%) and 37.7% (range: 32.7%-50.0%), respectively. LTCF resident immunization coverage levels in NYS have neared the Healthy People 2020 target of 90% but have not achieved high LTCF employee coverage, suggesting a need for more regulatory interventions.

Predictors of early mortality among hospitalized nursing home residents

BACKGROUND

Emergency admissions from nursing homes (NHs) are associated with high mortality. Understanding the predictors of early mortality in these patients may guide clinicians in choosing appropriate site and level of care.

METHODS

We identified all consecutive admissions from NHs (all ages) to an Acute Medical Assessment Unit between January 2005 and December 2007. Analysis was performed at the level of the admission. The predictors of in-patient mortality at 7 days were examined using a generalized estimating equations analysis.

RESULTS

A total of 314 patients [32% male, mean age: 84.2 years (SD: 8.3 years)] were admitted during the study period constituting 410 emergency episodes. Twenty-three percent of admissions resulted in hospital mortality with 73% of deaths occurring within 1 week (50% within the first 3 days). For 7-day mortality outcome, patients with a modified early warning score (MEWS) of 4-5 on admission had 12 times the odds of death [95% confidence interval (CI) 1.40-103.56], whereas those with a score of ≥6 had 21 times the odds of death (95% CI 2.71-170.57) compared with those with a score of ≤1. An estimated glomerular filtration rate (eGFR) of 30-60 and <30 ml/min/m(2) was associated with nearly a 3-fold increase in the odds of death at 1 week (95% CI 1.10-7.97) and a 5-fold increase in the odds of death within 1 week (95% CI 1.75-14.96), respectively, compared with eGFR > 60 ml/min/m(2). C-reactive protein (CRP) >100 mg/l on admission was also associated with a 2.5 times higher odds of death (95% CI 1.23-4.95). Taking eight or more different medication items per day was associated with only a third of the odds of death (95% CI 0.09-0.98) compared with patients taking only three or fewer per day.

CONCLUSION

In acutely ill NH residents, MEWS is an important predictor of early hospital mortality and can be used in both the community and the hospital settings to identify patients whose death maybe predictable or unavoidable, thus allowing a more holistic approach to management with discussion with patient and relatives for planning of immediate care. In addition, CRP and eGFR levels on admission have also been shown to predict early hospital mortality in these patients and can be used in conjunction with MEWS in the same way to allow decision making on the appropriate level of care at the point of hospital admission.

Functional status of older nursing home residents can affect the efficacy of influenza vaccination

BACKGROUND

The efficacy of influenza vaccination in older nursing home residents is frequently overestimated due to frailty selection bias. Limited data exist to examine this issue.

METHODS

We conducted a prospective cohort study from December 2009 to November 2010 to evaluate the efficacy of influenza vaccination in old nursing home residents with respect to their functional status. Participants were stratified according to the Barthel Index (BI) into good functioning (GF; BI > 60), intermediate functioning (IF; BI = 5-60), and poor functioning (PF; BI = 0). Participants were vaccinated by monovalent H1N1 2009 and trivalent seasonal influenza vaccinations (H1N1-TIV), TIV alone, or remained unvaccinated by choice. The associations between all-cause mortality, vaccination efficacy, and functional status were examined.

RESULTS

A total of 711 older nursing home residents were enrolled (GF group: N = 230; IF group: N = 246; PF group: N = 235). At 12 months, H1N1-TIV recipients had the lowest all-cause mortality, whereas unvaccinated residents had the highest all-cause mortality in all three functional status groups. In the comparison between H1N1-TIV recipients and TIV alone recipients, the hazard ratios (HRs) of all-cause mortality were lower in the GF group and higher in the PF group (GF group: HR 0.30 [0.07-0.95], p < .05; IF group: HR 0.40 [0.18-0.86], p < .05; PF group: HR 0.53 [0.28-0.99], p < .05). The same observation was found in comparison between other vaccination statuses (H1N1-TIV vs unvaccinated and TIV alone vs unvaccinated).

CONCLUSIONS

Influenza vaccination was associated with reduced all-cause mortality in older nursing home residents with different functional statuses. Vaccine efficacy in reducing mortality declined with increasingly impaired functional status.

Despite small improvement, black nursing home residents remain less likely than whites to receive flu vaccine

Vaccination is a key deterrent to influenza and its related complications and outcomes, including hospitalization and death. Using 2006-09 data, we found a small improvement in vaccination rates among nursing home residents, particularly for blacks. Nonetheless, overall vaccination rates remained well below the 90 percent target for high-quality care, and black nursing home residents remained less likely to be vaccinated than whites. Blacks were less likely to be vaccinated than were whites in the same facility and were more likely to live in facilities with lower vaccination rates. Blacks were also more likely to be noted as refusing vaccination. Strategies are needed to ensure that facilities offer vaccination to all residents and to make vaccination more acceptable to black residents and their families.

Hospitalization rates of nursing home residents and community-dwelling seniors in British Columbia

The overall use of acute care services by nursing home (NH) residents in Canada has not been well documented. Our objectives were to identify the major causes of hospitalization among NH facility residents and to compare rates to those of community-dwelling seniors. A retrospective cohort was defined using population-level health administrative data, including all individuals aged 65 years and older living in a British Columbia NH facility between April 1996 and March 1999. Hospitalization rates of NH residents were compared to estimated rates for community-dwelling seniors, using age- and sex-adjusted standardized incidence ratios (SIRs): SIR = 2.81 (95%CI: 2.71, 2.91) for femoral fractures, 1.96 (1.88, 2.04) for pneumonia, 0.73 (0.70, 0.76) for other heart disease, and 1.01 (0.99, 1.02) for all causes. NH residents have disproportionately higher rates of hospitalization for femoral fractures and pneumonia, with NH residents accounting for approximately one quarter of all femoral fracture hospitalizations of BC seniors.

Influenza vaccination and its impact on hospitalization events in nursing homes

OBJECTIVES

To examine trends of influenza vaccination in nursing homes before and after public reporting (objective-1), and to assess the effect of influenza vaccinations on hospitalization events (objective-2).

RESEARCH DESIGN

Nursing Home Compare (NHC) database was used to obtain influenza vaccination rates during the 2005-2006, 2006-2007, and 2007-2008 flu seasons (objective-1). The 2005-2007 Minimum Data Set for New York State (NYS) was obtained and linked with the NHC data (objective-2).

SETTINGS AND PARTICIPANTS

All nursing homes in the United States were included in the analysis of objective-1. All eligible NYS nursing homes and their residents, during 2005-2006 and 2006-2007 flu seasons, were included in the analysis of objective-2.

MEASUREMENTS

Nursing home was the unit of analysis. Influenza vaccination rates in nursing homes over the 3 flu seasons were compared nationwide. A first-differenced model was fit to examine the relationship between facility vaccination rates and hospitalization rates in NYS.

RESULTS

There was an increase in influenza vaccination rates in nursing homes over the 3 flu seasons, but this increase was no greater than that among community-dwelling elderly. In NYS facilities with high baseline vaccination rates, the effect of vaccination on reducing hospitalizations was small. In NYS facilities with a low baseline rate, a 10.0% increase in vaccination rate for long-term care residents was correlated with a 6.2% decline in baseline hospitalization rates. However, a 10.0% increase in vaccination rate for short-term care residents was correlated with a 4.6% increase in baseline hospitalization rates.

CONCLUSIONS

There is no clear evidence that public reporting improves vaccination rates in nursing homes. The effects of vaccination on hospitalization events in nursing homes are mixed.

Vital signs as determinants of immediate and longer term mortality outcome of patients admitted from nursing homes

BACKGROUND AND AIMS

Hospital admissions from Nursing Homes (NHs) are associated with high mortality. Identifying people with a poor prognosis admitted from NHs is essential to inform appropriate clinical decision making.

METHODS

We identified all consecutive admissions from NHs (all ages) to an Acute Medical Assessment Unit (AMU) of a large District General Hospital in UK with a catchment population of ~360,000 between January 2005-December 2007 and reviewed their outcome to end of March 2009 (median follow-up=133 days). The relation between admission vital signs (systolic blood pressure, pulse rate, respiratory rate, body temperature and Glasgow Coma Scale-GCS) and outcomes including in-patient mortality, hospital length of stay and mortality at followup were examined using logistic and Cox regression models.

RESULTS

The cohort consisted of 316 patients (32% male), mean age at admission was 83.8 years (SD 8.36 yrs; range=49-99 yrs). Sixty-seven (21%) had at least two admissions during the study period; the maximum number of readmissions was five. We found strong evidence that lower systolic blood pressure and higher respiratory rate at the time of admission were associated with increased probability of in-patient death and reduced survival time but not with length of stay. Older age and lower admission GCS were additionally associated with overall poor prognosis.

CONCLUSION

Simple and readily available hospital admission parameters predict not only the in-patient mortality but also longer term outcome for NH residents who require acute hospital admission. Further studies are required to examine whether opportunities exist to intervene and improve outcome in this patient population.

High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: the Norfolk experience

There is a high mortality rate in patients admitted to hospitals acutely from care homes. In a retrospective case analysis study of 3772 older people admitted to the Department of Medicine for the Elderly between January and June 2005, 340 (9.0%) were from care homes, and 93 (27.3%) of the residents died during the index admission. Nearly 40% of these deaths occurred within 24h of admission indicating a high level of less appropriate admissions. Investigating eight nursing homes which admitted the highest number of patients from one primary care trust revealed that the most cited reasons for admission were the lack of advance care plans, access to General Practitioners (GPs) out of hours, as well as general access to palliative care and specialist nurses, and poor communication between patient, relatives, GPs, hospitals and care home staff. Our findings provide some useful insight into the factors that need to be addressed to avoid unnecessary or inappropriate admissions from care homes for better end of life care in aging societies.

Influenza vaccination coverage of healthcare workers and residents and their determinants in nursing homes for elderly people in France: a cross-sectional survey

Background

Nursing home residents bear a substantial burden of influenza morbidity and mortality. Vaccination of residents and healthcare workers (HCWs) is the main strategy for prevention. Despite recommendations, influenza vaccination coverage among HCWs remains generally low.

Methods

During the 2007-2008 influenza season, we conducted a nationwide survey to estimate influenza vaccination coverage of HCWs and residents in nursing homes for elderly people in France and to identify determinants of vaccination rates. Multivariate analysis were performed with a negative binomial regression.

Results

Influenza vaccination coverage rates were 33.6% (95% CI: 31.9-35.4) for HCWs and 91% (95% CI: 90-92) for residents. Influenza vaccination uptake of HCWs varied by occupational category. Higher vaccination coverage was found in private elderly care residences, when free vaccination was offered (RR: 1.89, 1.35-2.64), in small nursing homes (RR: 1.54, 1.31-1.81) and when training sessions and staff meetings on influenza were organized (RR: 1.20, 1.11-1.29). The analysis by occupational category showed that some determinants were shared by all categories of professionals (type of nursing homes, organization of training and staff meetings on influenza). Higher influenza vaccination coverage was found when free vaccination was offered to recreational, cleaning, administrative staff, nurses and nurse assistants, but not for physicians.

Conclusions

This nationwide study assessed for the first time the rate of influenza vaccination among residents and HCWs in nursing homes for elderly in France. Better communication on the current recommendations regarding influenza vaccination is needed to increase compliance of HCWs. Vaccination programmes should include free vaccination and education campaigns targeting in priority nurses and nurse assistants.

Use of emergency departments by older people from residential care: a population based study

OBJECTIVE

to investigate the differences between emergency department (ED) presentations of older people who do and do not live in residential care facilities (RCFs).

DESIGN

a population-based retrospective cohort study. ED records linked to ambulance and hospital morbidity records.

SETTING

public EDs in Perth, Western Australia.

SUBJECTS

all patients 65 years and older who presented to EDs between 1 January 2003 and 31 December 2006 (n = 97,161).

MEASUREMENTS

patient demographic and clinical characteristics. Logistic regression was used to model the effect of living in RCFs on the likelihood of a particular ED diagnosis, hospital admission and in-hospital death.

RESULTS

the age-sex standardised rate of ED presentation for those living in RCFs was 1.69 times that of community dwellers. Compared to community dwellers, people from RCFs were older (mean age 84.7 years vs. 76.0 years, P < 0.001) and a lower proportion were male (28.7% vs. 46.7%, P < 0.001). Adjusting for age and sex revealed that people from RCFs were more likely to be diagnosed with pneumonia/influenza [odds ratio (OR) 1.94, 95% confidence interval (CI) = 1.72-2.19], urinary tract infections (OR 1.72, 95% CI 1.49-1.98) or hip fractures (OR 1.16, 95% CI 1.03-1.32); less likely to be diagnosed with circulatory system diseases (OR 0.69, 95% CI 0.64-0.75) or neoplasms (OR 0.47, 95% CI 0.31-0.72); more likely to be admitted (OR 1.13, 95% CI 1.06-1.20) and to die in hospital (OR 1.57, 95% CI 1.40-1.75).

CONCLUSION

there are different patterns of ED presentations and hospital admissions of older people who do and do not live in RCFs. The appropriateness of these differences is uncertain.

Cross-sectional and longitudinal factors predicting influenza vaccination in Hong Kong Chinese elderly aged 65 and above

OBJECTIVES

The study investigated cross-sectional predictors of ever-undergone influenza vaccination (IV) and longitudinal predictors of first-time IV among Chinese elderly in Hong Kong.

METHODS

A random telephone survey interviewed 886 Chinese respondents aged 65 and above and 483 of these 886 respondents (54.5%) completed another follow-up questionnaire.

RESULTS

Of the 483 respondents, 25.1% (or 121) had ever undergone IV at baseline; 13% (47 of 362) were vaccinated for the first time during the follow-up period. The cross-sectional data identified 10 significant variables related to the Health Belief Model (HBM) predicting having ever undergone IV (e.g., perceived efficacy of prevention, side effects, financial difficulty, univariate OR=1.58-68.14 and 0.31-0.47). None of these variables could prospectively predict first-time IV during the follow-up period; the only significant variable was whether the respondent visited social centers during the follow-up period (OR=2.74).

CONCLUSIONS

The 10 studied variables (e.g., perceived efficacy, perceived side effects) were predictive of whether ever undergone IV in the cross-sectional survey. These variables were, however, unable to predict first-time IV in the longitudinal study. Therefore, programs modifying these cross-sectional factors (e.g. change perceptions on efficacy and safety) may not be effective in promoting first-time IV among the elderly. Longitudinal intervention studies are warranted.

Impact of flu on hospital admissions during 4 flu seasons in Spain, 2000-2004

Background

Seasonal flu epidemics in the European region cause high numbers of cases and deaths. Flu-associated mortality has been estimated but morbidity studies are necessary to understand the burden of disease in the population. Our objective was to estimate the excess hospital admissions in Spain of diseases associated with influenza during four epidemic influenza periods (2000 – 2004).

Methods

Hospital discharge registers containing pneumonia, chronic bronchitis, heart failure and flu from all public hospitals in Spain were reviewed for the years 2000 to 2004. Epidemic periods were defined by data from the Sentinel Surveillance System. Excess hospitalisations were calculated as the difference between the average number of weekly hospitalisations/100,000 in epidemic and non-epidemic periods. Flu epidemics were defined for seasons 2001/2002, 2002/2003, 2003/2004.

Results

A(H3N2) was the dominant circulating serotype in 2001/2002 and 2003/2004. Negligible excess hospitalisations were observed during the 2002/2003 epidemic where A(H1N1) was circulating. During 2000/2001, flu activity remained below threshold levels and therefore no epidemic period was defined. In two epidemic periods studied a delay between the peak of the influenza epidemic and the peak of hospitalisations was observed. During flu epidemics with A(H3N2), excess hospitalisations were higher in men and in persons <5 and >64 years higher than 10 per 100,000. Pneumonia accounted for 70% of all flu associated hospitalisations followed by chronic bronchitis. No excess flu-specific hospitalisations were recorded during all seasons.

Conclusion

Flu epidemics have an impact on hospital morbidity in Spain. Further studies that include other variables, such as temperature and humidity, are necessary and will deepen our understanding of the role of each factor during flu epidemics and their relation with morbidity.

Impact of influenza vaccination disparities on elderly mortality in the United States

PURPOSE

Racial and ethnic disparities in influenza vaccination among the elderly are well documented, but their impact on minority mortality is unknown.

METHODS

We model racial and ethnic parity in influenza vaccination on reduction in annual minority deaths among the elderly using age-, sex-, race-, and ethnicity-specific influenza vaccination data from the 2002 Medicare Current Beneficiary Survey, national mortality data and a relative risk (0.89; 95% confidence interval 0.80-0.98) for all-cause mortality during influenza season associated with vaccination. We also estimate the impact of 90% influenza coverage (Healthy People 2010 objective) on annual minority and white deaths. Lastly, we estimate years of minority lives saved from parity in annual vaccination beginning at age 65.

RESULTS

Parity in influenza vaccination would reduce elderly minority deaths by 1880 annually. Achievement of 90% vaccination coverage would reduce minority and White deaths by 3750 and 11,840 annually. Parity in vaccination beginning at age 65 and continuing through out life would save more than 33,000 minority years of life.

CONCLUSIONS

Based on conservative estimates, elimination of racial and ethnic disparities in influenza vaccination would significantly reduce elderly minority mortality and save substantial years of minority life.

Seasonal variation in orthopedic health services utilization in Switzerland: the impact of winter sport tourism

BACKGROUND

Climate- or holiday-related seasonality in hospital admission rates is well known for many diseases. However, little research has addressed the impact of tourism on seasonality in admission rates. We therefore investigated the influence of tourism on emergency admission rates in Switzerland, where winter and summer leisure sport activities in large mountain regions can generate orthopedic injuries.

METHODS

Using small area analysis, orthopedic hospital service areas (HSAo) were evaluated for seasonality in emergency admission rates. Winter sport areas were defined using guest bed accommodation rate patterns of guest houses and hotels located above 1000 meters altitude that show clear winter and summer peak seasons. Emergency admissions (years 2000-2002, n = 135'460) of local and nonlocal HSAo residents were evaluated. HSAo were grouped according to their area type (regular or winter sport area) and monthly analyses of admission rates were performed.

RESULTS

Of HSAo within the defined winter sport areas 70.8% show a seasonal, summer-winter peak hospital admission rate pattern and only 1 HSAo outside the defined winter sport areas shows such a pattern. Seasonal hospital admission rates in HSAo in winter sport areas can be up to 4 times higher in winter than the intermediate seasons, and they are almost entirely due to admissions of nonlocal residents. These nonlocal residents are in general -and especially in winter- younger than local residents, and nonlocal residents have a shorter length of stay in winter sport than in regular areas. The overall geographic distribution of nonlocal residents admitted for emergencies shows highest rates during the winter as well as the summer in the winter sport areas.

CONCLUSION

Small area analysis using orthopedic hospital service areas is a reliable method for the evaluation of seasonality in hospital admission rates. In Switzerland, HSAo defined as winter sport areas show a clear seasonal fluctuation in admission rates of only nonlocal residents, whereas HSAo defined as regular, non-winter sport areas do not show such seasonality. We conclude that leisure sport, and especially ski/snowboard tourism demands great flexibility in hospital beds, staff and resource planning in these areas.

Influenza Vaccination in the Elderly

Influenza causes substantial morbidity across the age spectrum. However, the elderly are especially vulnerable to the serious complications of influenza that might result in hospitalisation or death, and high rates of influenza-associated excess hospitalisation or death that exceed by several-fold the rates seen among most other age groups have consistently been observed in many countries and across many seasons. Thus, the elderly are included among the high priority groups for routine influenza vaccination by many national health authorities. Inactivated influenza virus vaccines are widely available across the globe and are safe and effective. Vaccination of elderly persons has been associated with significant reductions in hospitalisations for pneumonia and influenza as well as hospitalisations for other cardiopulmonary disorders and even cerebrovascular disease. Vaccination has also been associated with reductions in influenza-associated and all-cause mortality during influenza seasons. The benefits of vaccination extend not only to community-dwelling elderly but also to elderly who reside in nursing homes. Likewise, vaccination provides benefits to the very old and to elderly persons with underlying co-morbidities as well as to the healthy elderly. Despite the substantially increased risk for serious complications and impressive benefits from vaccination among the elderly, influenza vaccine utilisation remains below target rates for this group in nearly all countries. The need for improved prevention and control of influenza is recognised as a priority for the global community--both to reduce the morbidity and mortality associated with epidemic influenza and to prepare for the next pandemic. Enhancing vaccine delivery to elderly persons would represent important progress toward that goal.