Download Pneumococcal Vaccination Status for Older Adults

Draft Document for HEDIS® 2017 Public Comment—Obsolete After March 16, 2016
Proposed Changes to Existing Measure for HEDIS®1 2017:
Pneumococcal Vaccination Status for Older Adults (PNU)
NCQA seeks comments on proposed modifications to the Pneumococcal Vaccination for Older Adults
measure. This measure is collected through a single question in the Medicare Consumer Assessment of
Healthcare Providers and Systems (CAHPS®2) and assesses the percentage of Medicare plan members
65 years of age and older who report ever having received a pneumococcal vaccination. We propose
revising the survey question to more closely align the measure with updated Advisory Committee on
Immunization Practices (ACIP) guidelines.
Updated ACIP recommendations, published in 2014, recommend that two pneumococcal vaccines be
administered to adults age 65 and older: 13-valent pneumococcal conjugate vaccine (PCV13) and 23valent pneumococcal polysaccharide vaccine (PPSV23). The current CAHPS question does not specify
whether both recommended vaccines were received and could imply that only one vaccine is needed.
The current question asks:
“Have you ever had a pneumonia shot? This shot is usually given only once or twice
in a person’s lifetime and is different from a flu shot. It is also called the
pneumococcal vaccine.”
NCQA and our measurement advisory panels are concerned that a single survey question will not be able
to reliably identify whether individuals received both vaccinations, due to the complicated sequence and
timing of the vaccinations for different populations. Therefore, NCQA recommends minor revisions to the
current CAHPS question to maintain continued measurement while we explore options for developing a
measure of pneumococcal vaccination using alternative data sources.
Our proposed revised question:
“Have you ever had one or more pneumonia shots? Two shots are usually given in a
person’s lifetime and these are different from a flu shot. It is also called the
pneumococcal vaccine.”
We acknowledge the challenges of capturing vaccination rates through a survey-based measure.
Revising the survey question will allow continued measurement of this important concept while NCQA
explores the feasibility of developing a nonsurvey-based measure.
Supporting documents include the current measure specification, evidence work-up and performance
data.
NCQA acknowledges the contributions of the Geriatric Measurement Advisory Panel.
1
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
2
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
©2016 National Committee for Quality Assurance
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Draft Document for HEDIS® 2017 Public Comment—Obsolete After March 16, 2016
Pneumococcal Vaccination Status for Older Adults (PNU)
SUMMARY OF CHANGES TO HEDIS 2017
 Revised CAHPS survey question.
Description
The percentage of Medicare members 65 years of age and older who have ever received a
pneumococcal vaccination.
Eligible Population
Product line
Medicare.
Ages
65 years and older as of January 1 of the measurement year.
Continuous
enrollment
Six months prior to the CMS administration of the survey.
Allowable gap
None.
Current enrollment
Currently enrolled at the time the survey is completed.
Protocol and Survey Instrument
Medicare
Collected by CMS using the Medicare CAHPS Survey.
Questions Included in the Measure
Table PNU: Pneumococcal Vaccination Status for Older Adults
Question
Have you ever had one or more a pneumonia shots? Two shots are This shot is usually given
only once or twice in a person’s lifetime and these are is different from a flu shot. It is also
called the pneumococcal vaccine.
Response
Choices
Yes
No
Don’t know
Calculation of Pneumococcal Vaccination Status for Older Adults
Denominator
The number of members who responded “Yes” or “No” to the question “Have you
ever had one or more a pneumonia shots? Two shots are This shot is usually given
only once or twice in a person’s lifetime and these are is different from a flu shot. It is
also called the pneumococcal vaccine.
Numerator
The number of members in the denominator who responded “Yes” to the question
“Have you ever had one or more a pneumonia shots? Two shots are This shot is
usually given only once or twice in a person’s lifetime and these are is different from
a flu shot. It is also called the pneumococcal vaccine.”
©2016 National Committee for Quality Assurance
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Draft Document for HEDIS® 2017 Public Comment—Obsolete After March 16, 2016
Pneumococcal Vaccination Status for Older Adults
Measure Work-up
Topic Overview
Health Importance and Prevalence
Pneumococcal infection is a common cause of illness and death in older adults and in persons with
certain underlying conditions. Pneumococcal pneumonia is the most common clinical presentation of
pneumococcal infection in adults; in the United States there are an estimated 900,000 cases each year
and a 5 percent–7 percent mortality rate (CDC, 2015). Pneumococcal infection accounts for more deaths
than any other vaccine-preventable bacterial disease (CDC, 1997). Pneumococcal pneumonia accounts
for nearly 400,000 hospitalizations annually in the United States, and is second only to urinary tract
infections in cause of nosocomial infections (CDC, 2015; Janssens and Krause, 2004).
The annual incidence of pneumonia in older adults is four times that in younger populations (Janssens
and Krause, 2004). Among older adults, mortality rates for community-acquired pneumonia can be as
high as 30 percent, with certain subpopulations, such as nursing home residents, having mortality rates of
up to 57 percent (Janssens and Krause, 2004). The severity and burden of pneumonia in this older
population can be explained by the existence of risk factors such as comorbidities, an increase in the
number of medications taken and weakness or disease of the lung tissue (Janssens and Krause, 2004).
Although vaccination is the safest and most effective way to prevent infection in older adults, it is often
underused or not recommended by physicians (Janssens and Krause, 2004). The objective of Healthy
People 2020 is to increase pneumococcal immunization levels for the noninstitutionalized adults over the
age of 65, to at least 90 percent (HHS, 2010). While the number of older adults receiving the
pneumococcal vaccine has increased 14 percentage points—from 46 percent in 1998 to 60 percent in
2010—it remains considerably below the Healthy People 2020 objective. An estimated 67 million adults
have not been vaccinated (HHS, 2010). Data from the Consumer Assessment of Healthcare Providers
and Systems (CAHPS®) Survey suggest this rate may be higher for Medicare Advantage beneficiaries at
71 percent.
Costeffectiveness of
vaccination
Pneumococcal infections result in significant health care costs each year. Geriatric
patients with pneumonia require hospitalization in nearly 90 percent of cases, and their
average length of stay is twice that of younger adults (Janssens and Krause, 2004).
Pneumonia in the older adult population is associated with high acute-care costs and
an overall impact on total direct medical costs and mortality during and after an acute
episode (Thomaset al., 2012). Total medical costs for Medicare beneficiaries during
and one year following a hospitalization for pneumonia were found to be $15,682
higher than matched beneficiaries without pneumonia (Thomas et al., 2012). It was
estimated that in 2010, the total annual excess cost of hospital-treated pneumonia in
the fee-for-service Medicare population was approximately $7 billion (Thomas et al.,
2012).
When comparing costs, outcomes and quality adjusted life years (QALY), immunization
with the two recommended vaccines (13-valent pneumococcal conjugate vaccine
(PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) was
found to be more economically efficient than no vaccination, with an incremental costeffectiveness ratio of $25,841 per QALY gained. (Chen et al., 2014).
Drug resistance
Strains of antibiotic-resistant S. pneumoniae, the most common cause of bacterial
pneumonia and the most prevalent in older adults, have become increasingly common
in the U.S. and other parts of the world (CDC, 2015). In the 1980s, rates of penicillin
resistance remained low; however, more recently as many as 30 percent of severe S.
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pneumoniae cases, bacteria are fully resistant to penicillin and other antimicrobial
drugs (Herman and Chen, 1998). Strains that are resistant to penicillin and other
antibiotics are more difficult and costly to treat, and cause an increase in hospital stays
and the need for more expensive alternative treatment (Herman, 1998). Studies have
shown that the average length of stay for patients with penicillin-resistant bacteremia is
15.8 days versus 12 days for those with penicillin-sensitive strains, representing an
increased length of stay of 32 percent (Herman and Chen, 1998). Because vaccines
achieve protection via a different route from antibiotic treatment, vaccine use in the
population has reduced the burden of invasive pneumococcal disease and has reduced
transmission of antibiotic-resistant S. pneumoniae strains (CDC, 2015).
Evidence Supporting Routine Vaccination
ACIP Recommendation
There are currently two licensed pneumococcal vaccines in the United States: the 13-valent
pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine
(PPSV23) (Kobayashi et al., 2015). In 2014, the CDC’s Advisory Committee on Immunization Practices
(ACIP) began recommending a dose of PCV13, followed by a dose of PPSV23 6–12 months later, in
adults ≥65 who had not previously received a pneumococcal vaccination, and in persons >2 years who
are considered at higher risk for pneumococcal disease due to an underlying condition (Kobayashi et al.,
2015).
In 2015, ACIP updated its recommendation and changed the interval between PCV13 and PPSV23 from
6–12 months to at least 1 year for immunocompetent adults ≥65 who had not previously received
pneumococcal vaccine. For immunocompromised vaccine-naïve adults, the minimum acceptable interval
between PCV13 and PPSV23 is 8 weeks. (Refer to Appendix A, Table 1 for recommended intervals for
immunocompromised adults.) Both immunocompetent and immunocompromised adults ≥65 years who
previously received a dose of PPSV23 when ≥65 should receive a dose of PCV13 at least 1 year after
PPSV23.
Immunocompetent and immunocompromised adults ≥65 who previously received a dose of PPSV23
when younger than 65 should also receive a dose of PCV13 at least 1 year after PPSV23, and then
another dose of PPSV23 at least one year after PCV13. The three doses should be spread over five
years or more (Kobayashi et al., 2015). (Refer to Appendix B, Figure 1 for a visual of recommended
vaccine schedules for immunocompetent patients.)
Effectiveness
of Vaccination
In 2011 the FDA licensed PCV13 for use among adults 50 and older. Among
adults, the incidence of invasive pneumococcal disease (IPD) declined by 12
percent–32 percent overall after the introduction of PCV13 (Moore et al., 2015). It
was found that IPD caused by strains protected against in PCV13, and not in the
first pneumococcal conjugate vaccine (PCV7), declined by 58 percent–72 percent
after the introduction of the PCV13 vaccine, depending on patient age (Moore et
al., 2015). It is estimated that overall, more than 30,000 cases of IPD and more
than 3,000 deaths were prevented within the first three years of its introduction
into the adult vaccination schedule (Moore et al., 2015).
The pneumococcal polysaccharide vaccine that includes 23 serotypes (PPSV23),
has been shown to be 50 percent–85 percent effective in preventing invasive
disease caused by the 23 serotypes in adults with healthy immune systems (CDC,
2015). However, recent studies have found that the influence of PPV23 on
community-acquired pneumonia could be contingent on the amount of time since
the vaccination and could be more protective in subsets of older patients who are
moderately ill or <75 years of age (Gubbins and Li, 2015).
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Health care
disparities
Disparities in vaccination coverage leave certain populations at greater risk of
pneumococcal infection. National data indicate that 57.1 percent of males and
61.8 percent of females report receiving the vaccine (HHS, 2010). Disparities
were also found among various ethnicities, with non-Hispanic Blacks having a
vaccination coverage rate of 57.7 percent, Hispanics having a coverage rate of
51.9 percent and non-Hispanic Whites having a coverage rate of 71.1 percent
(O’Halloran et al., 2015).
Gaps in care
Pneumococcal vaccination has been covered under Medicare Part B since 1981,
and sequential administration of PCV13 and PPSV23 has been covered since
2015 (CMS, 2015). Despite this, pneumococcal vaccination rates for adults fall
well below public health goals. The average performance rate for the HEDIS
pneumococcal vaccination measure is 71.08 percent among the Medicare
population. The performance rate has not increased noticeably over the past four
years. National data show differences in coverage between states, with New
Jersey having the lowest coverage (61.9 percent) and Oregon having the highest
(75.6 percent) (O’Halloran et al., 2015).
References
Centers for Disease Control and Prevention (CDC). 2015. Pneumococcal Vaccination. June 19, 2015.
http://www.cdc.gov/pneumococcal/clinicians/clinical-features.html#pneumonia
Centers for Disease Control and Prevention (CDC). 1997. Prevention of Pneumococcal Disease:
Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR. 46(RR08):
1–24.
Centers for Medicare and Medicaid Services (CMS). 2015. Modifications to Medicare Part B Coverage of
Pneumococcal Vaccinations. MLN Matters®. https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf
Chen, J., M.A. O’Brien, H.K. Yang, et al. 2014. Cost-effectiveness of pneumococcal vaccines for adults in
the United States. Adv Ther. 31(4):392–409.
Gubbins, P., C. Li. 2015. The Influence of Influenza and Pneumococcal Vaccines on CommunityAcquired Pneumonia (CAP) Outcomes Among Elderly Patients. Curr Infect Dis Rep. 17(1)49–58.
Herman, C., G. Chen, K. High. 1998. Pneumococcal Penicillin Resistance and the Cost-effectiveness of
Pneumococcal Vaccine.” Infect Med. 15(4):233, 236–7, 241–3, 275.
Janssens, J.P. and K.H. Krause. 2004. Pneumonia in the very old. Lancet Infect Dis. 4(2):112–24.
Kobayashi, M., N.M. Bennett, R. Gierke, et al. 2015. Intervals between PCV13 and PPSV23 vaccines:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR.
64(34):944–7.
Moore, M., R. Link-Gelles, W. Schaffner, et al. 2015. Effect of use of 13-valent pneumococcal conjugate
vaccine in children on invasive pneumococcal disease in children and adults in the USA: analysis of
multisite, population-based surveillance. Lancet Infect Dis. Mar;15(3):301–9.
O’Halloran, A.C., P.J. Lu, T. Pilishvili. 2015. Pneumococcal vaccination coverage among persons >=65
years- United States-2013. Vaccine. 33(42):5503–6.
Thomas, .C.P., M. Ryan, J.D. Chapman, et al. 2012. Incidence and cost of pneumonia in Medicare
beneficiaries. Chest. 142(4):973–81.
U.S. Department of Health and Human Services (HHS). 2010. Healthy People 2020: Immunization and
Infectious Diseases. https://www.healthypeople.gov/2020/topics-objectives/objective/iid-131
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Appendix A
TABLE 1. Summary of Recommended Intervals, by Risk and Age Group, for Persons With
Indications To Receive PCV13 and PPSV23 Sequence1
Intervals for PCV13–PPSV23
Sequence, by Age Group
Risk group/Underlying
Medical Condition
Intervals for PPSV23–PCV13
Sequence, by Age Group
24–71
Months
6–18
Years
19–64
Years
≥65
Years
24–71
Months
6–18
Years
19–64
Years
≥65
Years
NA
NA
NA
≥1 year
NA
NA
NA
≥1 year
NA
NA
≥1 year
≥8 weeks
NA
NA
≥1 year
Immunocompetent persons
≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks
 Cerebrospinal fluid leak
 Cochlear implant
≥1 year
≥1 year
Persons with functional or
anatomic asplenia
 Sickle cell disease/other
hemaglobinopathy
 Congenital or acquired
asplenia
≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks
≥1 year
≥1 year
Immunocompromised
persons
 Congenital or acquired
immunodeficiency
 Human immunodeficiency
virus infection
 Chronic renal failure
 Nephrotic syndrome
 Leukemia
 Lymphoma
 Hodgkin disease
 Generalized malignancy
 Iatrogenic
immunosuppression
 Solid organ transplant
 Multiple myeloma*
≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks ≥8 weeks
≥1 year
≥1 year
No underlying chronic
conditions
Immunocompetent persons
 Chronic heart disease
 Chronic lung disease
 Diabetes mellitus
≥8 weeks
 Alcoholism*
 Chronic liver disease,
cirrhosis*
 Cigarette smoking*
Abbreviation: NA = Not Applicable; sequential use of PCV13 and PPSV23 is not recommended for these age and risk groups.
*Underlying medical conditions that are not included in the recommendations for children aged <6 years.
1Advisory
Committee on Immunization Practices, United States, September 2015 (CDC, MMWR).
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Appendix B
Figure 1. Recommended Intervals for Sequential Use of PCV13 and PPSV23 for
Immunocompetent Adults Aged ≥65 Years1
Abbreviations: PCV13 = 13-valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide
vaccine.
Note:
 For immunocompetent adults who previously received PPSV23 when <65 years and for whom an additional dose of PPSV23
is indicated when ≥65 years, the subsequent PPSV23 dose should be given ≥1 year after PCV13 and ≥5 years after the most
recent dose of PPSV23.
 For adults ≥65 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks or
cochlear implants, the recommended interval between PCV13 followed by PPSV23 is ≥8 weeks.
1Advisory
Committee on Immunization Practices, United States (CDC, MMWR)
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HEDIS® Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Performance Rates:
Pneumococcal Vaccination in Older Adults (PNU)
Product Line: Medicare
Table 1. HEDIS PNU Measure Performance Rate—All Plans
Year
2011
2012
2013
2014
Total Number of
Plans Able to Report
427
445
444
435
Average
(%)
69.2
70.0
70.4
71.1
Standard
Deviation (%)
12.9
12.3
11.3
11.1
10th
Percentile (%)
53.4
54.6
57.7
57.7
25th
Percentile (%)
65.2
66.3
66.9
67.5
©2016 National Committee for Quality Assurance
50th
Percentile (%)
71.3
72.8
72.8
74.0
75th
Percentile (%)
77.6
77.5
77.3
78.2
90th
Percentile (%)
82.4
81.8
80.5
81.3
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