The study cohort was derived from a national source population of LTCF residents with more than 21 million Minimum Data Set–defined episodes of care between July 3, 2011, and July 1, 2017. The entire study period included 6 distinct respiratory seasons, with each season starting on the Sunday of Morbidity and Mortality Weekly Report (MMWR) week 27 of one year and ending on the Saturday of MMWR week 26 of the following year.28 Eligible long-stay LTCF residents had a total stay of 100 consecutive days or more and no more than 10 days outside of the facility. Index dates were assigned as the 100th day of a stay for long-stay residents. Follow-up ranged from each resident’s index date until hospitalization, discharge from the LTCF, disenrollment from Medicare, death, or the end of the study period, whichever occurred first. The first long-stay episode of care was identified within a respiratory season, and subsequent stays were excluded. If LTCF residents were censored in 1 season, they could re-enter during a subsequent season. Person-time for LTCF residents was then aggregated within the MMWR-defined weeks. For example, if residents were in an LTCF for 7 person-days from Sunday to Saturday, they were associated with 1 person-week during a specific MMWR-defined week. Long-stay residents included in the study population had 6 months of continuous enrollment in Medicare Part A immediately before and were at least aged 65 years at the index date in each season. Individuals were categorized into the following age groups according to their age at index date in each season: 65 to 74 years, 75 to 84 years, and 85 years or older.

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