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Release Notes:
Measure Information Form
Version 2010A1


Measure Information Form

Measure Set: Pneumonia(PN)

Set Measure ID: PN-7

Performance Measure Name: Influenza Vaccination

Description: Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, February or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated.

Rationale: Influenza vaccination is indicated for people age 50 years and older, because it is highly effective in preventing influenza-related pneumonia, hospitalization, and death. Vaccine coverage in the United States is suboptimal. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to adults.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients discharged during October, November, December, January, February or March with pneumonia, age 50 and older, who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Pneumonia patients 50 years of age and older who were discharged during October, November, December, January, February or March

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
  • With an ICD-9-CM Other Diagnosis Code of pneumonia (Appendix A, Table 3.1)

Excluded Populations:

  • Patients less than 50 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 with a secondary diagnosis of 487.0 (influenza with pneumonia)
  • 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 opportunity for improvement at the point of care/service. However, complete documentation includes the final 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: Health care organizations may be interested in knowing how many patients were screened for influenza vaccination and those that were actually vaccinated.

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

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

Selected References:

  • Centers for Disease Control. Prevention of Influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. April 2002;51(No.RR-02):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.
  • 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.

Measure Algorithm:

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Related Topics

Measure Information Form PN-7
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)