Missed Opportunities for Pneumococcal and Influenza Vaccination of Medicare Pneumonia Inpatients -- 12 Western States, 1995

Invasive pneumococcal infection (i.e., bacteremia and meningitis) and influenza are important causes of morbidity and mortality among Medicare beneficiaries aged greater than or equal to 65 years. In the United States, the estimated annual incidence of pneumococcal bacteremia among persons aged greater than or equal to 65 years is 50-83 cases per 100,000 persons (1), and such infections are associated with a high case-fatality rate. Older persons account for greater than 90% of influenza-related deaths (2), and Medicare costs for influenza-related hospitalizations can reach $1 billion each year (3). The Advisory Committee on Immunization Practices (ACIP) recommends that persons aged greater than or equal to 65 years receive at least one lifetime dose of pneumococcal vaccine (1) and annual influenza vaccination (2) and that hospitalization should be used as an opportunity to vaccinate. This report describes an assessment of the vaccination coverage of Medicare pneumonia patients who were admitted to hospitals in 12 western states * from October 1994 through September 1995 (fiscal year 1995); the findings of this assessment indicate that the opportunity to provide pneumococcal vaccine was missed for up to 80% of those hospitalized at any time during the year, and the opportunity to provide influenza vaccine was missed for 65% of those who were admitted during October-December 1994.

As part of an assessment of pneumonia treatment provided in these states during fiscal year 1995, Medicare billing data maintained by the Health Care Financing Administration (HCFA) were used to identify pneumonia inpatients (i.e., those with an admitting or principal diagnosis International Classification of Diseases, Ninth Revision, Clinical Modification {ICD-9-CM}, code of 480.0-483.99 or 485-486.99 {pneumonia}, 487.0 {influenza with pneumonia}, 510.0-510.9 {empyema}, 511.1 {pleurisy, bacterial}, or 513.0-513.09 {lung abscess}, or with an admitting or principal diagnosis code of either 038.2 {septicemia, pneumococcal} or 038.41 {septicemia, Hemophilus influenzae} and a secondary diagnosis code of 480.0-483.99, 485-486.99, or 487.0). A total of 87,230 such hospitalizations were identified. This report includes data from state-specific random samples totaling 5048 hospitalizations of beneficiaries who were aged greater than or equal to 65 years, had no inpatient care during the 14 days before admission, were not admitted from another acute-care hospital, and were discharged alive to other than an acute-care hospital. The state-distribution of the 5048 hospitalizations was as follows: Alaska (4.1%), Arizona (6.8%), California (five regional samples, 33.6%), Colorado (7.2%), Hawaii (5.2%), Idaho (6.1%), Montana (5.9%), Nevada (6.3%), New Mexico (6.6%), Oregon (6.9%), Utah (6.2%), and Wyoming (5.1%). Inpatient data were abstracted by FMAS Corporation ** (Columbia, Maryland) from hospital medical records and linked to Medicare pneumococcal vaccine billing data for 1991 through 1995 and influenza vaccine billing data for September-December 1994, the periods for which data are available. Of the 5048 hospitalizations, 1312 occurred during October-December 1994, the primary influenza vaccination season. The analysis for pneumococcal vaccine excluded data for beneficiaries who were enrolled in a managed-care plan at any time during 1991-1995 (n=500), and the influenza vaccine analysis excluded data for beneficiaries who were enrolled at any time during September-December 1994 (n=70) because plans do not bill Medicare for vaccinations. State-weighted vaccine coverage estimates and 95% confidence intervals (CIs) were calculated.

Of the 4548 patients who were included in the analysis and who had been admitted during fiscal year 1995, 19.6% (95% CI=18.3%-20.9%) had evidence of pneumococcal vaccination at some time during 1991-1995 (Table_1). This estimate included 12.3% (95% CI=11.2%-13.4%) for whom a bill had been submitted for vaccination at any time from 1991 to the date of admission, 6.9% (95% CI=6.1-7.7) for vaccination from the date of discharge through 1995, and 0.4% (95% CI=0.2%-0.6%) with vaccination during hospitalization. Estimated vaccination coverage was similar in all age groups. Previous pneumococcal vaccination was listed on 2.4% (95% CI=1.9%-2.8%) of admission histories. Of the patients for whom there was no evidence of pneumococcal vaccination at any time during 1991-1995, 66.6% (95% CI=64.7%-68.4%) had at least one chronic condition (e.g., diabetes or chronic lung disease) associated with a possible increased risk for serious pneumococcal infection, and 9.2% (95% CI=8.1%-10.3%) had a condition (e.g., leukemia, lymphoma, or human immunodeficiency virus infection) associated with substantially reduced immunogenicity of the vaccine.

Of 1242 patients who were included in the analysis and who had been admitted during October-December 1994, 35.4% (95% CI=32.3%-38.5%) had evidence of influenza vaccination during September-December 1994 (Table_2). This estimate included 29.4% (95% CI=26.5%-32.3%) for whom a bill had been submitted for vaccination from September 1 to the date of admission, 5.3% (95% CI=3.9%-6.7%) for vaccination from the date of discharge through December 31, and 0.7% (95% CI=0.2%-1.2%) with vaccination during hospitalization. Estimated vaccination coverage was similar in all age groups. Previous vaccination was listed on 4.7% (95% CI=3.4%-5.9%) of admission histories.

Reported by: PM Houck, MD, JK Lowery, PhD, CM Prela, PharmD, Div of Clinical Standards and Quality, Health Care Financing Administration, Region 10, Seattle, Washington.

Editorial Note

Editorial Note: ACIP recommends administration of pneumococcal and influenza vaccines to inpatients as a strategy for increasing vaccination coverage among adults (1,2). In addition, the American Hospital Association Technical Panel on Infections within Hospitals has encouraged hospitals to assist in vaccinating adults, suggested that clinical staff obtain vaccination histories from all inpatients, and suggested that recommendations for vaccinations should be incorporated into discharge plans or implemented during prolonged hospitalizations (4). However, the findings in this report indicate that for elderly persons with pneumonia who were hospitalized in states in the West, vaccination histories rarely are included in the hospital medical record; in addition, indicated vaccines consistently are not provided to inpatients and are provided infrequently following discharge. Specifically, the opportunities to provide pneumococcal and influenza vaccines were missed for up to 80% and 65%, respectively, of eligible persons.

An important feature of hospital-based vaccination programs is that they permit the targeting of vaccines to persons within the health-care system who may be at increased risk for subsequent serious pneumococcal disease and influenza. Previous hospitalization has been a risk factor for subsequent serious pneumococcal infection, and modest levels of inpatient vaccination could substantially reduce admissions (5). High coverage levels can be attained in hospital-based influenza vaccination programs, although such programs must be well organized (6); optimal coverage may be attained when standing orders are written to allow nursing staff to offer and administer vaccine to patients who do not have contraindications.

Low coverage levels, regardless of patient setting, may reflect physician and patient beliefs that these vaccines are not effective, fears about adverse reactions, and concerns about reimbursement. However, influenza vaccine is both clinically effective and highly cost-effective (7); and pneumococcal vaccine is approximately 75% effective in preventing invasive pneumococcal disease in persons aged greater than or equal to 65 years, including those with chronic diseases (8). Medicare has paid for pneumococcal vaccination since 1981 and for influenza vaccination since 1993.

One important limitation of the analysis described in this report is the potential underestimation of outpatient vaccine administration. Bills submitted before 1991 for pneumococcal vaccine would have been missed, and Medicare billing data miss approximately 20% of influenza vaccinations in the fee-for-service population. In addition, vaccine may have been withheld for legitimate reasons not apparent from the medical record. However, inpatient vaccination data presented in this report are highly reliable because the actual medical records were examined.

Based on Behavioral Risk Factor Surveillance System (BRFSS) estimates for each state in 1995, among persons aged greater than or equal to 65 years the median pneumococcal vaccine coverage was only 37%, and only 59% had received influenza vaccine during the previous year (9). The BRFSS estimates in 1995 and the findings in this report underscore that hospitalization represents an opportunity to vaccinate Medicare beneficiaries who may be at high risk for subsequent severe pneumococcal and influenza infections. The results of this assessment are being used by HCFA Quality Improvement Organizations (formerly Peer Review Organizations) to encourage physicians and other providers to administer needed vaccines during or immediately following hospitalization.

References

1. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(no. RR-8).

2. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996;45(no. RR-5).

3. McBean AM, Babish D, Warren JL. The impact and cost of influenza in the elderly. Arch Intern Med 1993;153:2105-11.

4. American Hospital Association Technical Panel on Infections within Hospitals. Management advisory -- health care delivery: immunization. Am J Infect Control 1994;22:42-6.

5. Fedson DS. Improving the use of pneumococcal vaccine through a strategy of hospital-based immunization: a review of its rationale and implications. J Am Geriatric Soc 1985;33:142-50.

6. Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-based strategies for improving influenza vaccination rates. J Fam Pract 1994;38:258-61.

7. Nichol KL, Margolis KL, Wuorenma J, Von Sternberg T. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med 1994;331:778-84.

8. Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993;270: 1826-31.

9. CDC. State- and sex-specific prevalence of selected characteristics -- Behavioral Risk Factor Surveillance System, 1994 and 1995. In: CDC surveillance summaries (August). MMWR 1997;46 (no. SS-3):25.

* Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Wyoming. ** Use of trade names and commercial sources is for identification only and does not imply endorsement by CDC or the U.S. Department of Health and Human Services.

+------------------------------------------------------------------- ------+ | Errata: Vol. 46, No. 39 | |             | | In the article "Missed Opportunities for Pneumococcal and | | Influenza Vaccination of Medicare Pneumonia Inpatients -- 12 Western | | States, 1995," on page 921, the title of Table 1 gave incorrect | | dates. The correct title should be "TABLE 1. Pneumococcal | | vaccination * coverage levels among Medicare pneumonia patients | | admitted to hospitals, by age group -- 12 western states, ** October | | 1994-September 1995." | +------------------------------------------------------------------- ------+
Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Pneumococcal vaccination* coverage levels among Medicare pneumonia patients admitted to hospitals, by age group -- 12 western states, + October-December 1994
==========================================================================================================================================================================
                                                                     Age group (yrs)
                               ------------------------------------------------------------------------------------------------------------
                                    65-69 (n=662)                70-74 (n=877)                75-79 (n=911)               >=80 (n=2098)               Total (n=4548)
                               -----------------------      -----------------------     -----------------------          ------------------      -------------------------
Vaccination                      %           (95% CI&)        %           (95% CI)         %          (95% CI)               %     (95% CI)         %           (95% CI)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Billed before admission          9.4         (+/-2.3%)       12.7        (+/-2.6%)       12.3        (+/-2.4%)            13.0    (+/-1.7%)       12.3         (+/-1.1%)
Administered in hospital         0           (+/-0.5%)        0.8        (+/-0.7%)        0.5        (+/-0.5%)             0.4    (+/-0.3%)        0.4         (+/-0.2%)
Billed after discharge           9.4         (+/-2.4%)        9.0        (+/-2.2%)        7.7        (+/-2.0%)             5.0    (+/-1.0%)        6.9         (+/-0.8%)

Any time,1991-1995              18.8         (+/-3.3%)       22.5        (+/-3.2%)       20.5        (+/-3.0%)            18.4    (+/-1.9%)       19.6         (+/-1.3%)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Medicate billing during 1991-1995 or documented inpatient administration during pneumonia hospitalization, October 1994-September 1995.
+ Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Wyoming.
& Confidence interval.
==========================================================================================================================================================================

TABLE 2. Influenza vaccination* coverage levels among Medicare pneumonia patients admitted to hospitals, by age group -- 12 western states,+ September-December 1994
===================================================================================================================================================================================
                                                                                       Age group (yrs)
                                         -----------------------------------------------------------------------------------------------------------
                                             65-69 (n=180)                70-74 (n=239)               75-79 (n=229)               >=80 (n=594)               Total (n=1242)
                                         ---------------------        ---------------------       ---------------------     ------------------------     --------------------------
Vaccination                               %          (95% CI&)         %           (95% CI)        %           (95% CI)        %          (95% CI)         %            (95% CI)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Billed before admission                  22.1        (+/-7.3%)        33.9        (+/-7.1%)       33.0        (+/-6.9%)      28.9        (+/-4.2%)        29.4         (+/-2.9%)
Administered in hospital                  0              --            0.9        (+/-1.2%)        0.9        (+/-1.4%)       0.8        (+/-0.8%)         0.7         (+/-0.5%)
Billed after discharge                    7.9        (+/-4.6%)         6.0        (+/-3.1%)        2.3        (+/-1.9%)       5.4        (+/-1.9%)         5.3         (+/-1.4%)

Any time,September- December 1994        30.0        (+/-8.0%)        40.8        (+/-7.3%)       36.2        (+/-7.1%)      35.1        (+/-4.4%)        35.4         (+/-3.1%)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Medicare billing, September-December 1994, or documented inpatient administration during pneumonia hospitalization, October-December 1994.
+ Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Wyoming.
& Confidence interval.
===================================================================================================================================================================================

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