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Medical Care:
doi: 10.1097/MLR.0b013e3182a50297
Original Articles

Hospitalization and Skilled Nursing Care are Predictors of Influenza Vaccination Among Patients on Hemodialysis: Evidence of Confounding by Frailty

McGrath, Leah J. PhD*; Cole, Stephen R. PhD*; Kshirsagar, Abhijit V. MD; Weber, David J. MD*,‡; Stürmer, Til MD*; Brookhart, M. Alan PhD*

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Abstract

Background: Observational studies of preventive medications, such as vaccinations, can suffer from the healthy-user bias because vaccinated patients may be healthier than unvaccinated patients. Indicators of health status and frailty suitable for attenuating this bias could be identified in administrative data.

Objective: To examine the association of baseline variables and time-dependent hospitalization and skilled nursing care with the receipt of influenza vaccination in patients with end-stage renal disease.

Research Design: Observational cohort study using United States Renal Data System files each year from 1999 to 2005.

Subjects: Population-based cohorts that included >115,000 adult, hemodialysis patients each year.

Measures: We estimated hazard ratios for the association of baseline variables and time-dependent hospitalization days and skilled nursing days with influenza vaccination, controlling for demographic and baseline health status variables.

Results: Vaccination coverage increased from 47% in 1999 to 60% in 2005. Patients with any length of hospitalization were less likely to be vaccinated, however, the association was stronger in patients with longer stays [15–25 d: hazard ratio=0.64 (95% confidence interval, 0.62–0.65); 26–30 d: 0.40 (0.38–0.42)]. Patients with any length of skilled nursing care of >1 day had similar estimates; these patients were also less likely to be vaccinated [26–30 d: 0.66 (0.64–0.69)].

Conclusions: Patients with long hospitalizations or skilled nursing stays were less likely to be vaccinated suggesting evidence of the healthy-user effect. These variables could be used to account for bias in studies of preventive services in patients on dialysis.

© 2013 by Lippincott Williams & Wilkins.

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