Vincent Mor

Brown University School of Public Health · Health Services, Policy & Practice

Background To improve the assessment of COVID-19 vaccine use, safety, and effectiveness in older adults and persons with complex multimorbidity, the COVid VAXines Effects on the Aged (COVVAXAGE) database was established by linking CVS Health and Walgreens pharmacy customers to Medicare claims. Methods We deterministically linked CVS Health and Walg...

IntroductionCOVID-19 booster vaccines are highly effective at reducing severe illness and death from COVID-19. Research is needed to identify whether racial and ethnic disparities observed for the primary series of the COVID-19 vaccines persist for booster vaccinations and how those disparities may vary by other characteristics. We aimed to measure...

IMPORTANCE: Head-to-head safety comparisons of the mRNA vaccines for SARS-CoV-2 are needed for decision making; however, current evidence generalizes poorly to older adults, lacks sufficient adjustment, and inadequately captures events shortly after vaccination. Additionally, no studies to date have explored potential variation in comparative vacci...

Objectives: Nursing home (NH) Minimum Data Set (MDS) have frequently been used to measure medication use in epidemiologic studies, but there is little evidence on the accuracy of MDS-based medication records. We compared antipsychotic use estimated using 2 data sources-MDS and NH electronic medication administration records (eMAR). Design: Cross...

Background/aims: When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home-based pragmatic cluster randomized trials to compare nursing home and resi...

Objective: To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). Data sources: 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Data collection/extraction methods: Not Applicable. Study design: W...

Unlabelled: Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating dispari...

Objective: To examine incidence of and resident characteristics associated with breakthrough infections (BTIs) and severe illness among residents with 2 messenger RNA (mRNA) vaccinations. Design: Retrospective cohort study. Setting and participants: Nursing home (NH) residents who completed their primary series of mRNA COVID-19 vaccination by...

COVID-19 vaccination and regular testing of nursing home staff have been critical interventions for mitigating COVID-19 outbreaks in US nursing homes. Although implementation of testing has largely been left to nursing home organizations to coordinate, vaccination occurred through a combination of state, federal, and organization efforts. Little re...

Importance: Individuals with Alzheimer disease and related dementias (ADRD) frequently require skilled nursing facility (SNF) care following hospitalization. Despite lower SNF incentives to care for the ADRD population, knowledge on how the quality of SNF care differs for those with vs without ADRD is limited. Objective: To examine whether perso...

Background: Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. Methods: We...

Literature suggests that public reporting of quality may exacerbate disparities in access to high-quality post-acute and long-term care for older adults. The objective of this study was to evaluate the impact of the home health (HH) 5-star ratings on changes in high-quality HH agency (HHA) use, by race, ethnicity, income level, and place-based fact...

Purpose: Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on pat...

Despite important advances in the linkage of residents’ claims and Minimum Data Set (MDS) information, the data infrastructure for long-term care remains inadequate for public health surveillance and clinical research. It is widely known that the evidence base supporting treatment decisions for elderly nursing home residents is scant as residents a...

Nursing home residents continue to experience significant COVID-19 morbidity and mortality (1). On March 29, 2022, the Advisory Committee on Immunization Practices (ACIP) recommended a second mRNA COVID-19 vaccine booster dose for adults aged ≥50 years and all immunocompromised persons who had received a first booster ≥4 months earlier.* On Septemb...

Background: During the deadly 2020 SARS-CoV-2 surge in nursing homes (NHs), Massachusetts (MA) initiated a multicomponent infection control intervention to mitigate its spread. Methods: We aimed to assess the intervention's impact by comparing the weekly risk of PCR-confirmed infections among MA NH residents to those in neighboring New England s...

Objectives Reverse transcription polymerase chain reaction (PCR) and antigen tests for SARS-CoV-2 are sometimes discordant. We evaluated the discordance between antigen and PCR tests sampled in skilled nursing facilities (SNFs) to assess the relationship of symptom presence, timing between tests, and the presence of a facility outbreak. Design Obs...

Objectives To examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death. Design Cohort study using Minimum Data Set and electronic health record data from a large multi-state long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-a...

Background The purpose of the study is to evaluate the effect of an Advance Care Planning (ACP) Video Program on documented Do-Not-Hospitalize (DNH) orders among nursing home (NH) residents with advanced illness. Methods Secondary analysis on a subset of NHs enrolled in a cluster-randomized controlled trial (41 NHs in treatment arm implemented the...

Objectives The Veterans Health Administration (VA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VA. This study aimed to describe how the VA's purchasing policies impede or facilitate contracting with nursing homes. Design Semistructured interviews of key stakeholders...

Background: We sought to compare rates of adverse events among nursing home residents who received an mRNA COVID-19 vaccine booster dose with those who had not yet received their booster. Methods: We assessed a prospective cohort of 11,200 nursing home residents who received a primary COVID-19 mRNA vaccine series at least six months prior to Sep...

Background: The Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD. Methods: We examined MA beneficiaries who completed the Medicare...

See related Special Articles by Gurwitz el al. and Levy et al. and Resnick et al. in this issue.

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the p...

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconom...

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the p...

Importance: Identifying successful strategies to increase COVID-19 vaccination among skilled nursing facility (SNF) residents and staff is integral to preventing future outbreaks in a continually overwhelmed system. Objective: To determine whether a multicomponent vaccine campaign would increase vaccine rates among SNF residents and staff. Desi...

Background A SARS-CoV-2 vaccine booster dose has been recommended for all nursing home residents. However, we lack effectiveness data on boosters preventing infection, death and hospitalization in this frail population. Methods We emulated nested target trials in two large nursing home systems in parallel to evaluate the effectiveness of a SARS-Co...

Background In pragmatic trials, on-site partners, rather than researchers, lead intervention delivery, which may result in implementation variation. There is a need to quantitatively measure this variation. Applying the Framework for Implementation Fidelity (FIF), we develop an approach for measuring variability in site-level implementation fidelit...

Objective To test the effect of a personalized music intervention on agitated behaviors and medication use among long-stay nursing home residents with dementia. Design Pragmatic, cluster-randomized controlled trial of a personalized music intervention. Staff in intervention facilities identified residents' early music preferences and offered music...

Background Nursing home (NH) residents, especially those who were Black or with dementia, had the highest infection rates during the COVID-19 pandemic. A 9-week COVID-19 infection control intervention in 360 Massachusetts NHs showed adherence to an infection control checklist with proper personal protective equipment (PPE) use and cohorting was ass...

Reports of fatal adverse events following mRNA-based vaccination for COVID-19 in Norwegian nursing home (NH) residents have raised concern regarding vaccine safety in very old and frail persons. A limitation of these reports, however, is the absence of contemporaneous control groups, particularly given the high baseline mortality in this population...

The Veterans Health Administration (VA) is increasingly purchasing long-term care for eligible Veterans from non-VA, community nursing homes (CNHs). Antipsychotics present safety risks for older adults, but it is unknown how the prevalent use of antipsychotics at CNHs influences whether newly admitted Veterans will initiate antipsychotic therapy. T...

Nursing home (NH) residents, especially those who were Black or had dementia, had the highest infection rates during the COVID-19 pandemic. A 9-week COVID-19 infection control intervention in 360 Massachusetts NHs showed that adherence to an infection control checklist with proper PPE use and cohorting, was associated with declines in weekly infect...

In the Veterans’ Administration (VA), medical centers contract with community nursing homes to provide care to Veterans. As a purchaser, the VA could pursue a strategy of selecting a high-quality network; alternatively, it could focus resources on oversight by its nursing-home coordinators. The question of whether narrow networks are good for Veter...

This study examines rates of home dialysis and transplant at dialysis facilities that serve patients with high social risk to understand how they fare under the End-Stage Renal Disease Treatment Choices Model.

Background: Prior studies have identified lower mortality in Black Veterans compared with White Veterans after hospitalization for common medical conditions, but these studies adjusted for comorbid conditions identified in administrative claims. Objectives: The objectives of this study were to compare mortality for non-Hispanic White (hereafter,...

Objectives To assess whether prevailing antipsychotic use rates in community nursing homes (CNH) influence new initiation of antipsychotics and diagnosis with antipsychotic indications among Veterans. Methods We used linked 2013–2016 Veterans Administration (VA) data, Medicare claims, Nursing Home Compare, and Minimum Data Set (MDS) assessments. T...

Background Agitated and aggressive behaviors (behaviors) are common in nursing home (NH) residents with dementia. Medications commonly used to manage behaviors have dangerous side effects. NHs are adopting non-pharmacological interventions to manage behaviors, despite a lack of effectiveness evidence and an understanding of optimal implementation s...

Objective: To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness. Design: Pragmatic cluster randomized clinical trial. Five ACP videos were available...

Background: At the height of the COVID-19 pandemic, a large nursing home chain implemented a policy to temporarily hold potentially unnecessary medications. We describe rates of held and discontinued medications after a temporary hold policy of potentially unnecessary or nonessential medications. Methods: This retrospective cohort study uses ele...

Two influenza vaccines are licensed in the U.S. exclusively for the 65 years and older population: a trivalent inactivated high-dose influenza vaccine (HD-IIV3) and a trivalent inactivated adjuvanted influenza vaccine (aIIV3). In a recent publication, we estimated a relative vaccine effectiveness (rVE) of HD-IIV3 vs. aIIV3 of 12% (95% CI: 3.3-20%)...

Background/objectives: The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths. Design: Systematic review. Setting: Long-term care facilities (nursin...

Objective To compare the impact of the introduction of two distinct sets of star ratings, quality of care and patient experience, on home health agency (HHA) selection. Data Sources We utilized 2014–2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website....

Objectives To compare rates of adverse events following COVID-19 vaccination among nursing home residents with and without previous SARS-CoV-2 infection. Design Prospective cohort. Setting and Participants 20,918 nursing home residents who received the first dose of mRNA COVID-19 vaccine from December 18, 2020 through February 14, 2021 in 284 fac...

Background Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus...

Importance Medicare Advantage (MA) plans, which disproportionately enroll racial/ethnic minorities and persons with socioeconomic disadvantage, receive bonus payments on the basis of overall performance on a 5-star rating scale. The association between plans’ overall quality and disparities in quality is not well understood. Objective To examine t...

Our objective was to identify the influencing factors associated with the implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement program within a national healthcare system. INTERACT focuses on early identification and management of changes in residents’ condition leading to a reduction in potentially prev...

Expansion of the Medicare Advantage program during 2009-18 saw greater enrollment among racial/ethnic minorities and other traditionally marginalized groups. Growth was more rapid among Black, Hispanic, and dually enrolled beneficiaries than among White and nondual beneficiaries. The implications of greater heterogeneity in the program for enrollee...

Background The devastating impact of the SARS-CoV-2 pandemic prompted the development and emergency use authorization of two mRNA vaccines in early 2020. Vaccine trials excluded nursing home (NH) residents, limiting adverse event data that directly apply to this population. Methods To prospectively monitor for potential adverse events associated w...

Objective: To compare rates of incident SARS-CoV-2 infection and 30-day hospitalization or death among residents with confirmed infection in nursing homes with earlier versus later SARS-CoV-2 vaccine clinics. Design: Matched pairs analysis of nursing homes that had their initial vaccine clinics between December 18, 2020, and January 2, 2021, ver...

Background Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience.Objectives To measure the effec...

Introduction: Patients with Alzheimer's disease and related dementias (ADRD) face substantial challenges in selecting, and remaining enrolled in, health insurance. Little is known about how patients with ADRD experience the Medicare Advantage (MA) program. Methods: We used, hospital, outpatient, and post-acute care data to identify MA beneficiar...

Improved therapeutics and supportive care in hospitals have helped reduce mortality from COVID-19. However, there is limited evidence as to whether nursing home residents, who account for a disproportionate share of COVID-19 deaths and are often managed conservatively in the nursing home instead of being admitted to the hospital, have experienced s...

Objective To examine the population‐level impacts of the introduction of novel cancer therapies with high cost in the United States, using immunotherapies in advanced nonsmall cell lung cancer (NSCLC) as an example. Data Sources Surveillance, Epidemiology, and End Results data in 2012‐2015 linked to Medicare fee‐for‐service claims until 2016. Stu...

Objective To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower‐risk patients being admitted to SNF. Data Sources/Collection We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient ad...

Objective: To describe the frequency and timing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody detection in a convenience sample of skilled nursing facility (SNF) residents with and without confirmed SARS-CoV-2 infection. Design: Retrospective analysis of SNF electronic health records. Setting: Qualitative SARS-CoV-2...

Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-r...

BACKGROUND Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted. AIM To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation...

Importance: The Hospital Readmissions Reduction Program publicly reports and financially penalizes hospitals according to 30-day risk-standardized readmission rates (RSRRs) exclusively among traditional Medicare (TM) beneficiaries but not persons with Medicare Advantage (MA) coverage. Exclusively reporting readmission rates for the TM population m...

Background Influenza outbreaks in nursing homes pose a threat to frail residents and occur even in vaccinated populations. We conducted a pragmatic cluster-randomized trial comparing adjuvanted trivalent influenza vaccine (aTIV) versus trivalent influenza vaccine (TIV). Here, we report an exploratory analysis to compare the effect of aTIV versus TI...

Importance The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing homes. Vulnerable nursing home residents are at high risk for adverse outcomes, but improved understanding is needed to identify risk factors for mortality among nursing home residents. Objective To identify risk factors for 30-day all-cause mortality among U...

Background Nursing home residents account for 45% SARS-CoV-2 related deaths in the U.S. but only 0.6% of the population. Our research group conducted a large pragmatic cluster randomized influenza vaccine trial in 965 nursing homes (NCT03965195). Due to the pandemic and its impact after the influenza season, we prospectively collected reports of SA...

Using the National Institutes of Health (NIH) Stage Model framework, we are conducting a Stage III/IV embedded trial to evaluate the effects of personalized music on agitated behaviors in nursing home (NH) residents with dementia under two research conditions--less pragmatic, more researcher involvement (Stage III) and more pragmatic, less research...

Background/Objectives We sought to compare the post‐acute and long‐term care experience of Medicare beneficiaries with and without Alzheimer Disease and Related Dementias (ADRD), and whether differences changed from January 1, 2007 to September 30, 2015. Design Retrospective cross‐sectional trend study using Medicare claims linked to the Centers f...

Importance Socioeconomic factors are associated with worse outcomes after hospitalization, but neither the Centers for Medicare & Medicaid Services (CMS) nor the Veterans Affairs (VA) health care system adjust for socioeconomic factors in profiling hospital mortality. Objective To evaluate changes in Veterans Affairs medical centers’ (VAMCs’) risk...

BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short‐stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two h...

Background and Objectives U.S. Department of Veterans Affairs Medical Centers (VAMCs) contract with nursing homes (NHs) in their community to serve Veterans. This study compares characteristics and performance of VA-paid and non-VA-paid NHs both nationally and within local VAMC markets. Research Design and Methods VA-paid NHs were identified, char...

Background/objectives: Infection screening tools classically define fever as 38.0°C (100.4°F). Frail older adults may not mount the same febrile response to systemic infection as younger or healthier individuals. We evaluate temperature trends among nursing home (NH) residents undergoing diagnostic SARS-CoV-2 testing and describe the diagnostic ac...

Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) constitute a worldwide public health crisis. In light of the AD/ADRD epidemic now existing within the global COVID-19 pandemic, the need for global action to improve dementia care is greater than ever. The article collection “Dementia- an Interdisciplinary Approach,” in the Isr...

Background and objectives: Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011-when the VA implemented a process of standardizing payments and establishing national contracts for community-base...

Background Influenza leads in preventable infection-related hospitalization in nursing home (NH) residents. The adjuvanted trivalent influenza vaccine (aTIV) is more immunogenic than similarly dosed nonadjuvanted trivalent influenza vaccine (TIV), and observational studies suggest aTIV better prevents hospitalizations in older adults. We prospectiv...

Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, we found that as SNFs moved incre...

End‐stage kidney disease (ESKD) is common among Veterans. VA’s limited capacity to deliver dialysis treatment means that VA relies heavily on community providers, making chronic dialysis the single largest VA expenditure for outpatient community care. In the past, VA paid for non‐VA dialysis on a local, ad hoc basis, with some payments greatly exce...

Importance Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. Objective To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. Design, Setting, and Partici...