Abstract
The availability of a rural health clinic (RHC) database over the period of 6 years (2008–2013) offers a unique opportunity to examine the trends and patterns of disparities in immunization for influenza and pneumonia among Medicare beneficiaries in the southeastern states. The purpose of this exploratory study was twofold. First, it examined the rural trends and patterns of immunization rates before (2008–2009) and after (2010–2013) the Affordable Care Act (ACA) enactment by state and year. Second, it investigated how contextual, organizational, and aggregate patient characteristics may influence the variations in immunization for influenza and pneumonia of Medicare beneficiaries served by RHCs. Four data sources from federal agencies were merged to perform a longitudinal analysis of the influences of contextual, organizational, and aggregate patient characteristics on the disparities in immunization rates of rural Medicare beneficiaries for influenza and pneumonia. We included both time-varying and time-constant predictors in a multivariate analysis using Generalized Estimating Equation. This study revealed the increased immunization rates for both influenza and pneumonia over a period of 6 years. The ACA had a positive effect on increased immunization rates for pneumonia, but not for influenza, in rural Medicare beneficiaries in the eight states. The RHCs that served more dually-eligible patients had higher immunization rates. For influenza immunization, provider-based RHCs had a higher rate than the independent RHCs. For pneumonia immunization, no organizational variables were relevant in the explanation of the variability. The results also showed that no single dominant factor influenced health care disparities. This investigation suggested further improvements in preventive care are needed to target poor and isolated rural beneficiaries. Furthermore, the integration of immunization data from multiple sources is critically needed for understanding health disparities.
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References
American Lung Association. (2014). Missed opportunities: Influenza and pneumonia vaccination in older adults. Washington, DC: American Lung Association.
Anderson, K. F., & Fullerton, A. S. (2012). Racial segregation and access to health-care coverage: A multilevel analysis. Research in the Sociology Health Care, 30, 133–158. doi:10.1108/S0275-4959(2012)0000030009.
Castilla, J., Guevara, M., Matinez-Baz, I., Ezpeleta, C., Delfrade, J., Irisarri, F., et al. (2015). Enhanced estimates of the influenza vaccination effect in preventing mortality: A prospective cohort study. Medicine (Baltimore), 94(30), e1240. doi:10.1097/MD.0000000000001240.
Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services. (2011). Enhancing use of clinical preventive services among older adults. Washington, DC: AARP. www.cdc.gov/aging and www.aarp.org/healthpros.
Chang, D. H., Bednarczyk, R. A., Becker, E. R., Hockenberry, J. M., Weiss, P. S., Orenstein, W. A., et al. (2015). Trend in U.S. hospitalizations and inpatient deaths from pneumonia and influenza, 1996–2011. Vaccine, 34, 486–594. doi:10.1016/j.vaccine.2015.12.003.
Diggle, P. J., Liang, K. Y., & Zeger, S. L. (1994). Analysis of longitudinal data. Oxford: Oxford University Press.
Eberhardt, M., Ingram, D., Makuc, D. M., Pamuk, E. R., Freid, V. M., Harper, S. B., et al. (2001). Urban and rural chartbook. Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics.
Farmer, M. M., & Ferraro, K. F. (2005). Are racial disparities in health conditional on socioeconomic status? Social Science and Medicine, 60(1), 191–204. doi:10.1016/j.socscimed.2004.04.026.
Gorska-Ciebiada, M., Saryusz-Wolska, M., Ciebiada, M., & Loba, J. (2015). Pneumococcal and seasonal influenza vaccination among elderly patients with diabetes. Postepy Higieny I Medycyny Doswiadczalnej (Online), 69, 1182–1189.
Hanley, J. A., Negassa, A., Edwardes, M. D., & Forrester, J. E. (2003). Statistical analysis of correlated data using generalized estimating equations: An orientation. American Journal of Epidemiology, 157(4), 364–375. doi:10.1093/aje/kwf215.
Hardin, J. W., & Hilbe, J. M. (2003). Generalized estimating equations. Boca Raton, FL: Chapman and Hall/CRC Press.
Health Research & Educational Trust. (2013). Reducing health care disparities: Collection and use of race, ethnicity and language data. Chicago: Health Research & Educational Trust. Retrieved from www.hpoe.org.
Hebert, P. L., Frick, K. D., Kane, R. L., & McBean, A. M. (2005). The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries. Health Services Research, 40(2), 517–538. doi:10.1111/j.1475-6773.2005.00370.x.
Hutchison, L., & Peck, J. (2010). Immunizations and infectious diseases in rural areas. In L. Gamm & L. Hutchison (Eds.). Rural healthy people 2010: A companion document to healthy people (Vol. 3). (www.srph.tamhsc.edu/centers/rhp2010).
IBM Corp. (2013). IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Released.
Johnson, D., Nichol, S. L., & Lipczynski, K. (2008). Barriers to adult immunization. The American Journal of Medicine, 7(2), S28–S35. doi:10.1016/j.amjmed.2008.05.005.
Liang, K. Y., & Zeger, S. L. (1986a). Longitudinal data analysis using generalized linear models. Biometrika, 73(1), 13–22. doi:10.1093/biomet/73.1.13.
Liang, K. Y., & Zeger, S. L. (1986b). Longitudinal data analysis for discrete and continuous outcomes. Biometrics, 42(1), 121–130.
Locher, K. A., Wynne, M. A., Wheatcroft, G. H., Worrall, C. M., & Kelman, J. A. (2015). Medicare claims versus beneficiary self-report for influenza vaccination surveillance. American Journal of Preventive Medicine, 48(4), 384–391. doi:10.1016/j.amepre.2014.10.016.
Multuck, M., & Flowers, L. (2012). Racial and ethnic disparities in influenza and pneumococcal immunization rates among Medicare beneficiaries. A report from the AARP Public Policy Institute, May.
National Vaccine Advisory Committee. (2011). Adult immunization: Complex challenges and recommendations for improvement. A report of the Adult Immunization Working Group to the National Vaccine Advisory Committee, February 25.
Pennant, K. N., Costa, J. J., Fuhlbrigge, A. L., Sax, P. E., Szent-Gyorgyi, L. E., Coblyn, J., et al. (2015). Improving influenza and pneumococcal vaccination rates in ambulatory specialty practices. Open Forum Infectious Diseases, 2(4), 1–9. doi:10.1093/ofid/ofv119.
Sarrazin, M. S. V., Campbell, M. E., Richardson, K. K., & Rosenthal, G. E. (2009). Racial segregation and disparities in health care delivery: Conceptual model and empirical assessment. Health Services Research, 44(4), 1424–1443. doi:10.1111/j.1475-6773.2009.00977.x.
Sudore, R. L., Mehta, K. M., Simonsick, E. M., Harris, T. B., Newman, A. B., Satterfield, S., et al. (2006). Limited literacy in older people and disparities in health and healthcare access. Journal of American Geriatrics Society, 54, 770–776. doi:10.1111/j.1532-5415.2006.00691.x.
Williams, D. R. (2012). Miles to go before we sleep: Racial inequities in health. Journal of Health and Social Behavior, 53(3), 279–295. doi:10.1177/0022146512455804.
Williams, D. R., & Jackson, P. B. (2005). Social sources of racial disparities in health. Health Affairs, 24(2), 325–334. doi:10.1377/hlthaff.24.2.325.
Williams, D. R., & Mohammed, S. A. (2013). Racism and health I: Pathways and scientific evidence. American Behavior Scientist, 57(8), 1152–1173. doi:10.1177/0002764213487340.
Yoo, B. K., Hasebe, T., & Szilagyi, P. G. (2015). Decomposing racial/ethnic disparities in influenza vaccination among the elderly. Vaccine, 33(26), 2997–3002. doi:10.1016/j.vaccine.2015.03.054.
Zheng, B. (2000). Summarizing the goodness of fit on generalized linear models for longitudinal data. Statistics in Medicine, 19, 1265–1275. doi:10.1002/(SICI)1097-0258(20000530)19:10<1265:AID-SIM486>3.0.CO;2-U.
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The analysis for this paper was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number U24MD006954. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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This study, which involved human participants, received institutional review board approval from the University of Central Florida.
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Wan, T.T.H., Lin, YL. & Ortiz, J. Variations in Influenza and Pneumonia Immunizations for Medicare Beneficiaries Served by Rural Health Clinics. J Primary Prevent 38, 403–417 (2017). https://doi.org/10.1007/s10935-017-0468-5
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DOI: https://doi.org/10.1007/s10935-017-0468-5