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Papers by Abigail Shefer

Research paper thumbnail of Managed Care Organizations’ Performance in Delivery of Adolescent Immunizations, HEDIS®, 1999–2002

Journal of Adolescent Health, Feb 1, 2008

The Health Plan Employer Data Information Set (HEDIS) provides comparative information across hea... more The Health Plan Employer Data Information Set (HEDIS) provides comparative information across health plans to measure the quality of care and preventive services for health plan beneficiaries. We examined recent trends in adolescent immunizations recommended by the Advisory Committee for Immunization Practices (ACIP) measured through HEDIS and reported to the National Committee for Quality Assurance (NCQA). The study was based on a longitudinal regression analysis of commercial managed care organizations' HEDIS measures from 1999-2002. HEDIS performance measures and plan characteristics include a sample of approximately 100-400 enrollees per plan each year. The outcome measures were the proportions of enrollees aged 13 years sampled in the plan who received measles-mumps-rubella vaccine (MMR), hepatitis B vaccine, and varicella vaccine. The immunization rates for all three antigens increased significantly from 1999 to 2002 (MMR: 57-68%; hepatitis B: 28-51%; and varicella: 21-38%). Factors in the final multivariable models that were found to be significantly associated with increased proportions immunized with MMR vaccine, hepatitis B vaccine, and varicella vaccine include year of report, presence of school entry laws, years in business up to 25 years, and operating in the northeastern U.S. region; the only factor associated with decreasing immunization rates for all antigens was the number of providers per 100 commercial enrollees. Consistent with previous reports, adolescent immunization rates are improving yet remain suboptimal. Strategies to increase immunization rates, as well as to improve documentation of immunization status, among commercial health insurance plans need to be developed and implemented.

Research paper thumbnail of Childhood Immunization Coverage by Provider Type

Journal of Public Health Management and Practice, Nov 1, 2007

Objective: To determine how child characteristics and immunization coverage levels differ among c... more Objective: To determine how child characteristics and immunization coverage levels differ among children using public and private providers. Methods: Immunization coverage rates between 1996 and 2004 were compared among children aged 19-35 months, using data from the National Immunization Survey. Coverage was based on the 4:3:1:3:3 vaccine series: four or more doses of diphtheria, tetanus toxoids, acellular pertussis vaccine; three or more doses of poliovirus vaccine; one or more doses of measles-mumps-rubella vaccine; three or more doses of Haemophilus influenzae type b vaccine; and three or more doses of hepatitis B vaccine. Coverage differences were examined by provider types (child vaccinated by private, public, or a mix of providers), and stratified by child's race/ethnicity, area of residence, and household income level. Results: Between 1996 and 2004, the proportion of children seeing exclusively private providers increased (58%-61%; P < .05); the proportion seeing only public providers decreased (19%-15%; P < .01). Coverage levels increased among children seeing all provider types. Coverage levels were higher for children using private providers than those using public providers in 2004 (83% vs 79%; P < .05). Except for White race (coverage was higher among those using private providers vs public providers), coverage levels by demographic variables did not significantly differ between children using only public or only private providers in 2004. Conclusions: Equal emphasis should be placed on the efforts of public providers and private providers to increase coverage among children of all race/ethnicity, income, and residential groups.

Research paper thumbnail of Pneumococcal Vaccination in Nursing Homes: Does Race Make a Difference?

Journal of the American Medical Directors Association, Nov 1, 2008

Known disparities in pneumococcal vaccination in the community raise the question of whether disp... more Known disparities in pneumococcal vaccination in the community raise the question of whether disparities also exist in the nursing home setting, which is better controlled. This study used nationally representative nursing home data to compare black and white nursing home residents with respect to receiving, not receiving, or having an unknown PPV vaccination status, and to examine the interaction of race with various facility characteristics. Design: Multinomial logistic regression was used to analyze a 2-year merged file (1997 and 1999) of the National Nursing Home Survey, a cross-sectional national probability sample of nursing homes and residents.

Research paper thumbnail of Influenza vaccine in african-american and white nursing home residents: is there a gap?

Journal of the American Geriatrics Society, Nov 1, 2009

preparation of the letter. Jacques Duysens contributed to study concept and design and preparatio... more preparation of the letter. Jacques Duysens contributed to study concept and design and preparation of the letter. Sponsor's Role: The funding source had no role in the design, methods, data analysis, or preparation of the letter.

Research paper thumbnail of Are Standing Order Programs Associated With Influenza Vaccination? – NNHS, 2004

Journal of the American Medical Directors Association, Nov 1, 2010

Background: Influenza vaccination coverage among nursing home residents has consistently been rep... more Background: Influenza vaccination coverage among nursing home residents has consistently been reported well below the Healthy People goals. We sought to determine if standing order programs (SOPs) in longterm care facilities are associated with greater influenza vaccination coverage among residents. Methods: The National Nursing Home Survey (2004) is cross-sectional. A total of 1152 US long-term care facilities were systematically sampled with probability proportional to number of beds. A total of 11,939 people aged 65 years or older residing in sampled long-term care facilities between August and December 2004 were randomly sampled. Influenza vaccination coverage of residents was obtained from facility records. Facility's immunization program included standing orders versus other (preprinted admission order, advance physician order, personal physician order, and no program). Multinomial logistic regression was used to examine the relationship between type of influenza immunization program and receipt of vaccination, adjusted for resident and facility confounders. Results: The proportion of residents aged 65 years or older who received influenza vaccination was 64%; 41% of residents lived in a facility with an SOP. Influenza vaccination coverage among residents residing in facilities with standing orders was 68% compared with 59% to 63% of residents in facilities with other program types. Logistic regression showed that standing order programs were independently associated with greater influenza vaccination coverage (66.7% versus 62.0%, P \ .01). Conclusion: This study indicates that residents in long-term care facilities having standing order programs for influenza were more likely to be immunized. More research needs to be done to understand how to facilitate adoption of these programs.

Research paper thumbnail of 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

Background: In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that l... more Background: In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that long-term care (LTC) facilities certified by CMS offer each resident annual influenza vaccination. Subsequently, vaccination status was added to resident assessments collected beginning in the influenza season, 2005-2006. This is the first year immunization coverage can be reported based on a census of LTC residents. Objectives: Report influenza immunization coverage for LTC residents by state, resident, and facility characteristics. Identify uses of the data and areas in need of improvement. Methods: Analysis of CMS' Minimum Data Set of 1,851,676 residents in nursing homes from October 1 through December 31 but who could have been discharged between January 1 and March 31 merged with data for 14,493 non-hospital-based facilities from the Online Survey and Certification Assessment Reporting System. Results: Overall, 83% of residents were offered the vaccine and 72% had received the vaccine. Almost 10% refused to receive the vaccine, 14% were not offered the vaccine, 1% were ineligible, and 3% were missing vaccination status. Vaccination coverage varied significantly among states (range: 49% to 87%). Fewer African Americans and Hispanics than whites were offered the vaccine (79% and 79% versus 84%, respectively) and received it (65% and 66% versus 73%, respectively); more African Americans refused the vaccine (12%) than residents of other races and/ or ethnicities. Residents of Medicaid-certified-only facilities had higher levels of vaccination than residents of other facilities (82% versus #73%). Conclusion: MDS immunization data can be used as surveillance to work with states to improve coverage. Further research to examine racial disparities in vaccination among LTC residents is needed.

Research paper thumbnail of Public Health Application Comparing Multilevel Analysis with Logistic Regression: Immunization Coverage among Long-Term Care Facility Residents

Annals of Epidemiology, Nov 1, 2005

Public health studies often sample populations using nested sampling plans. When the variance of ... more Public health studies often sample populations using nested sampling plans. When the variance of the residual errors is correlated between individual observations as a result of these nested structures, traditional logistic regression is inappropriate. We used nested nursing home patient data to show that one-level logistic regression and hierarchical multilevel regression can yield different results. METHODS: We performed logistic and multilevel regression to determine nursing home resident characteristics associated with receiving pneumococcal immunizations. Nursing home characteristics such as type of ownership, immunization program type, and certification were collected from a sample of 249 nursing homes in 14 selected states. Nursing home resident data including demographics, receipt of immunizations, cognitive patterns, and physical functioning were collected on 100 randomly selected residents from each facility. RESULTS: Factors associated with receipt of pneumococcal vaccination using logistic regression were similar to those found using multilevel regression model with some exceptions. Predictors using logistic regression that were not significant using multilevel regression included race, speech problems, infections, renal failure, legal responsibility for oneself, and affiliation with a chain. Unstable health conditions were significant only in the multilevel model. CONCLUSIONS: When correlation of resident outcomes within nursing home facilities was not considered, statistically significant associations were likely due to residual correlation effects. To control the probability of type I error, epidemiologists evaluating public health data on nested populations should use methods that account for correlation among observations.

Research paper thumbnail of Assessing Immunization Interventions in the Women, Infants, and Children (WIC) Program

American Journal of Preventive Medicine, 2014

Background-Vaccination promotion strategies are recommended in Women, Infants, and Children (WIC)... more Background-Vaccination promotion strategies are recommended in Women, Infants, and Children (WIC) settings for eligible children at risk for under-immunization due to their lowincome status. Purpose-To determine coverage levels of WIC and non-WIC participants and assess effectiveness of immunization intervention strategies. Methods-The 2007-2011 National Immunization Surveys were used to analyze vaccination histories and WIC participation among children aged 24-35 months. Grantee data on immunization activities in WIC settings were collected from the 2010 WIC Linkage Annual Report Survey. Coverage by WIC eligibility and participation status and grantee-specific coverage by intervention strategy were determined at 24 months for select antigens. Data were collected 2007-2011 and analyzed in 2013. Results-Of 13,183 age-eligible children, 5,699 (61%, weighted) had participated in WIC, of which 3,404 (62%, weighted) were current participants. In 2011, differences in four or more doses of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine by WIC participation status were observed: 86% (ineligible); 84% (current); 77% (previous); and 69% (never-eligible). Children in WIC exposed to an immunization intervention strategy had higher coverage levels than WIC-eligible children who never participated, with differences as great as 15% (DTaP). Conclusions-Children who never participated in WIC, but were eligible, had the lowest vaccination coverage. Current WIC participants had vaccination coverage comparable to more affluent children, and higher coverage than previous WIC participants.

Research paper thumbnail of Factors Associated with Underimmunization at 3 Months of Age in Four Medically Underserved Areas

Public Health Reports, 2004

Objective.Risk factors for underimmunization at 3 months of age are not well described. This stud... more Objective.Risk factors for underimmunization at 3 months of age are not well described. This study examines coverage rates and factors associated with underimmunization at 3 months of age in four medically underserved areas.Methods.During 1997–1998, cross-sectional household surveys using a two-stage cluster sample design were conducted in four federally designated Health Professional Shortage Areas. Respondents were parents or caregivers of children ages 12–35 months: 847 from northern Manhattan, 843 from Detroit, 771 from San Diego, and 1,091 from rural Colorado. A child was considered up-to-date (UTD) with vaccinations at 3 months of age if documentation of receipt of diphtheria-tetanus-pertussis, polio, haemophilus influenzae type B, and hepatitis B vaccines was obtained from a provider or a hand-held vaccination card, or both.Results.Household response rates ranged from 79% to 88% across sites. Vaccination coverage levels at 3 months of age varied across sites: 82.4% in norther...

Research paper thumbnail of Factors Predictive of Increased Influenza and Pneumococcal Vaccination Coverage in Long-term Care Facilities: The CMS-CDC Standing Orders Program Project

Journal of the American Medical Directors Association, 2005

Background: Between 1999 and 2002, a multistate demonstration project was conducted in long-term ... more Background: Between 1999 and 2002, a multistate demonstration project was conducted in long-term care facilities (LTCFs) to encourage implementation of standing orders programs (SOP) as evidence-based vaccine delivery strategies to increase influenza and pneumococcal vaccination coverage in LTCFs. Objective: Examine predictors of increase in influenza and pneumococcal vaccination coverage in LTCFs. Design: Intervention study. Self-administered surveys of LTCFs merged with data from OSCAR (On-line Survey Certification and Reporting System) and immunization coverage was abstracted from residents' medical charts in LTCFs. Setting and Participants: Twenty LTCFs were sampled from 9 intervention and 5 control states in the 2000 to 2001 influenza season for baseline and during the 2001 to 2002 influenza season for postintervention. Intervention: Each state's quality improvement organization (QIO) promoted the use of standing orders for immunizations as well as other strategies to increase immunization coverage among LTCF residents. Main Outcome Measures: Multivariate analysis included Poisson regression to determine independent predictors of at least a 10 percentage-point increase in facility influenza and pneumococcal vaccination coverage. Results: Forty-two (20%) and 59 (28%) of the facilities had at least a 10 percentage-point increase in influenza and pneumococcal immunizations, respectively. In the multivariate analysis, predictors associated with increase in influenza vaccination coverage included adoption of requirement in written immunization protocol to document refusals, less-demanding consent requirements, lower baseline influenza coverage, and small facility size. Factors associated with increase in pneumococcal vaccination coverage included adoption of recording pneumococcal immunizations in a consistent place, affiliation with a multifacility chain, and provision of resource materials. Conclusions: To improve the health of LTCF residents, strategies should be considered that increase immunization coverage, including written protocol for immunizations and documentation of refusals, documenting vaccination status in a consistent place in medical records, and minimal consent requirements for vaccinations.

Research paper thumbnail of Characteristics of long-term care facilities associated with standing order programs to deliver influenza and pneumococcal vaccinations to residents in 13 states

Journal of the American Medical Directors Association, 2005

Standing order programs (SOPs) are effective evidence-based interventions in which nurses or phar... more Standing order programs (SOPs) are effective evidence-based interventions in which nurses or pharmacists are authorized to vaccinate according to an approved protocol without a physician order or examination. National rates for influenza and pneumococcal vaccination in long-term care facilities (LTCF) are far below HP2010 goals of 90%. The aim of this study was to describe the prevalence of SOPs and other types of immunization programs in LTCFs and determine characteristics of LTCFs implementing SOPs. Mailed survey. All Medicare- or Medicaid-licensed LTCFs in 13 states. Directors of Nursing (DONs). Survey collecting information on SOPs and barriers to their use in respondents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; LTCF. Data from this survey were linked to the On-line Survey and Certification Administrative Record (OSCAR), a federal administrative database containing structural, staffing and other information on LTCFs. A total of 3,451 of 4,366 (79%) LTCFs completed surveys. Few facilities used SOPs for influenza (9%) or pneumococcal vaccination (7%). The greatest use of influenza SOPs compared with other immunization program types were seen in facilities that were government owned or owned by nonprofit entities compared with for-profit entities (15% and 10% vs. 7%; odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5 to 3.4 and OR = 1.4, CI = 1.1 to 1.8, respectively); dually-certified (both Medicare- and Medicaid-certified) nursing facilities compared with distinct part skilled nursing facilities in which beds are set aside for residents with a specific payment source (11% vs. 7%; OR = 1.6, CI = 1.3 to 2.1); independent facility compared with one that is part of a multi-facility chain (10% vs. 7%; OR = 1.3, CI = 1.1 to 1.7); and lower acuity index (resident resource needs) compared with higher (10% vs. 7%; OR = 1.4, CI = 1.1 to 1.7). Findings were similar for pneumococcal vaccination SOPs. SOP use varied substantially by state (range = 0% to 23% influenza; range = 3% to 15% pneumococcal). The most frequently reported barriers to SOP use were legal concerns: liability for the facility (53%) and staff lacking legal authority (39%) to vaccinate by standing orders. Although LTCFs with certain characteristics used SOPs more often, overall few facilities (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;10%) used SOPs to improve vaccination rates. SOP use varied by state indicating that state policies or other factors may promote or inhibit SOP use. More studies are needed to examine the causes of state-level variations in vaccination interventions and their relationships to health outcomes of residents in LTCFs. The federal government&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s resources to promote SOPs should focus on all LTCFs, but with a particular focus on those that are less likely to be using SOPs and that represent a large proportion of homes nationally (i.e., for-profit and chain facilities).

Research paper thumbnail of Are Standing Order Programs Associated With Influenza Vaccination? – NNHS, 2004

Journal of the American Medical Directors Association, 2010

Background: Influenza vaccination coverage among nursing home residents has consistently been rep... more Background: Influenza vaccination coverage among nursing home residents has consistently been reported well below the Healthy People goals. We sought to determine if standing order programs (SOPs) in longterm care facilities are associated with greater influenza vaccination coverage among residents. Methods: The National Nursing Home Survey (2004) is cross-sectional. A total of 1152 US long-term care facilities were systematically sampled with probability proportional to number of beds. A total of 11,939 people aged 65 years or older residing in sampled long-term care facilities between August and December 2004 were randomly sampled. Influenza vaccination coverage of residents was obtained from facility records. Facility's immunization program included standing orders versus other (preprinted admission order, advance physician order, personal physician order, and no program). Multinomial logistic regression was used to examine the relationship between type of influenza immunization program and receipt of vaccination, adjusted for resident and facility confounders. Results: The proportion of residents aged 65 years or older who received influenza vaccination was 64%; 41% of residents lived in a facility with an SOP. Influenza vaccination coverage among residents residing in facilities with standing orders was 68% compared with 59% to 63% of residents in facilities with other program types. Logistic regression showed that standing order programs were independently associated with greater influenza vaccination coverage (66.7% versus 62.0%, P \ .01). Conclusion: This study indicates that residents in long-term care facilities having standing order programs for influenza were more likely to be immunized. More research needs to be done to understand how to facilitate adoption of these programs.

Research paper thumbnail of Influenza Vaccine in African-American and White Nursing Home Residents: Is There a Gap?

Journal of the American Geriatrics Society, 2009

preparation of the letter. Jacques Duysens contributed to study concept and design and preparatio... more preparation of the letter. Jacques Duysens contributed to study concept and design and preparation of the letter. Sponsor's Role: The funding source had no role in the design, methods, data analysis, or preparation of the letter.

Research paper thumbnail of Managed Care Organizations’ Performance in Delivery of Adolescent Immunizations, HEDIS®, 1999–2002

Journal of Adolescent Health, 2008

Research paper thumbnail of Do vaccination strategies implemented by nursing homes narrow the racial gap in receipt of influenza vaccination in the United States?

Journal of the American Geriatrics Society, 2011

To determine whether the racial inequity between African Americans and Caucasians in receipt of i... more To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies.

Research paper thumbnail of Racial inequities in receipt of influenza vaccination among long-term care residents within and between facilities in Michigan

Medical care, 2011

Although influenza vaccination is recommended for all nursing home residents and is covered by Me... more Although influenza vaccination is recommended for all nursing home residents and is covered by Medicare, racial inequities remain.

Research paper thumbnail of Characteristics of Long-Term–Care Facility Residents Associated With Receipt of Influenza and Pneumococcal Vaccinations

Infection Control & Hospital Epidemiology, 2004

Background:Studies have found residency in long-term–care facilities (LTCFs) a risk factor for in... more Background:Studies have found residency in long-term–care facilities (LTCFs) a risk factor for influenza and pneumonia and have demonstrated that vaccinations against these diseases reduce the risk of disease. However, rates are below Healthy People 2010 goals of 90% for LTCFs. During 1999–2002, a multi-state demonstration project was conducted in LTCFs to implement standing orders programs for immunizations.Objective:Identify nursing home resident–specific characteristics associated with vaccination coverage at baseline.Methods:Facility-level data were collected from self-reported surveys of selected nursing homes in 14 states and from the On-line Survey and Certification Reporting System. Resident-level data, including demographics and physical functioning, were obtained from the Centers for Medicare & Medicaid Services' Minimum Data Set; 2000–2001 vaccination status was obtained by chart review. Influenza vaccination status reflected a single season, whereas pneumococcal vacc...

Research paper thumbnail of The state of measles and rubella in the WHO European Region, 2013

Clinical Microbiology and Infection, 2014

Measles and rubella persist in the World Health Organization European Region despite long-standin... more Measles and rubella persist in the World Health Organization European Region despite long-standing and widespread use of vaccines against them. Our aim was to review the epidemiology of measles and rubella in relation to the goal of eliminating these diseases from the Region by 2015. We report on the number of measles and rubella cases by country in 2012 and present an analysis of preliminary measles and rubella surveillance data for 2013. We analysed data of these diseases for 2013 by age group, diagnosis confirmation (clinical, laboratory-confirmed and epidemiologically linked), and vaccination, hospitalization and importation status. We also report on measles-related deaths. For 2012, there were 27 134 measles cases and 29 601 rubella cases reported in the Region. For 2013, these figures were 31 520 and 39 367 respectively. Most measles cases in 2013 (96%; n = 30 178) were reported by nine countries: Georgia (7830), Germany (1773), Italy (2216), the Netherlands (2499), Romania (1074), the Russian Federation (2174), Turkey (7404), Ukraine (3308) and the United Kingdom (1900). In 2013, most measles cases were among unvaccinated persons and over one in three patients were aged 20 years and older. For 2013, almost all rubella cases were reported by Poland (n = 38 585; 98%). High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. Without sustained political commitment and accelerated action by Member States and partners, the elimination of measles and rubella in the WHO European Region may not be achieved.

Research paper thumbnail of Public Health Application Comparing Multilevel Analysis with Logistic Regression: Immunization Coverage among Long-Term Care Facility Residents

Annals of Epidemiology, 2005

Public health studies often sample populations using nested sampling plans. When the variance of ... more Public health studies often sample populations using nested sampling plans. When the variance of the residual errors is correlated between individual observations as a result of these nested structures, traditional logistic regression is inappropriate. We used nested nursing home patient data to show that one-level logistic regression and hierarchical multilevel regression can yield different results. METHODS: We performed logistic and multilevel regression to determine nursing home resident characteristics associated with receiving pneumococcal immunizations. Nursing home characteristics such as type of ownership, immunization program type, and certification were collected from a sample of 249 nursing homes in 14 selected states. Nursing home resident data including demographics, receipt of immunizations, cognitive patterns, and physical functioning were collected on 100 randomly selected residents from each facility. RESULTS: Factors associated with receipt of pneumococcal vaccination using logistic regression were similar to those found using multilevel regression model with some exceptions. Predictors using logistic regression that were not significant using multilevel regression included race, speech problems, infections, renal failure, legal responsibility for oneself, and affiliation with a chain. Unstable health conditions were significant only in the multilevel model. CONCLUSIONS: When correlation of resident outcomes within nursing home facilities was not considered, statistically significant associations were likely due to residual correlation effects. To control the probability of type I error, epidemiologists evaluating public health data on nested populations should use methods that account for correlation among observations.

Research paper thumbnail of Influenza Immunization in Nursing Homes: Who Does Not Get Immunized and Whose Status Is Unknown?

Infection Control & Hospital Epidemiology, 2006

Objective.To identify nursing home resident and facility characteristics associated with patients... more Objective.To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status.Design.Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey.Setting.A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds.Patients.A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility).Main Outcome Measure.Immunization status of residents.Results.Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and ...

Research paper thumbnail of Managed Care Organizations’ Performance in Delivery of Adolescent Immunizations, HEDIS®, 1999–2002

Journal of Adolescent Health, Feb 1, 2008

The Health Plan Employer Data Information Set (HEDIS) provides comparative information across hea... more The Health Plan Employer Data Information Set (HEDIS) provides comparative information across health plans to measure the quality of care and preventive services for health plan beneficiaries. We examined recent trends in adolescent immunizations recommended by the Advisory Committee for Immunization Practices (ACIP) measured through HEDIS and reported to the National Committee for Quality Assurance (NCQA). The study was based on a longitudinal regression analysis of commercial managed care organizations&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; HEDIS measures from 1999-2002. HEDIS performance measures and plan characteristics include a sample of approximately 100-400 enrollees per plan each year. The outcome measures were the proportions of enrollees aged 13 years sampled in the plan who received measles-mumps-rubella vaccine (MMR), hepatitis B vaccine, and varicella vaccine. The immunization rates for all three antigens increased significantly from 1999 to 2002 (MMR: 57-68%; hepatitis B: 28-51%; and varicella: 21-38%). Factors in the final multivariable models that were found to be significantly associated with increased proportions immunized with MMR vaccine, hepatitis B vaccine, and varicella vaccine include year of report, presence of school entry laws, years in business up to 25 years, and operating in the northeastern U.S. region; the only factor associated with decreasing immunization rates for all antigens was the number of providers per 100 commercial enrollees. Consistent with previous reports, adolescent immunization rates are improving yet remain suboptimal. Strategies to increase immunization rates, as well as to improve documentation of immunization status, among commercial health insurance plans need to be developed and implemented.

Research paper thumbnail of Childhood Immunization Coverage by Provider Type

Journal of Public Health Management and Practice, Nov 1, 2007

Objective: To determine how child characteristics and immunization coverage levels differ among c... more Objective: To determine how child characteristics and immunization coverage levels differ among children using public and private providers. Methods: Immunization coverage rates between 1996 and 2004 were compared among children aged 19-35 months, using data from the National Immunization Survey. Coverage was based on the 4:3:1:3:3 vaccine series: four or more doses of diphtheria, tetanus toxoids, acellular pertussis vaccine; three or more doses of poliovirus vaccine; one or more doses of measles-mumps-rubella vaccine; three or more doses of Haemophilus influenzae type b vaccine; and three or more doses of hepatitis B vaccine. Coverage differences were examined by provider types (child vaccinated by private, public, or a mix of providers), and stratified by child's race/ethnicity, area of residence, and household income level. Results: Between 1996 and 2004, the proportion of children seeing exclusively private providers increased (58%-61%; P < .05); the proportion seeing only public providers decreased (19%-15%; P < .01). Coverage levels increased among children seeing all provider types. Coverage levels were higher for children using private providers than those using public providers in 2004 (83% vs 79%; P < .05). Except for White race (coverage was higher among those using private providers vs public providers), coverage levels by demographic variables did not significantly differ between children using only public or only private providers in 2004. Conclusions: Equal emphasis should be placed on the efforts of public providers and private providers to increase coverage among children of all race/ethnicity, income, and residential groups.

Research paper thumbnail of Pneumococcal Vaccination in Nursing Homes: Does Race Make a Difference?

Journal of the American Medical Directors Association, Nov 1, 2008

Known disparities in pneumococcal vaccination in the community raise the question of whether disp... more Known disparities in pneumococcal vaccination in the community raise the question of whether disparities also exist in the nursing home setting, which is better controlled. This study used nationally representative nursing home data to compare black and white nursing home residents with respect to receiving, not receiving, or having an unknown PPV vaccination status, and to examine the interaction of race with various facility characteristics. Design: Multinomial logistic regression was used to analyze a 2-year merged file (1997 and 1999) of the National Nursing Home Survey, a cross-sectional national probability sample of nursing homes and residents.

Research paper thumbnail of Influenza vaccine in african-american and white nursing home residents: is there a gap?

Journal of the American Geriatrics Society, Nov 1, 2009

preparation of the letter. Jacques Duysens contributed to study concept and design and preparatio... more preparation of the letter. Jacques Duysens contributed to study concept and design and preparation of the letter. Sponsor's Role: The funding source had no role in the design, methods, data analysis, or preparation of the letter.

Research paper thumbnail of Are Standing Order Programs Associated With Influenza Vaccination? – NNHS, 2004

Journal of the American Medical Directors Association, Nov 1, 2010

Background: Influenza vaccination coverage among nursing home residents has consistently been rep... more Background: Influenza vaccination coverage among nursing home residents has consistently been reported well below the Healthy People goals. We sought to determine if standing order programs (SOPs) in longterm care facilities are associated with greater influenza vaccination coverage among residents. Methods: The National Nursing Home Survey (2004) is cross-sectional. A total of 1152 US long-term care facilities were systematically sampled with probability proportional to number of beds. A total of 11,939 people aged 65 years or older residing in sampled long-term care facilities between August and December 2004 were randomly sampled. Influenza vaccination coverage of residents was obtained from facility records. Facility's immunization program included standing orders versus other (preprinted admission order, advance physician order, personal physician order, and no program). Multinomial logistic regression was used to examine the relationship between type of influenza immunization program and receipt of vaccination, adjusted for resident and facility confounders. Results: The proportion of residents aged 65 years or older who received influenza vaccination was 64%; 41% of residents lived in a facility with an SOP. Influenza vaccination coverage among residents residing in facilities with standing orders was 68% compared with 59% to 63% of residents in facilities with other program types. Logistic regression showed that standing order programs were independently associated with greater influenza vaccination coverage (66.7% versus 62.0%, P \ .01). Conclusion: This study indicates that residents in long-term care facilities having standing order programs for influenza were more likely to be immunized. More research needs to be done to understand how to facilitate adoption of these programs.

Research paper thumbnail of 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

Background: In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that l... more Background: In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that long-term care (LTC) facilities certified by CMS offer each resident annual influenza vaccination. Subsequently, vaccination status was added to resident assessments collected beginning in the influenza season, 2005-2006. This is the first year immunization coverage can be reported based on a census of LTC residents. Objectives: Report influenza immunization coverage for LTC residents by state, resident, and facility characteristics. Identify uses of the data and areas in need of improvement. Methods: Analysis of CMS' Minimum Data Set of 1,851,676 residents in nursing homes from October 1 through December 31 but who could have been discharged between January 1 and March 31 merged with data for 14,493 non-hospital-based facilities from the Online Survey and Certification Assessment Reporting System. Results: Overall, 83% of residents were offered the vaccine and 72% had received the vaccine. Almost 10% refused to receive the vaccine, 14% were not offered the vaccine, 1% were ineligible, and 3% were missing vaccination status. Vaccination coverage varied significantly among states (range: 49% to 87%). Fewer African Americans and Hispanics than whites were offered the vaccine (79% and 79% versus 84%, respectively) and received it (65% and 66% versus 73%, respectively); more African Americans refused the vaccine (12%) than residents of other races and/ or ethnicities. Residents of Medicaid-certified-only facilities had higher levels of vaccination than residents of other facilities (82% versus #73%). Conclusion: MDS immunization data can be used as surveillance to work with states to improve coverage. Further research to examine racial disparities in vaccination among LTC residents is needed.

Research paper thumbnail of Public Health Application Comparing Multilevel Analysis with Logistic Regression: Immunization Coverage among Long-Term Care Facility Residents

Annals of Epidemiology, Nov 1, 2005

Public health studies often sample populations using nested sampling plans. When the variance of ... more Public health studies often sample populations using nested sampling plans. When the variance of the residual errors is correlated between individual observations as a result of these nested structures, traditional logistic regression is inappropriate. We used nested nursing home patient data to show that one-level logistic regression and hierarchical multilevel regression can yield different results. METHODS: We performed logistic and multilevel regression to determine nursing home resident characteristics associated with receiving pneumococcal immunizations. Nursing home characteristics such as type of ownership, immunization program type, and certification were collected from a sample of 249 nursing homes in 14 selected states. Nursing home resident data including demographics, receipt of immunizations, cognitive patterns, and physical functioning were collected on 100 randomly selected residents from each facility. RESULTS: Factors associated with receipt of pneumococcal vaccination using logistic regression were similar to those found using multilevel regression model with some exceptions. Predictors using logistic regression that were not significant using multilevel regression included race, speech problems, infections, renal failure, legal responsibility for oneself, and affiliation with a chain. Unstable health conditions were significant only in the multilevel model. CONCLUSIONS: When correlation of resident outcomes within nursing home facilities was not considered, statistically significant associations were likely due to residual correlation effects. To control the probability of type I error, epidemiologists evaluating public health data on nested populations should use methods that account for correlation among observations.

Research paper thumbnail of Assessing Immunization Interventions in the Women, Infants, and Children (WIC) Program

American Journal of Preventive Medicine, 2014

Background-Vaccination promotion strategies are recommended in Women, Infants, and Children (WIC)... more Background-Vaccination promotion strategies are recommended in Women, Infants, and Children (WIC) settings for eligible children at risk for under-immunization due to their lowincome status. Purpose-To determine coverage levels of WIC and non-WIC participants and assess effectiveness of immunization intervention strategies. Methods-The 2007-2011 National Immunization Surveys were used to analyze vaccination histories and WIC participation among children aged 24-35 months. Grantee data on immunization activities in WIC settings were collected from the 2010 WIC Linkage Annual Report Survey. Coverage by WIC eligibility and participation status and grantee-specific coverage by intervention strategy were determined at 24 months for select antigens. Data were collected 2007-2011 and analyzed in 2013. Results-Of 13,183 age-eligible children, 5,699 (61%, weighted) had participated in WIC, of which 3,404 (62%, weighted) were current participants. In 2011, differences in four or more doses of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine by WIC participation status were observed: 86% (ineligible); 84% (current); 77% (previous); and 69% (never-eligible). Children in WIC exposed to an immunization intervention strategy had higher coverage levels than WIC-eligible children who never participated, with differences as great as 15% (DTaP). Conclusions-Children who never participated in WIC, but were eligible, had the lowest vaccination coverage. Current WIC participants had vaccination coverage comparable to more affluent children, and higher coverage than previous WIC participants.

Research paper thumbnail of Factors Associated with Underimmunization at 3 Months of Age in Four Medically Underserved Areas

Public Health Reports, 2004

Objective.Risk factors for underimmunization at 3 months of age are not well described. This stud... more Objective.Risk factors for underimmunization at 3 months of age are not well described. This study examines coverage rates and factors associated with underimmunization at 3 months of age in four medically underserved areas.Methods.During 1997–1998, cross-sectional household surveys using a two-stage cluster sample design were conducted in four federally designated Health Professional Shortage Areas. Respondents were parents or caregivers of children ages 12–35 months: 847 from northern Manhattan, 843 from Detroit, 771 from San Diego, and 1,091 from rural Colorado. A child was considered up-to-date (UTD) with vaccinations at 3 months of age if documentation of receipt of diphtheria-tetanus-pertussis, polio, haemophilus influenzae type B, and hepatitis B vaccines was obtained from a provider or a hand-held vaccination card, or both.Results.Household response rates ranged from 79% to 88% across sites. Vaccination coverage levels at 3 months of age varied across sites: 82.4% in norther...

Research paper thumbnail of Factors Predictive of Increased Influenza and Pneumococcal Vaccination Coverage in Long-term Care Facilities: The CMS-CDC Standing Orders Program Project

Journal of the American Medical Directors Association, 2005

Background: Between 1999 and 2002, a multistate demonstration project was conducted in long-term ... more Background: Between 1999 and 2002, a multistate demonstration project was conducted in long-term care facilities (LTCFs) to encourage implementation of standing orders programs (SOP) as evidence-based vaccine delivery strategies to increase influenza and pneumococcal vaccination coverage in LTCFs. Objective: Examine predictors of increase in influenza and pneumococcal vaccination coverage in LTCFs. Design: Intervention study. Self-administered surveys of LTCFs merged with data from OSCAR (On-line Survey Certification and Reporting System) and immunization coverage was abstracted from residents' medical charts in LTCFs. Setting and Participants: Twenty LTCFs were sampled from 9 intervention and 5 control states in the 2000 to 2001 influenza season for baseline and during the 2001 to 2002 influenza season for postintervention. Intervention: Each state's quality improvement organization (QIO) promoted the use of standing orders for immunizations as well as other strategies to increase immunization coverage among LTCF residents. Main Outcome Measures: Multivariate analysis included Poisson regression to determine independent predictors of at least a 10 percentage-point increase in facility influenza and pneumococcal vaccination coverage. Results: Forty-two (20%) and 59 (28%) of the facilities had at least a 10 percentage-point increase in influenza and pneumococcal immunizations, respectively. In the multivariate analysis, predictors associated with increase in influenza vaccination coverage included adoption of requirement in written immunization protocol to document refusals, less-demanding consent requirements, lower baseline influenza coverage, and small facility size. Factors associated with increase in pneumococcal vaccination coverage included adoption of recording pneumococcal immunizations in a consistent place, affiliation with a multifacility chain, and provision of resource materials. Conclusions: To improve the health of LTCF residents, strategies should be considered that increase immunization coverage, including written protocol for immunizations and documentation of refusals, documenting vaccination status in a consistent place in medical records, and minimal consent requirements for vaccinations.

Research paper thumbnail of Characteristics of long-term care facilities associated with standing order programs to deliver influenza and pneumococcal vaccinations to residents in 13 states

Journal of the American Medical Directors Association, 2005

Standing order programs (SOPs) are effective evidence-based interventions in which nurses or phar... more Standing order programs (SOPs) are effective evidence-based interventions in which nurses or pharmacists are authorized to vaccinate according to an approved protocol without a physician order or examination. National rates for influenza and pneumococcal vaccination in long-term care facilities (LTCF) are far below HP2010 goals of 90%. The aim of this study was to describe the prevalence of SOPs and other types of immunization programs in LTCFs and determine characteristics of LTCFs implementing SOPs. Mailed survey. All Medicare- or Medicaid-licensed LTCFs in 13 states. Directors of Nursing (DONs). Survey collecting information on SOPs and barriers to their use in respondents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; LTCF. Data from this survey were linked to the On-line Survey and Certification Administrative Record (OSCAR), a federal administrative database containing structural, staffing and other information on LTCFs. A total of 3,451 of 4,366 (79%) LTCFs completed surveys. Few facilities used SOPs for influenza (9%) or pneumococcal vaccination (7%). The greatest use of influenza SOPs compared with other immunization program types were seen in facilities that were government owned or owned by nonprofit entities compared with for-profit entities (15% and 10% vs. 7%; odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5 to 3.4 and OR = 1.4, CI = 1.1 to 1.8, respectively); dually-certified (both Medicare- and Medicaid-certified) nursing facilities compared with distinct part skilled nursing facilities in which beds are set aside for residents with a specific payment source (11% vs. 7%; OR = 1.6, CI = 1.3 to 2.1); independent facility compared with one that is part of a multi-facility chain (10% vs. 7%; OR = 1.3, CI = 1.1 to 1.7); and lower acuity index (resident resource needs) compared with higher (10% vs. 7%; OR = 1.4, CI = 1.1 to 1.7). Findings were similar for pneumococcal vaccination SOPs. SOP use varied substantially by state (range = 0% to 23% influenza; range = 3% to 15% pneumococcal). The most frequently reported barriers to SOP use were legal concerns: liability for the facility (53%) and staff lacking legal authority (39%) to vaccinate by standing orders. Although LTCFs with certain characteristics used SOPs more often, overall few facilities (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;10%) used SOPs to improve vaccination rates. SOP use varied by state indicating that state policies or other factors may promote or inhibit SOP use. More studies are needed to examine the causes of state-level variations in vaccination interventions and their relationships to health outcomes of residents in LTCFs. The federal government&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s resources to promote SOPs should focus on all LTCFs, but with a particular focus on those that are less likely to be using SOPs and that represent a large proportion of homes nationally (i.e., for-profit and chain facilities).

Research paper thumbnail of Are Standing Order Programs Associated With Influenza Vaccination? – NNHS, 2004

Journal of the American Medical Directors Association, 2010

Background: Influenza vaccination coverage among nursing home residents has consistently been rep... more Background: Influenza vaccination coverage among nursing home residents has consistently been reported well below the Healthy People goals. We sought to determine if standing order programs (SOPs) in longterm care facilities are associated with greater influenza vaccination coverage among residents. Methods: The National Nursing Home Survey (2004) is cross-sectional. A total of 1152 US long-term care facilities were systematically sampled with probability proportional to number of beds. A total of 11,939 people aged 65 years or older residing in sampled long-term care facilities between August and December 2004 were randomly sampled. Influenza vaccination coverage of residents was obtained from facility records. Facility's immunization program included standing orders versus other (preprinted admission order, advance physician order, personal physician order, and no program). Multinomial logistic regression was used to examine the relationship between type of influenza immunization program and receipt of vaccination, adjusted for resident and facility confounders. Results: The proportion of residents aged 65 years or older who received influenza vaccination was 64%; 41% of residents lived in a facility with an SOP. Influenza vaccination coverage among residents residing in facilities with standing orders was 68% compared with 59% to 63% of residents in facilities with other program types. Logistic regression showed that standing order programs were independently associated with greater influenza vaccination coverage (66.7% versus 62.0%, P \ .01). Conclusion: This study indicates that residents in long-term care facilities having standing order programs for influenza were more likely to be immunized. More research needs to be done to understand how to facilitate adoption of these programs.

Research paper thumbnail of Influenza Vaccine in African-American and White Nursing Home Residents: Is There a Gap?

Journal of the American Geriatrics Society, 2009

preparation of the letter. Jacques Duysens contributed to study concept and design and preparatio... more preparation of the letter. Jacques Duysens contributed to study concept and design and preparation of the letter. Sponsor's Role: The funding source had no role in the design, methods, data analysis, or preparation of the letter.

Research paper thumbnail of Managed Care Organizations’ Performance in Delivery of Adolescent Immunizations, HEDIS®, 1999–2002

Journal of Adolescent Health, 2008

Research paper thumbnail of Do vaccination strategies implemented by nursing homes narrow the racial gap in receipt of influenza vaccination in the United States?

Journal of the American Geriatrics Society, 2011

To determine whether the racial inequity between African Americans and Caucasians in receipt of i... more To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies.

Research paper thumbnail of Racial inequities in receipt of influenza vaccination among long-term care residents within and between facilities in Michigan

Medical care, 2011

Although influenza vaccination is recommended for all nursing home residents and is covered by Me... more Although influenza vaccination is recommended for all nursing home residents and is covered by Medicare, racial inequities remain.

Research paper thumbnail of Characteristics of Long-Term–Care Facility Residents Associated With Receipt of Influenza and Pneumococcal Vaccinations

Infection Control & Hospital Epidemiology, 2004

Background:Studies have found residency in long-term–care facilities (LTCFs) a risk factor for in... more Background:Studies have found residency in long-term–care facilities (LTCFs) a risk factor for influenza and pneumonia and have demonstrated that vaccinations against these diseases reduce the risk of disease. However, rates are below Healthy People 2010 goals of 90% for LTCFs. During 1999–2002, a multi-state demonstration project was conducted in LTCFs to implement standing orders programs for immunizations.Objective:Identify nursing home resident–specific characteristics associated with vaccination coverage at baseline.Methods:Facility-level data were collected from self-reported surveys of selected nursing homes in 14 states and from the On-line Survey and Certification Reporting System. Resident-level data, including demographics and physical functioning, were obtained from the Centers for Medicare & Medicaid Services' Minimum Data Set; 2000–2001 vaccination status was obtained by chart review. Influenza vaccination status reflected a single season, whereas pneumococcal vacc...

Research paper thumbnail of The state of measles and rubella in the WHO European Region, 2013

Clinical Microbiology and Infection, 2014

Measles and rubella persist in the World Health Organization European Region despite long-standin... more Measles and rubella persist in the World Health Organization European Region despite long-standing and widespread use of vaccines against them. Our aim was to review the epidemiology of measles and rubella in relation to the goal of eliminating these diseases from the Region by 2015. We report on the number of measles and rubella cases by country in 2012 and present an analysis of preliminary measles and rubella surveillance data for 2013. We analysed data of these diseases for 2013 by age group, diagnosis confirmation (clinical, laboratory-confirmed and epidemiologically linked), and vaccination, hospitalization and importation status. We also report on measles-related deaths. For 2012, there were 27 134 measles cases and 29 601 rubella cases reported in the Region. For 2013, these figures were 31 520 and 39 367 respectively. Most measles cases in 2013 (96%; n = 30 178) were reported by nine countries: Georgia (7830), Germany (1773), Italy (2216), the Netherlands (2499), Romania (1074), the Russian Federation (2174), Turkey (7404), Ukraine (3308) and the United Kingdom (1900). In 2013, most measles cases were among unvaccinated persons and over one in three patients were aged 20 years and older. For 2013, almost all rubella cases were reported by Poland (n = 38 585; 98%). High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. Without sustained political commitment and accelerated action by Member States and partners, the elimination of measles and rubella in the WHO European Region may not be achieved.

Research paper thumbnail of Public Health Application Comparing Multilevel Analysis with Logistic Regression: Immunization Coverage among Long-Term Care Facility Residents

Annals of Epidemiology, 2005

Public health studies often sample populations using nested sampling plans. When the variance of ... more Public health studies often sample populations using nested sampling plans. When the variance of the residual errors is correlated between individual observations as a result of these nested structures, traditional logistic regression is inappropriate. We used nested nursing home patient data to show that one-level logistic regression and hierarchical multilevel regression can yield different results. METHODS: We performed logistic and multilevel regression to determine nursing home resident characteristics associated with receiving pneumococcal immunizations. Nursing home characteristics such as type of ownership, immunization program type, and certification were collected from a sample of 249 nursing homes in 14 selected states. Nursing home resident data including demographics, receipt of immunizations, cognitive patterns, and physical functioning were collected on 100 randomly selected residents from each facility. RESULTS: Factors associated with receipt of pneumococcal vaccination using logistic regression were similar to those found using multilevel regression model with some exceptions. Predictors using logistic regression that were not significant using multilevel regression included race, speech problems, infections, renal failure, legal responsibility for oneself, and affiliation with a chain. Unstable health conditions were significant only in the multilevel model. CONCLUSIONS: When correlation of resident outcomes within nursing home facilities was not considered, statistically significant associations were likely due to residual correlation effects. To control the probability of type I error, epidemiologists evaluating public health data on nested populations should use methods that account for correlation among observations.

Research paper thumbnail of Influenza Immunization in Nursing Homes: Who Does Not Get Immunized and Whose Status Is Unknown?

Infection Control & Hospital Epidemiology, 2006

Objective.To identify nursing home resident and facility characteristics associated with patients... more Objective.To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status.Design.Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey.Setting.A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds.Patients.A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility).Main Outcome Measure.Immunization status of residents.Results.Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and ...