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Release Notes:
Measure Information Form
Version 2010A1


**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Pneumonia(PN)

Set Measure ID: PN-2

Performance Measure Name: Pneumococcal Vaccination

Description: Pneumonia patients, age 65 and older, who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.

Rationale: Pneumococcal vaccination is indicated for persons 65 years of age and older, because it is up to 75% effective in preventing pneumococcal bacteremia and meningitis. It is also an important vaccine due to increasing antibiotic resistance among pneumococci. In the United States today, vaccine coverage is suboptimal. Although inpatient vaccine screening and administration are recommended, hospitalization is an underutilized opportunity for adult vaccination.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients with pneumonia, age 65 and older, who were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Pneumonia patients 65 years of age and older

Included Populations: Discharges:
  • With an ICD-9-CM Principal Diagnosis Code of pneumonia as defined in Appendix A, Table 3.1 OR ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) as defined in Appendix A, Tables 3.2, or 3.3
    AND
  • With an ICD-9-CM Other Diagnosis Code of pneumonia (Appendix A, Table 3.1)

Excluded Populations:

  • Patients less than 65 years of age
  • Patients who have a Length of Stay >120 days
  • Patients with Cystic Fibrosis (Appendix A, Table 3.4)
  • Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization
  • Patients with Comfort Measures Only documented
  • Patients enrolled in clinical trials
  • Patients discharged/transferred to another hospital for inpatient care
  • Patients who left against medical advice or discontinued care
  • Patients who expired
  • Patients discharged/transferred to a federal health care facility
  • Patients discharged/transferred to hospice

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective, data sources for required data elements include administrative data and medical record documents. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal and other ICD-9-CM diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

  • Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare inpatients: a missed opportunity. Arch Intern Med 2002;162:2349-2356.
  • Centers for Disease Control and Prevention. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR. 2002;51(RR02):1-36.
  • Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton’s Law applied to prevention. Infect Control Hosp Epi. 2000;21:692-699.
  • Fine MF, Smith MAA, Carson CA, Meffe P, Sankery SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials. Arch Intern Med. 1994(December); 154:2666-2677.
  • Kissam S, Gifford DR, Patry G, et al. Is signed consent for influenza or pneumococcal polysaccharide vaccination required? Arch Intern Med 2004; 164:13-16.
  • Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
  • Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA, 1997; 278:1333-1339.

Measure Algorithm:

Attach file

Related Topics

Measure Information Form PN-2
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)