Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003

OBJECTIVES: To examine vaccination in seniors in the five U.S. communities of the Racial and Ethnic Adult Disparities in Immunization Initiative. DESIGN: Cross-sectional telephone survey in spring 2003 using stratified sampling by ZIP code and race/ethnicity. SETTING: New York, Texas, Wisconsin, Illinois, and Mississippi. PARTICIPANTS: Four thousand five hundred seventy-seven Medicare beneficiaries. MEASUREMENTS: Outcomes were pneumococcal vaccination ever and influenza vaccination in 2002/03 and were determined according to race/ethnicity, awareness of vaccination, and provider recommendation. Survey questions also asked about future plans for vaccination, whether respondents believed they had become sick from prior influenza vaccination, and whether unvaccinated respondents would be vaccinated if a health professional recommended it. RESULTS: Pneumococcal vaccination coverage was 70.3% for whites, 40.8% for blacks, and 53.2% for Hispanics, and the proportion reporting provider recommendation for vaccination differed significantly according to race/ethnicity. In multivariate regression, provider recommendation (risk ratio (RR) = 2.32, 95% confidence intervals (CI) = 2.10-2.57) and awareness of vaccination (RR = 1.60, 95% CI = 1.40-1.82) were associated with greater pneumococcal vaccination. Influenza vaccination coverage was 76.2% for whites, 50.7% for blacks, and 65.7% for Hispanics. A little more than half of respondents reported provider recommendation for influenza vaccination, with no differences according to race/ethnicity. Provider recommendation was associated with influenza vaccination (RR = 1.31, 95% CI = 1.25-1.38). More blacks and Hispanics believed they had become sick from prior influenza vaccination than whites, and this belief was associated with lower vaccination rates. CONCLUSION: This survey details vaccination patterns in an ethnically and geographically diverse sample of seniors and identifies some differences between blacks, Hispanics, and whites that may contribute to disparities in vaccination coverage. Survey findings highlight the importance of provider vaccination recommendations.     

Understanding the reasons for the underuse of pneumococcal vaccination by community-dwelling older African Americans

OBJECTIVES: To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare‐eligible older African Americans. DESIGN: The Cardiovascular Health Study. SETTING: Four U.S. states. PARTICIPANTS: Seven hundred ninety‐five pairs of community‐dwelling Medicare‐eligible African‐American and white adults aged 65 and older, balanced according to age and sex. MEASUREMENTS: Data on self‐reported race, receipt of pneumococcal vaccination, and other important sociodemographic and clinical variables were collected at baseline. RESULTS: Participants had a mean age ± standard deviation of 73 ± 6; 63% were female. Pneumococcal vaccination rates were 22% for African Americans and 28% for whites (unadjusted odds ratios (OR) for African Americans=0.75; 95% confidence interval (CI)=0.60–0.94; P=.01). This association remained significant despite adjustment for sociodemographic and clinical confounders, including education, income, chronic obstructive pulmonary disease, and prior pneumonia (OR=0.74, 95% CI=0.56–0.97; P=.03), but the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR=0.79, 95% CI=0.59–1.06; P=.12). Receipt of influenza vaccination was associated with higher odds of receiving pneumococcal vaccination (unadjusted OR=6.43, 95% CI=5.00–8.28; P<.001), and the association between race and pneumococcal vaccination lost significance when adjusted for influenza vaccination alone (OR=0.81, 95% CI=0.63–1.03; P=.09). CONCLUSION: The strong association between receipt of influenza and pneumococcal vaccinations suggests that patient and provider attitudes toward vaccination, rather than traditional confounders such as education and income, may help explain the underuse of pneumococcal vaccination in older African Americans.     

Barriers to pneumococcal and influenza vaccination in older community-dwelling adults (2000-2001)

OBJECTIVES: To identify facilitators of and barriers to vaccination in patients from a range of socioeconomic levels. DESIGN: A survey was conducted in 2001 using computer-assisted telephone interviewing. SETTING: Patients from inner-city health centers and suburban practices were interviewed. PARTICIPANTS: Inclusion criteria were aged 66 and older and an office visit after September 30, 1998. MEASUREMENTS: Self-reported influenza and pneumococcal vaccination status and facilitating conditions, attitudes, social influences, and perceived consequences from the Triandis model were assessed. RESULTS: Overall, 557 interviews were completed with 775 eligible patients (72%). Patients who reported having received pneumococcal vaccine more frequently believed that their physicians recommended the vaccine than did the unvaccinated (97% vs 49%; P=.001). This was also true for influenza vaccine (99% vs 80%; P<.001). More unvaccinated patients than vaccinated patients felt that obtaining either vaccine was more trouble than it is worth (pneumococcal 19% vs 1%; P=.04, influenza 20% vs 1%; P=.004). The vaccinated were more likely to be willing to obtain the influenza and pneumococcal vaccines at the same time (pneumococcal 91% vs 59%; P=.002, influenza 91% vs 55%; P=.014). CONCLUSION: Physicians should take every opportunity to recommend vaccination to their eligible adult patients. Offering influenza and pneumococcal vaccines at the same visit is an acceptable means to ensure that adults are fully vaccinated.     

Racial similarities in response to standardized offer of influenza vaccination

BACKGROUND: Despite known benefits of influenza vaccination and coverage by Medicare Part B, elderly minority patients are less likely to receive influenza vaccination than whites. OBJECTIVES: To test whether a nonphysician-initiated standardized offer of influenza vaccination to all elderly primary care patients would result in similar proportions of African-American and white patients accepting vaccine. DESIGN: In 7 metropolitan Detroit primary care practices during the 2003 influenza vaccination season, medical assistants assessed influenza immunization status of all patients 65 years and older and collected limited demographic data. Eligible patients were offered vaccination. MEASUREMENTS: Proportion of patients accepting influenza vaccination by race and predictors of vaccine acceptance. RESULTS: Four hundred and fifty-four eligible patients with complete racial information were enrolled: 40% African American, 52% white, 8% other race/ethnicity. Similar proportions of African Americans and whites had already received the 2003 vaccine (11.6% and 11.0%, respectively) or stated vaccination as the reason for visit (23.8% and 30.5%, respectively). Among the remainder, there also were similar proportions who accepted vaccination: 68.9% white and 62.1% African-American patients. History of previous vaccination was the only statistically significant predictor of vaccine acceptance (odds ratio [OR] 8.64, 95% confidence interval [CI] 4.17, 17.91, P<.001). After adjusting for history of previous vaccination, age, gender, and education, the odds of vaccine acceptance were no different for whites and African Americans (OR 1.20, 95% CI 0.63, 2.29, P=.57). CONCLUSIONS: Vaccination acceptance differed little between African-American and white elderly patients. Using nonphysician personnel to identify and offer influenza vaccine to eligible patients is easily accomplished in primary care offices and has the potential to eliminate racial disparities in influenza vaccination.     

The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease

BACKGROUND: More than 50% of the elderly population has not received pneumococcal vaccination. Uncertainty regarding the benefits of immunization, particularly for noninvasive disease, may contribute to the underuse of pneumococcal vaccine. OBJECTIVE: To assess the health and economic benefits associated with pneumococcal vaccination. METHODS: We conducted a 2-year retrospective cohort study among all elderly members of a staff-model managed care organization who had a baseline diagnosis of chronic lung disease. The study outcomes were assessed over 2 years, from November 15, 1993, through November 14, 1995, and included hospitalizations for pneumonia and influenza, death, and hospitalization costs. Using administrative data, we compared these outcomes for vaccinated and unvaccinated subjects using multivariate models to control for subjects' baseline demographic and health characteristics. The additive benefits of combined influenza and pneumococcal vaccination were also assessed for the 2 influenza seasons included in the study. RESULTS: There were 1898 subjects. Pneumococcal vaccination was associated with significantly lower risks for pneumonia hospitalizations (adjusted risk ratio [RR], 0.57; 95% confidence interval [CI], 0.38-0.84; P=.005) and for death (adjusted RR, 0.71; 95% CI, 0.56-0.91; P = .008). For the control outcome of all nonpneumonia hospitalizations, rates did not differ significantly between the 2 groups (adjusted RR, 0.91; 95% CI, 0.77-1.07; P= .24). During the influenza seasons included in the study, the benefits of pneumococcal and influenza vaccinations were additive, with an adjusted RR of 0.28 (95% CI, 0.14-0.58; P<.001) for the number of hospitalizations for pneumonia and influenza among persons who had received both vaccinations compared with those who had received neither and an adjusted odds ratio of 0.18 (95% CI, 0.11-0.31; P<.001) for death. Over the 2-year outcome period, pneumococcal vaccination was also associated with direct medical care cost savings. CONCLUSIONS: Pneumococcal vaccination of elderly persons with chronic lung disease was associated with fewer hospitalizations for pneumonia, fewer deaths, and direct medical care cost savings.     

Racial and sex differences in prevalence of hypothyroidism in patients with cardiomyopathies enrolled into a heart failure disease management program

The authors evaluated the prevalence of hypothyroidism in patients with heart failure (HF) to determine whether there are racial and sex differences and to determine the number of new cases of hypothyroidism. The study included 194 patients in an HF disease management program (HFDMP) in South Florida. Patients were interviewed for a history of hypothyroidism and referred for measurement of thyrotropin. The prevalence of hypothyroidism was calculated by race and sex. The prevalence of hypothyroidism was 18% for all patients with HF and 23% among Hispanics; however, this trend was not statistically significant (P = .06). More men than women had hypothyroidism (P = .04). Patients with hypothyroidism had higher mean lipid profiles (P < .01) and lower mean heart rates (P = .03) than healthy patients. Hypothyroidism is prevalent among HF patients, especially men. Hispanics with HF may have a higher prevalence of hypothyroidism. The standardized protocol of the HFDMP helped identify new cases of hypothyroidism.     

Introducing a pneumococcal vaccine to an existing influenza immunization program: vaccination rates and predictors of noncompliance.

PURPOSE: Influenza vaccination has been recommended for all elderly people in The Netherlands since 1996, with greater than 80% compliance. It is unknown, however, if the addition of another vaccine to this immunization program will affect compliance. SUBJECTS AND METHODS: General practitioners offered a pneumococcal vaccine together with the yearly influenza vaccination to 3365 patients aged 65 years and older. A questionnaire was then mailed to a stratified sample (n = 972) of these patients. Factors associated with noncompliance with vaccination were assessed using polytomous logistic regression. RESULTS: A total of 2529 patients (75%) received the pneumococcal vaccine and 2812 (84%) received the influenza vaccine. Predictors of noncompliance with the pneumococcal vaccine were perceived lack of recommendation by the general practitioner (odds ratio [OR] = 4.6; 95% confidence interval [CI], 2.6 to 8.3) and fear of local side effects (OR = 2.8; 95% CI, 1.6 to 4.6). Predictors of noncompliance with both vaccinations also included unwillingness to comply with the doctor's advice (OR = 6.1; 95% CI, 2.4 to 15.4), the belief that vaccinations weaken one's natural defenses (OR = 2.7; 95% CI, 1.4 to 5.3) or that influenza is not dangerous (OR = 2.9; 95% CI, 1.5 to 5.4), and the fear of becoming sick from pneumococcal vaccination (OR = 2.9; 95% CI, 1.1 to 7.9). People who felt healthy, found it difficult to visit the doctor's office, had private medical insurance, or were younger than 75 years of age also had a greater risk of not being vaccinated. CONCLUSION: Introducing a pneumococcal vaccine to an existing influenza immunization program resulted in high pneumococcal and influenza vaccination rates. A wider diversity of patient characteristics and attitudes was present when neither vaccination was received.     

Receipt of influenza and pneumonia vaccinations: the dual disparity of rural minorities

OBJECTIVES: To examine the receipt of age‐appropriate influenza and pneumococcal polysaccharide vaccinations (PPV), with particular attention to rural minority persons. DESIGN: Data were drawn from the 2005 Behavioral Risk Factor Surveillance System. The dependent variables were self‐reported receipt of annual influenza immunizations in adults aged 50 and older (n=177,417) or lifetime pneumococcal immunizations in adults aged 65 and older (n=81,762). The main independent variables were residence and race. MEASUREMENTS: All data are self‐reported. Multivariate analysis controlled for selected personal and county‐level characteristics. Analyses were conducted in 2009/10. RESULTS: Forty‐two percent of adults aged 50 and older reported an influenza vaccination; 31.1% of rural African Americans reported an influenza vaccination, and 64.6% reported a PPV. White and African‐American rural residents reported lower vaccination rates. Adjusted analysis indicated an interaction between race and rurality. White rural residents were more likely to be vaccinated than other whites, whereas rural African Americans were less likely to be vaccinated than urban African Americans. CONCLUSION: This study confirms previous findings while finding an interactive effect between rurality and race. The results indicated the importance of provider availability to delivery. Alternative delivery methods may be an effective solution to improve delivery rates.     

Increasing the pneumococcal vaccination rate of elderly patients in a general internal medicine clinic

To improve the pneumococcal vaccination status of an elderly patients group, those older than 64 years of age were identified from a computer file of all continuing care patients in a general internal medicine clinic. In a randomly chosen study group (N = 163), 91 elderly patients (56 per cent) had received the pneumococcal vaccine. Factors associated with a higher rate of pneumococcal vaccination included receiving the previous year's influenza vaccine, a medical problem list attached to the patient's chart, active clinic status (i.e., seen in the year before the study began), and more than two problems listed in the computer record. Letters encouraging pneumococcal vaccination were then sent to patients who had not been vaccinated. Twenty of 72 patients (28 per cent) who received the letter were vaccinated during the next year; 8 per cent of control patients (three of 39) who did not receive the letter were vaccinated. The 95 per cent confidence limit for the relative difference between the study and control group is 6 to 53 per cent. The relative difference was also significant for influenza vaccination between the intervention group and the portion of the control group that had not been vaccinated at the first chart review. Factors associated with pneumococcal vaccination rate following the mailing of the reminder letter were active clinic status and being up to date for either influenza or tetanus vaccination.(ABSTRACT TRUNCATED AT 250 WORDS)     

Increased utilization of influenza and pneumococcal vaccines in an elderly hospitalized population

This study compared three interventions designed to increase acceptance of influenza and pneumococcal vaccines among elderly hospitalized patients. All individuals 65 and older able to give informed consent (73 patients) who were admitted to one medical floor of an acute care hospital were randomized to one of three groups. All groups received informational pamphlets explaining influenza and pneumococcal disease, their respective vaccines, and indications for their use. The first group received pamphlets only, the second received nursing follow-up, and the third received trained volunteer follow-up. Patients on another medical floor served as controls. The results showed a significant improvement in vaccine acceptance in all three study groups compared to controls for both influenza (78% vs 0%) and pneumococcal (75% vs 0%) vaccines. The differences among the three groups were not significant. No significant differences were found among patients accepting or refusing vaccination with regard to diagnosis, age, length of stay, sex, or having a private physician. We conclude that a simple educational program followed by offering vaccination before hospital discharge can be easily implemented, and dramatically increase immunization rates in this high risk group.     

Influenza vaccine and pneumonia mortality in a nursing home population

The effectiveness of immunization against influenza in elderly persons is uncertain. A retrospective cohort study in a New York City nursing home examined the occurrence of pneumonia and its related mortality over three consecutive influenza seasons (Nov 1 through April 30, 1979 to 1980, 1980 to 1981, and 1981 to 1982). Nearly one half of approximately 450 residents (mean age, 84 years) accepted immunization each year. The vaccinated and unvaccinated groups were similar. The attack rate of pneumonia did not differ significantly between the vaccinated and unvaccinated groups in any of the three influenza seasons. When influenza was occurring in the community (1979 to 1980 and 1980 to 1981), however, the risk of death from pneumonia in the unvaccinated group was three-fold higher than in the vaccinated group (60% vs 18% and 73% vs 25%, respectively). In a year when influenza was specifically sought and not found in the facility (1981 to 1982), however, vaccination did not affect pneumonia-related mortality. This study also suggests that estimates of mortality due to pneumonia should include deaths that occur up to 60 days after onset of pneumonia; shorter follow-up may overestimate the protective effect of vaccination.     

Electronic nudges to increase influenza vaccination uptake among patients with heart failure: A pre-specified analysis of the NUDGE-FLU trial

Aims

Seasonal influenza vaccination is strongly recommended in patients with heart failure (HF). The NUDGE-FLU trial recently found two electronic behavioural nudging letter strategies – a letter highlighting potential cardiovascular benefits of vaccination and a repeated letter at day 14 –effective in increasing influenza vaccination in Denmark. The aims of this pre-specified analysis was to further examine vaccination patterns and effects of these behavioural nudges in patients with HF including potential off-target effects on guideline-directed medical therapy (GDMT) use.

Methods and results

The nationwide NUDGE-FLU trial randomized 964 870 Danish citizens ≥65 years to usual care or nine different electronic nudging letter strategies. Letters were delivered through the official Danish electronic letter system. The primary endpoint was the receipt of an influenza vaccine; additional outcomes for this analysis included GDMT use. In this analysis, we also assessed influenza vaccination rates in the overall Danish HF population including those <65 years (n = 65 075). During the 2022–2023 season, influenza vaccination uptake was 71.6% in the overall Danish HF population but this varied considerably with only 44.6% uptake in those <65 years. A total of 33 109 NUDGE-FLU participants had HF at baseline. Vaccination uptake was higher among those on higher levels of baseline GDMT (≥3 classes: 85.3% vs. ≤2 classes: 81.9%; p < 0.001). HF status did not modify the effects of the two overall successful nudging strategies on influenza vaccination uptake (cardiovascular gain-framed letter: p_interaction = 0.37; repeated letter: p_interaction = 0.55). No effect modification was observed across GDMT use levels for the repeated letter (p_interaction = 0.88), whereas a trend towards attenuated effect among those on low levels of GDMT was observed for the cardiovascular gain-framed letter (p_interaction = 0.07). The letters had no impact on longitudinal GDMT use.

Conclusions

Approximately one in four patients with HF did not receive influenza vaccination with a pronounced implementation gap in those <65 years where less than half were vaccinated. HF status did not modify the effectiveness of cardiovascular gain-framed and repeated electronic nudging letters in increasing influenza vaccination rates. No unintended negative effects on longitudinal GDMT use were observed. Clinical Trial Registration: ClinicalTrials.gov NCT05542004.     

Open access to an outpatient intravenous diuresis program in a systolic heart failure disease management program

In order to provide efficient utilization of resources in an outpatient setting for acute exacerbation of heart failure (HF), the authors piloted an open-access outpatient intravenous (IV) diuretic program (IVDP) to evaluate utilization in an HF disease management program (HFDMP), patient characteristics for users of the program, and safety. An outpatient HFDMP at Jackson Memorial Hospital in Miami, Florida, enrolling 577 patients 18 years and older with an ejection fraction ≤40% was implemented. For symptoms or weight gain ≥5 pounds, patients were eligible to use an open-access IVDP during clinic hours. A total of 130 HFDM patients (22.5%) used the IVDP. IVDP users were more likely to be diabetic, with lower body mass indices than non-IVDP users. New York Heart Association class IV patients and previously hospitalized patients were more likely to use the IVDP. There were no documented adverse reactions for patients receiving treatment and no difference in mortality between groups. This open-access outpatient IVDP model for patients with HF was readily utilized by the HFDMP participants and appears safe for use in this population. This unique model may provide alternative access for acute HF treatment. Congest Heart Fail.     

Influence of prior pneumococcal and influenza vaccination on outcomes of older adults with community-acquired pneumonia

OBJECTIVES: To determine whether prior pneumococcal and seasonal influenza vaccination improves outcomes in older adults hospitalized for community‐acquired pneumonia (CAP). DESIGN: Prospective, observational, multicenter study. SETTING: Five public hospitals providing universal free care to the whole population in three Spanish regions. PARTICIPANTS: Individuals aged 65 and older admitted to the hospital with CAP through the emergency department. MEASUREMENTS: Pneumococcal and influenza vaccination status. The primary study outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and overall case‐fatality rate. Outcome variables of individuals vaccinated with both vaccines were compared with outcomes of those who were unvaccinated. RESULTS: Two hundred thirty‐eight individuals had received 23‐valent pneumococcal polysaccharide vaccine and seasonal influenza vaccination and were compared with 195 unvaccinated individuals. No differences were found with respect to combined antibiotic therapy between groups (38.0% vs 39.7%; P=.80). Similar percentages of vaccinated and unvaccinated individuals required ICU admission (7.2% vs 8.2%; P=.69). Mean LOS was significantly shorter in vaccinated individuals (9.9 vs 12.4 days; P=.04). Overall case‐fatality rates were similar in both groups (5.9% vs 5.1%; P=.73). After adjustment, LOS, risk of ICU admission, and overall case‐fatality rate were not associated with prior pneumococcal and seasonal influenza vaccination. CONCLUSION: The clinical outcomes of vaccinated older adults hospitalized with CAP were not better than those observed in unvaccinated individuals.     

Vaccination adherence to influenza,pneumococcal and hepatitis B virus in adult type 1 diabetes mellitus patients

AimTo document adherence to influenza, pneumococcal and hepatitis B virus (HBV) vaccination programme in adult type 1 diabetes mellitus (T1DM) patients.Materials and methodsObservational retrospective study using data obtained from computerized clinical records. We contacted all adult T1DM registered in our database from a tertiary diabetes care hospital. Primary efficacy outcome was to describe influenza, pneumococcal and HBV vaccination status.ResultsThree hundred patients were analyzed (male 53%). Mean age was 40.0 ± 14.4 years and T1DM duration was 19.7 ± 11.8 years. Thirty-five percent of the patients had complementary indications for studied vaccines. Adherence to vaccination program for influenza, pneumococcal and HBV was achieved by 55%, 18% and 17% of the patients, respectively. Only 3% of the subjects were vaccinated against the three microorganisms. Predictor of correct vaccination were: age, shorter diabetes duration, insulin pump treatment, better diabetes control and being a health professional. We detected 17 sick leaves, 127 lost working days and 3 hospitalizations due to flue during the follow-up.ConclusionsThe uptake of recommended vaccinations against influenza, pneumococcal and HBV in adult T1DM patients was below desirable levels. A special effort is required to all health professionals to implement immunization among adult people with T1DM. Clinical Trials NCT03478254.     

Influenza and pneumococcal vaccination among Native American elders in a primary care practice

BACKGROUND: More than 2 million Native Americans (ie, Native Americans and Native Alaskans) live in the United States; 60% reside in cities. This population, especially its elders, is especially susceptible to respiratory diseases; yet, adherence to guidelines for influenza and pneumococcal immunizations is unknown. OBJECTIVES: To evaluate how frequently older and high-risk adults received vaccinations for influenza and pneumococcal infection and to identify patient characteristics associated with adherence to published recommendations. METHODS: Retrospective medical record review of 550 Native American elders seen in an urban primary care practice defined using a culturally appropriate age threshold (> or =50 years) and standard criteria (> or =65 years). Univariate analyses examined demographic and clinical information by vaccination status. Logistic regressions identified factors associated with adherence to immunization guidelines. RESULTS: Among patients aged 50 years and older with any indication according to published recommendations, rates were low for influenza (31%) and pneumococcal (21%) immunizations. Likewise, few subjects at least 65 years of age had been immunized appropriately against influenza (38%) or pneumococcus (32%). Younger age and alcohol use were significantly associated with less frequent immunization; Medicare insurance, depression, and more health problems and taking more medications predicted significantly higher immunization rates. Aged 65 years or older and having cardiovascular disease or diabetes mellitus were specific indications significantly correlated with receipt of influenza and pneumococcal vaccine. CONCLUSIONS: Regardless of age or risk, inadequate vaccination rates were observed in elderly Native Americans. Our findings suggest the need to identify obstacles to immunization and to conduct prospective and elderly intervention studies in Native American populations.     

Albuminuria as a predictor of heart failure hospitalizations in patients with type 2 diabetes

BACKGROUND: Heart failure (HF) occurs more frequently and is a significant cause of mortality in diabetic patients. The purpose of the current study is to ascertain risk factors that are predictive of HF hospitalizations in type 2 diabetic patients. METHODS: Longitudinal observational study of type 2 diabetic patients with baseline diastolic blood pressures > or =80 mm Hg and no history of New York Heart Association class III-IV HF or a serum creatinine > or =2.5 mg/dL nested within a randomized clinical trial. The outcome measure of this study was the first occurrence of HF hospitalization over a 5-year follow-up period. RESULTS: Patients with overt albuminuria at baseline had a higher and earlier occurrence of HF hospitalizations than those with micro- or normoalbuminuria (13.6% versus 3.3%, odds ratio [OR]=3.1, 95% confidence interval [CI]=2.15-4.60, P<.0001). In the multiple logistic regression analyses, the presence of overt albuminuria (OR 5.4, 95% CI=2.3-12.5, P<.001), history of myocardial infarction (OR 4.6, 95% CI=1.6-13.1, P=.004) and a history of New York Heart Association Class I or II HF (OR 8.0, 95% CI=2.2-28.6, P=.0014) at baseline were independently associated with HF hospitalizations. CONCLUSIONS: Overt albuminuria predicts the occurrence of HF hospitalizations in type 2 diabetic patients. Thus early aggressive treatment of diabetic nephropathy should be investigated as a means of preventing of HF.     

Failure to vaccinate Medicare inpatients: a missed opportunity

BACKGROUND: Hospitalized elderly patients are at risk for subsequent influenza and pneumococcal disease. Despite this risk, they are often not vaccinated in this setting. METHODS: We reviewed the medical records of a national sample of 107 311 fee-for-service Medicare patients, 65 years or older, discharged from April 1, 1998, through March 31, 1999, with a principal diagnosis of acute myocardial infarction, heart failure, pneumonia, or stroke. We linked patient identifiers to Medicare Part B claims to identify influenza and pneumococcal vaccines paid for before, during, or after hospitalization. The main outcome measures were documentation by chart review or paid claim of influenza or pneumococcal vaccination. RESULTS: Of the 104 976 patients with a single hospitalization, 35 169 (33.5%; 95% confidence interval [CI], 33.2%-33.8%) received pneumococcal vaccination prior to admission, 444 (0.4%; 95% CI, 0.4%-0.5%) were vaccinated in the hospital, and 1076 (1.0%; 95% CI, 1.0%-1.1%) were vaccinated within 30 days of discharge. In the subgroup of 40 488 patients discharged from October through December, 12 782 (31.6%; 95% CI, 31.1%-32.0%) received influenza vaccination prior to admission, 755 (1.9%; 95% CI, 1.7%-2.0%) were vaccinated in the hospital, and 4302 (10.6%; 95% CI, 10.3%-10.9%) were vaccinated after discharge. Of patients who were unvaccinated prior to admission, 97.3% (95% CI, 97.1%-97.5%) did not receive influenza vaccine and 99.4% (95% CI, 99.3%-99.4%) did not receive pneumococcal vaccine before hospital discharge. CONCLUSION: National recommendations for inpatient vaccination against influenza and pneumococcal disease are not being followed for the vast majority of eligible Medicare patients admitted to the hospital.     

Knowledge and beliefs about influenza,pneumococcal disease,and immunizations among older people

OBJECTIVES: Despite the burden of disease caused by influenza and pneumococcus, immunization rates are moderate and have not reached national goals set for 2010. This study's objective was to identify patient knowledge, attitudes, and beliefs that serve as facilitators of and barriers to influenza and pneumococcal vaccination. DESIGN: A survey conducted in 2000 by computer-assisted telephone interviewing. SETTING: To encounter a broad spectrum of patients and healthcare systems, we sampled patients at inner-city health centers, Department of Veterans Affairs outpatient clinics, and rural and suburban practices. PARTICIPANTS: Inclusion criteria were patients aged 66 and older and an office visit after September 30, 1998. MEASUREMENTS: Responses to questionnaire. RESULTS: Overall, 1,007 (82%) interviews were completed among 1,234 people contacted by phone. Vaccination against pneumococcal disease was significantly related to being able to accurately describe one or more classic symptoms of pneumonia (P =.05). Vaccination against influenza and pneumococcal disease was significantly related to belief that vaccination was the best way to prevent these diseases (P <.001). The unvaccinated reported that they felt they were not likely to contract influenza and that they did not know they needed the pneumococcal vaccine. Access was not related to vaccination status. CONCLUSIONS: Educational campaigns to increase vaccination rates among older adults should focus on symptoms of, risk for, and severity of influenza and pneumococcal diseases and encouraging physicians to recommend the vaccines to their patients.     

Does Sex Influence Immunization Status for Influenza and Pneumonia in Older Veterans?

OBJECTIVES: To compare the prevalence of influenza and pneumococcal immunization rates according to sex in a national sample of older veterans in the Department of Veterans Affairs (VA) healthcare system.
DESIGN: Retrospective, cross-sectional.
SETTING: VA healthcare system.
PARTICIPANTS: Current VA healthcare system users aged 65 and older eligible for immunization in fiscal years 2001 to 2003 (N=48,424 patient records).
MEASUREMENTS: Generalized estimating equations were performed to analyze combined chart review and administrative data to determine effect of sex on receipt of influenza and pneumococcal immunizations.
RESULTS: Unadjusted immunization rates were higher for men than women for influenza (73% vs 69%) and pneumococcal (87% vs 83%) vaccine. Adjusting for demographics, clinical comorbidities, use, and region, women had significantly lower odds of influenza (odds ratio (OR)=0.85, 95% confidence interval (CI=0.79–0.92) and pneumococcal (OR=0.77, 95% CI=0.71–0.84) immunization.
CONCLUSION: Older female veterans have lower rates of immunization than older male veterans in VA settings. Although VA remains above community levels for immunization, older female veterans will benefit from targeted efforts to increase immunization prevalence.