American Journal of Public Health Research, 2013, Vol. 1, No. 2, 38-46 Available online at http://pubs.sciepub.com/ajphr/1/2/1 © Science and Education Publishing DOI:10.12691/ajphr-1-2-1 Does Frailty Modify the Effect of Race on Influenza Vaccination within Nursing Facilities in Michigan, 2005- 2006? Barbara Bardenheier 1,2,* , Stefan Gravenstein 3 , Carolyn Furlow 1 , Faruque Ahmed 1 , Carol J. Rowland Hogue 2 1 Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA 2 Epidemiology Department, Rollins School of Public Health, Emory University, Atlanta, USA 3 Department of Community Health, Alpert Medical School, Brown University, Providence, USA *Corresponding author: bfb7@cdc.gov Received January 06, 2013; Revised February 07, 2013; Accepted March 15, 2013 Abstract Nursing home racial composition is associated with vaccine uptake; black residents are less well immunized than white residents. To determine if health status modifies the effect of race on receiving vaccination among nursing home residents, we used cross-sectional data from the Centers for Medicare & Medicaid Services for Michigan from October 1, 2005 through March 31, 2006 in 291 racially mixed nursing facilities (n=66,895 residents). Analyses included multilevel models, stratified by the proportion of black residents in the nursing home, to assess whether frailty, measured with the Cognitive Performance Scale (CPS), the Activities of Daily Living (ADL), and the Changes in Health, End-stage disease and Symptoms and Signs (CHESS), contributed to vaccination inequity (i.e., white-black difference) within nursing homes. In facilities with few (<5%) blacks, the median vaccination inequity increased when comparing non-frail to frail (CPS) residents: from 4.4 to 14.5 percentage points; ADL: 3.6 to 8.7; and CHESS: 4.1 to 9.4. Among residents of nursing homes with majority (> 50%) blacks, the inequity decreased with increasing frailty (CPS: 8.7 to 0.8; ADL: 9.3 to 2.1; and CHESS: 6.7 to 4.6). Frail residents of minority status within a facility were less likely to be vaccinated than either healthier minority status residents or majority status residents, frail or healthy. Keywords: vaccination, nursing home, frailty, racial inequity 1. Introduction The influenza vaccine is recommended for nursing home residents and persons with chronic underlying conditions. A national white-black difference in vaccine receipt has consistently remained at about 8 percentage points [2,3]. The biggest inequities were associated with the nursing home itself (higher vs lower quality ); however, there were also white-black differences within homes. In a study examining influenza vaccination in nursing homes in Michigan, racial differences within nursing homes were reported in vaccine receipt, refusals, and in being offered the vaccine, with and without adjustment for confounders [4]. The adjusted median range of inequity (i.e., white – black) within homes, stratified by proportion black residents in the facility, was 5.0 to 5.6 percentage points. The racial difference in refusing vaccine (range 2.1-2.5 percentage points) was about the same as the differences in not being offered the vaccine (2.2-3.0 percentage points) [1]. Offering an influenza vaccine is likely one of the least labor-intensive preventive care service offered in nursing homes and therefore racial differences in this service is likely indicative of more serious racial differences in quality of care. One study found that blacks often enter nursing homes in poorer health than whites [5]. We found in a previous study that very ill nursing home residents were less likely to receive the influenza vaccine [6]; however, we were unable to determine if those residents refused or were not offered the vaccine. Several studies have shown that poorer health may also be associated with the inability to access health care services such as vaccination, among community-dwelling adults [7,8]. Because difficulty in accessing healthcare providers is not an obstacle in nursing homes, any frailty- related difference in nursing homes would likely be due to attitudes and beliefs by staff resulting in residents not being offered the vaccine, residents‘ or their guardians‘ refusal of the vaccine, or vaccination policies (e.g., timing, frequency of offering vaccine, protocols such as standing orders, etc.). We hypothesized that the roughly 5.0-5.6 percentage point racial gap in vaccination among nursing home residents in Michigan [4] may be due to blacks being more frail and therefore were either not being offered the vaccine or refused the vaccine more often than their white counterparts. We used measures of cognition, functioning and end-stage symptoms and comorbidity, as reported for