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Medicare beneficiaries' plans for the COVID‐19 vaccine in Fall 2020, and why some planned to decline

1. The Covid Tracking Project. COVID-19 is Affecting Black, Indigenous, Latinx, and Other People of Color the Most. 2021. https:// covidtracking.com/race. 2. Cutler DM, Nikpay S, Huckman RS. The business of medicine in the era of COVID-19. JAMA. 2020;323(20):2003-2004. https:// doi.org/10.1001/jama.2020.7242. 3. Quan D, Luna Wong L, Shallal A, et al. Impact of race and socioeconomic status on outcomes in patients hospitalized with COVID-19. J Gen Intern Med. 2021;1-8. https://doi.org/10.1007/ s11606-020-06527-1. 4. Pierce RP, Stevermer JJ. Disparities in use of telehealth at the onset of the COVID-19 public health emergency. J Telemed Telecare. 2020;1357633X2096389. https://doi.org/10.1177/1357633X 20963893. 5. Centers for Disease Control. Medicare Current Beneficiary Survey (MCBS) COVID-19 Summer and Fall 2020 Rapid Response Supplements. 2021. https://www.cms.gov/Research-Statistics-Data-andSystems/Downloadable-Public-Use-Files/MCBS-Public-Use-File. 6. Pew Research Center. 53% of Americans Say the Internet Has Been Essential During the COVID-19 Outbreak. 2020. file:///C:/ Users/ellisc14/Downloads/PI_2020.04.30_COVID-internet_REP ORT.pdf. 7. Campos-Castillo C, Laestadius LI. Racial and ethnic digital divides in posting COVID-19 content on social media among US adults: secondary survey analysis. J Med Internet Res. 2020;22(7): e20472. https://doi.org/10.2196/20472. 8. Loeb TB, Atkins-Jackson AJ, Brown AF. No Internet, No Vaccine: How Lack of Internet Access has Limited Vaccine Availability for Racial and Ethnic Minorities. https://theconversation.com/nointernet-no-vaccine-how-lack-of-internet-access-has-limited-vaccineavailability-for-racial-and-ethnic-minorities-154063.


INTRODUCTION
Medicare beneficiaries are at increased risk of morbidity and mortality from COVID-19. 1 In the fall of 2020, vaccines had not yet been approved, but the public was forming opinions about them and deciding whether to undergo vaccination. We sought to determine whether the vaccination plans of Medicare beneficiaries in the fall mirror patterns in vaccine uptake observed in the first month of vaccination, 2 the reasons given by those who planned to decline, and whether sociodemographic differences exist among those who planned to decline and their reasons for saying so.

METHODS
We conducted a cross-sectional analysis using the Medicare Current Beneficiary Survey (MCBS) Fall COVID-19 Supplement, a nationally representative sample of the Medicare population involving telephone interviews in October or November of 2020 administered by NORC at the University of Chicago (formerly the National Opinion Research Center). Respondents were asked whether they would get a COVID-19 vaccine when it became available. Those who said "probably not" or "definitely not" were asked their reason(s) for planning to decline. Those responses were categorized by NORC into nine themes. We used chi-square tests to examine response differences by sociodemographic characteristics, including age, gender, and race/ethnicity. We performed analyses using Stata 16, and used MCBS sample weights to account for the complex survey weighting.
This study did not require IRB approval. We followed STROBE guidelines for cross-sectional studies.

RESULTS
Our analysis included 8,455 community-dwelling Medicare beneficiaries, representative of 50.2 million people, after excluding proxy-respondents (n = 1218), who were not asked about the vaccine, and those missing answers to the questions (n = 13). Overall, 58.7% said they would get a COVID-19 vaccine, 15.3% said they would not, and 26.1% were unsure. Responses differed among all sociodemographic groups (p-values all <0.001). Least likely to say they would get a vaccine were beneficiaries under 65 years old (48.8%, vs. 59.6% of 65 to 74-year-olds, and 63.5% of those 75 and older), women (53.2%, vs. 65.7% of men), Black beneficiaries (36.2%), and Hispanic beneficiaries (50.5%, vs. 62.1% of White beneficiaries) ( Table 1).

DISCUSSION
In the fall of 2020, just before COVID-19 vaccines became available in the United States, only 59% of Medicare beneficiaries planned to get the vaccine, despite being at the highest risk of morbidity and mortality. 1 To our knowledge, this is the first report specifically on the plans of Medicare recipients.
Demographic differences in vaccine intentions mirrored real-world uptake, as women and Black and Hispanic people were disproportionately less likely to be vaccinated in the first month. 2 While limited to Medicare beneficiaries, our findings suggest that disparities in vaccination are not driven by a dislike of vaccines. Instead, we need to acknowledge and address factors that erode trust in government, including racism, 3 and promote and support community-led efforts to deliver information about vaccines. [4][5][6]  Weighted percentages reflect Medicare Current Beneficiary Survey complex survey weighting and do not perfectly match the raw numbers. b "Yes" responses include those who said both "probably" and "definitely." c "No" responses include those who said both "probably not" and "definitely not." d Chi-square p-value for difference between groups <0.001.

INTRODUCTION
Transitions across acute and post-acute settings are complex processes that became more challenging during the COVID-19 pandemic. Prolonged hospital stays may result in deconditioning, necessitating patient discharge to skilled nursing facilities (SNFs) 1 for rehabilitation when discharge home is deemed unsafe. Although return home from SNF is the goal for these patients, a safe SNF discharge often requires additional support from home health care (HHC) or from patients' families. 2 Prior work has examined hospital discharge practices for COVID-19 patients, 3 but has not investigated post-acute SNF discharge patterns. Understanding the challenges to safe discharge at every healthcare transition is necessary for systems planning. To understand how post-acute SNF discharge was affected by the COVID-19 pandemic, we studied discharge processes for SNF patients with COVID-19.

METHODS
This was a retrospective cohort study of consecutive individuals discharged from hospital to a large urban SNF who developed COVID-19 symptoms with a positive COVID-19 PCR or antibody test between March 1, 2020 and June 1, 2020. To focus on the impact post-acute COVID-19 had on discharge planning of short-term SNF residents, we excluded patients whose COVID-19 onset was more than 30 days before or more than 100 days after SNF admission.
Using the facility's electronic medical record (EMR), we reviewed all medical, nursing, social work, and other notes to examine discharge planning processes. Charts were abstracted on average 186 days after the day of COVID-19 symptom onset. Specifically, we identified whether discharge planning was initiated, whether discharge was successful, and whether there was evidence that discharge was complicated by COVID-19-related challenges. The relationship between COVID-19-relatedbarriers and successful discharge was examined with a chi-square test.
Directed content analysis 4 was used to analyze EMR notes to identify COVID-19-related factors impacting discharge planning. The analysis was started deductively to develop the initial coding structure. Multiple codes could be applied to each case. The team then met collaboratively to discuss preliminary perceptions and refine coding definitions. Analysis then became inductive to identify emerging themes.
Discharge planning was initiated in 99 (81%) postacute patients, of which 82 were successfully discharged. Median length of stay for those discharged was 37.