1. 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

2. 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

3. 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:

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

5. 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:
CDC. MMWR. 1997;46:
Metersky ML, et al. Am J Med. 2001;110:
Dexter PR, et al. N Engl J Med. 2001;345:

6. Missed Opportunities Background
CDC. MMWR. 1997;46:

7. Missed Opportunities Background
CDC. MMWR. 1997;46:

8. 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:

9. 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:

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

11. 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

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

13. 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.

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

15. 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.

16. 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.

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

18. 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.

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

20. 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

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

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

23. Where’s the greater risk of liability??

24. 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.