Oklahoma Foundation for Medical Quality Trends in Hospital-based Vaccination of Medicare Inpatients with Pneumonia Dale W. Bratzler, DO, MPH Wato Nsa, MD, PhD Oklahoma Foundation for Medical Quality

Background Failure to vaccinate hospitalized patients is a missed opportunity Hospitalized patients may be at particularly risk of subsequent complications of influenza and pneumococcal disease CMS and JCAHO have adopted influenza and pneumococcal vaccination of inpatients as measures of hospital quality

Rationale for Hospital-based Influenza Vaccination Age Group Y Population N Discharged during the flu season N (%) Subsequent P&I hospitalizations* % Subsequent P&I deaths* 25-44 297,540 8,046 (3) 11 65 45-64 198,120 6,439 (3) 32 82 65-74 74,664 4,811 (6) 39 62 > 75 44,138 5,188 (12) 45 66 *Proportion of the population with subsequent hospitalization or death from pneumonia or influenza who had been discharged from a hospital. Fedson DS, Houck P, Bratzler D. [Editorial] Infect Control Hosp Epidemiol. 2000;21:692-699.

Missed Opportunities Background Fedson DS, et al. Infect Control Hosp Epidemiol. 2000;21:692-699.

Missed Opportunities Background Despite the risk of subsequent disease, immunization status is often not documented and vaccination is rarely offered to hospitalized patients Fedson DS, et al. Infect Control Hosp Epidemiol. 2000;21:692-699. CDC. MMWR. 1997;46:919-923. Metersky ML, et al. Am J Med. 2001;110:141-143. Dexter PR, et al. N Engl J Med. 2001;345:965-970.

Missed Opportunities Background CDC. MMWR. 1997;46:919-923.

Missed Opportunities Background CDC. MMWR. 1997;46:919-923.

Missed Opportunities Influenza vaccine in hospitalized patients Medicare patients aged > 65 years discharged alive from the hospital between October 1 and December 31, 1998. “Prior” based on Medicare claims analysis or medical record abstraction for 1998 flu season. “After discharge” based on Medicare claims analysis through January 31, 1999. Bratzler DW, Houck PM, et al. Arch Intern Med. 2002;162:2349-2356.

Missed Opportunities Pneumococcal vaccine in hospitalized patients Medicare patients aged > 65 years discharged alive from the hospital between July 1, 1998, and March 31, 1999. “Prior” based on Medicare claims analysis (Part B data back to 1991) or medical record abstraction. “After discharge” based on Medicare claims analysis for one month after dismissal. Bratzler DW, Houck PM, et al. Arch Intern Med. 2002;162:2349-2356.

Objective To evaluate trends in screening and vaccination of Medicare inpatients with a diagnosis of pneumonia

Methods Systematic national random samples of medical records Questions related to influenza limited to discharges from October through February (50 years and older) PPV for patients 65 years and older

Methods Cases were included in the numerator of the measures if: Documented prior vaccination Contraindication to vaccination Refusal of vaccination Vaccine administered

Results Influenza Vaccination Vaccination Status 10/2000 – 02/2001 01/2002 – 02/2002 10/2002 – 02/2003 10/2003 – 02/2004 P value Number of patients 19241 3023 7573 6618 Vaccinated 2.9 1.4 1.9 2.8 0.018 Prior to arrival 9.8 23.7 25.4 34.1 <0.001 Contraindicated 0.6 0.9 0.8 0.031 Refused 0.5 1.1 1.3 Overall rate 13.8 26.8 29.1 39.1 Based on national random samples of Medicare inpatients discharged with a principal diagnosis of pneumonia.

Results Influenza Proportion of Medicare patients discharged with a discharge diagnosis of pneumonia that were screened for or vaccinated prior to discharge.

Results Influenza Proportion of Medicare patients discharged from 10/2003 through 02/2004 with a discharge diagnosis of pneumonia that were screened for or vaccinated prior to discharge.

Results Pneumococcal Vaccination Vaccination Status 07/2000 – 03/2001 01/2002 – 12/2002 01/2003 – 12/2003 01/2004 – 06/2004 P value Number of patients 24978 16844 15549 7477 Vaccinated 2.3 2.0 2.7 3.7 <0.001 Prior to arrival 13.8 23.5 29.2 36.0 Contraindicated 0.1 0.3 0.2 0.004 Refused 0.7 1.0 1.3 Overall rate 16.5 26.4 33.2 41.2 Based on national random samples of Medicare inpatients discharged with a principal diagnosis of pneumonia.

Results Pneumococcal Proportion of Medicare patients discharged with a discharge diagnosis of pneumonia that were screened for or vaccinated prior to discharge.

Results Pneumococcal Proportion of Medicare patients discharged from 01/2004 through 06/2004 with a discharge diagnosis of pneumonia that were screened for or vaccinated prior to discharge.

Conclusions Targeted efforts to measure performance and promote quality improvement on hospital-based vaccination have resulted in improved documentation of patient vaccination status……………

Conclusions …….However Overall rates of inpatient vaccination have only marginally improved More than half of the Medicare patients discharged from the hospital are not being screened for vaccination status

Conclusions Refusals and contraindications accounted for a small proportion of the improvement in vaccination/screening documentation in Medicare patients

Conclusions Additional efforts are need to encourage or provide incentives to achieve high rates of screening and vaccination of hospital inpatients

Where’s the greater risk of liability??

Amsden said the jury's verdict would send a message to the hospital that it is focusing on the wrong areas for cost savings. Jordan's last day at the hospital cost $18,000 - the vaccine would have cost $25.