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  • Measure Summary
  • NQMC:010725
  • Oct 2015
  • NQF-Endorsed Measure

Long-stay nursing home care: percent of residents who did not receive, due to medical contraindication, the seasonal influenza vaccine.

RTI International. MDS 3.0 quality measures user's manual, v9.0. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2015 Oct 1. 80 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: RTI International. MDS 3.0 quality measures user's manual. v8.0. Baltimore (MD): Center for Medicare & Medicaid Services (CMS); 2013 Apr 15. 80 p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percent of long-stay residents who did not receive, due to medical contraindication, the influenza vaccination during the most recent influenza season.

Rationale

Morbidity and mortality data related to influenza are often reported in conjunction with data regarding pneumonia. Using data collected by the Centers for Disease Control and Prevention (CDC), Gorina and colleagues (2008) found that, in 2004, pneumonia and influenza was the seventh most common cause of death for persons aged 65 and older in the United States. Almost 60,000 deaths in 2004 were caused by influenza and pneumonia and more than 85% of those were for the elderly (Gorina et al., 2008). Frail elderly are especially vulnerable and subject to complications of influenza. In the same year, there were approximately 123,000 deaths with influenza and pneumonia mentioned on the death certificate as a secondary cause of death (Gorina et al., 2008).

According to the CDC ("Influenza E-brief," 2008), more than 200,000 people are hospitalized in the United States each year as a result of complications from influenza. The average hospital stay was approximately 5.3 days at a cost of $6,900 per stay (Milenkovic, Russo, & Elixhauser, 2006). Further, the death rate from influenza and pneumonia is nearly 130 times higher among persons aged 85 and older than among persons 45 to 54 years of age (Gorina et al., 2008).

Among adults aged 65 years and older, approximately 72.1% were vaccinated during the 2006 to 2007 influenza season, which is below the Healthy People 2010 target of 90% for this age group (CDC, "State-specific," 2008; Office of Disease Prevention and Health Promotion [ODPHP], 2000).

The Centers for Medicare and Medicaid Services (CMS) currently uses Minimum Data Set (MDS) 2.0 data to publicly report an influenza vaccination quality measure (QM) for nursing facility residents. The first quarter 2007 statewide averages for the long-stay population range from 75.9% to 96.5%, with an 87% national average (Colorado Foundation for Medical Care, 2007). According to the information currently available on Nursing Home Compare, the national average for the percent of long-stay residents given the influenza vaccine has increased to 90% (CMS, n.d.).

This measure is intended to encourage nursing facilities to focus on this important aspect of clinical care through the assessment of facility residents regarding the status of their seasonal flu vaccine immunization and to provide immunization as appropriate.

Evidence for Rationale

Centers for Disease Control and Prevention (CDC). Influenza E-brief: 2008-2009 flu facts for policymakers. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2008 Sep.

Centers for Disease Control and Prevention (CDC). State-specific influenza vaccination coverage among adults--United States, 2006-07 influenza season. MMWR Morb Mortal Wkly Rep. 2008 Sep 26;57(38):1033-9. PubMed External Web Site Policy

Centers for Medicare & Medicaid Services (CMS). Nursing home compare. [Web site]. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS);

Colorado Foundation for Medical Care. Environmental scan: review of the literature, clinical guidelines, and other sources of information pertinent to the CMS publicly reported nursing home quality measures. Englewood (CO): Colorado Foundation for Medical Care; 2007.

Gorina Y, Kelly T, Lubitz J, Hines Z. Trends in influenza and pneumonia among older persons in the United States. Hyattsville (MD): Centers for Disease Control and Prevention (CDC), National Center for Health Statistics; 2008.

Milenkovic M, Russo CA, Elixhauser A. Hospital stays for influenza, 2004. Rockville (MD): Agency for Health Care Policy and Research (AHRQ); 2006.  (Healthcare Cost and Utilization Project statistical brief; no. 16). 

National Quality Forum measure information: percent of residents assessed and appropriately given the seasonal influenza vaccine (long stay). Washington (DC): National Quality Forum (NQF); 2016 Jan 13. 12 p.

Office of Disease Prevention and Health Promotion (ODPHP). Healthy people 2010. [internet]. Washington (DC): U.S. Department of Health and Human Services (HHS); 2000. 

Primary Health Components

Nursing home; long-stay; influenza vaccination

Denominator Description

All long-stay residents with a selected influenza vaccination assessment, except those with exclusions (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Residents meeting the following criteria on the selected influenza vaccination assessment:

  1. Resident was ineligible due to contraindication(s) (e.g., anaphylactic hypersensitivity to eggs or other components of the vaccine, history of Guillain-Barré syndrome within 6 weeks after a previous influenza vaccination, bone marrow transplant within the past 6 months).

See the related "Numerator Inclusions/Exclusions" field.

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • According to the environmental scan conducted by the Colorado Foundation for Medical Care (2007), several expert organizations, such as the Advisory Committee on Immunization Practices, target influenza prevention through annual vaccination of post-acute care facility residents and staff (Fiore et al., 2009). Influenza vaccine can be cost-effective and successful in preventing influenza. However, despite evidence demonstrating the efficacy of the influenza vaccine, coverage remains low among residents (Colorado Foundation for Medical Care, 2007). A study conducted in 2002 by Nichol and Goodman found that vaccination of healthy elderly adults was associated with a 36% reduction in hospitalization for pneumonia or influenza (95% confidence interval [CI]: 2% to 39%), an 18% reduction in hospitalization for all respiratory conditions (95% CI: -6% to 37%), and a 40% reduction in death (95% CI: 14% to 38%). Vaccination was also associated with cost savings in all scenarios evaluated (Nichol & Goodman, 2002).
  • There is a demonstrated gap in performance in vaccination among adults age 65 years or older. Although the influenza vaccine can be successful in preventing the flu, vaccination rates remain low among nursing home residents (Gorina et al., 2008; Centers for Disease Control and Prevention [CDC], 2008), due in part, to patient confusion, poor documentation of vaccination status, and availability of records from previous facilities (Colorado Foundation for Medical Care, 2007). Further, according to research, approximately 72.1% of the elderly were vaccinated during the 2006 to 2007 influenza season, which is below the Healthy People 2010 target of 90% for this age group (Colorado Foundation for Medical Care, 2007; Office of Disease Prevention and Health Promotion [ODPHP], 2000).

    In their analysis of quality measures using MDS data from the first quarter of 2006 (presented below), the University of Colorado found that the influenza measure could be reported for 86.5% of facilities and had a fair amount of variability across facilities in the rates of influenza immunization. The quality measure varied from 63.9% at the 10th percentile to 100% at the 90th percentile (Brega et al., 2008).

  • Racial segregation between nursing homes has been shown to be a major factor in racial disparities in the nursing home population, primarily for African Americans. In 2000, a study drawing on national MDS and Online Survey, Certification, and Reporting (OSCAR) data found that two-thirds of all black residents were living in just 10% of all facilities (Smith et al., 2007). A 2002 survey of a stratified sample of 39 nursing facilities and 181 residential care/assisted living facilities in four states had similar findings (Howard et al., 2002). Facilities serving African Americans have demonstrated a lower level of quality care than those serving whites with lower staff to resident ratios and higher deficiency ratings (Grabowski, 2004). Minority groups in general and African Americans in particular have also had more limited access to nursing facility care than whites (National Center for Health Statistics [NCHS], CDC, 1997). Among adults age 18 and over, there are higher rates of seasonal influenza vaccinations in rural areas (53.7%) compared to urban areas (47.1%) but there is no published information specific to the elderly or to nursing facility residents (NCHS, CDC, 2009).

    A search of PubMed did not reveal any recently published research studies specifically related to racial and ethnic disparities for influenza immunization in nursing facilities. However, differences in influenza vaccination between whites and non-white Medicare beneficiaries and Medicare beneficiaries in general have been documented (Flowers, Sinclair, & Figueiredo, 2008).

    Bardenheier and colleagues (2004) conducted a study to identify nursing facility resident-specific characteristics associated with vaccination coverage and at baseline. Results of their bivariate analysis showed that residents with cognitive, psychiatric, or neurologic problems were more likely to be vaccinated than those without these conditions. Results of the multilevel analysis also showed that the presence of cognitive deficits was one of the strongest resident characteristics associated with receipt of immunizations, controlling facility variation (Bardenheier et al., 2004).

Evidence for Additional Information Supporting Need for the Measure

Bardenheier B, Shefer A, McKibben L, Roberts H, Bratzler D. Characteristics of long-term-care facility residents associated with receipt of influenza and pneumococcal vaccinations. Infect Control Hosp Epidemiol. 2004 Nov;25(11):946-54. PubMed External Web Site Policy

Brega A, Goodrich G, Nuccio E, Hittle D. Transition of publicly reported nursing home quality measures to MDS 3.0-draft. Denver (CO): Division of Health Care Policy and Research University of Colorado at Denver; 2008.

Centers for Disease Control and Prevention (CDC). State-specific influenza vaccination coverage among adults--United States, 2006-07 influenza season. MMWR Morb Mortal Wkly Rep. 2008 Sep 26;57(38):1033-9. PubMed External Web Site Policy

Colorado Foundation for Medical Care. Environmental scan: review of the literature, clinical guidelines, and other sources of information pertinent to the CMS publicly reported nursing home quality measures. Englewood (CO): Colorado Foundation for Medical Care; 2007.

Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NJ, Centers for Disease Control and Prevention (CDC). Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2009 Jul 31;58(RR-8):1-52.

Flowers F, Sinclair S, Figueiredo C. Racial and ethnic disparities in influenza and pneumococcal immunization rates among Medicare beneficiaries. Washington (DC): AARP Public Policy Institute; 2008. 6 p.

Gorina Y, Kelly T, Lubitz J, Hines Z. Trends in influenza and pneumonia among older persons in the United States. Hyattsville (MD): Centers for Disease Control and Prevention (CDC), National Center for Health Statistics; 2008.

Grabowski DC. The admission of blacks to high-deficiency nursing homes. Med Care. 2004 May;42(5):456-64. PubMed External Web Site Policy

Howard DL, Sloane PD, Zimmerman S, Eckert JK, Walsh JF, Buie VC, Taylor PJ, Koch GG. Distribution of African Americans in residential care/assisted living and nursing homes: more evidence of racial disparity. Am J Public Health. 2002 Aug;92(8):1272-7. PubMed External Web Site Policy

National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). Health, United States 1996-97 and injury chartbook. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 1997. 341 p.

National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). Health, United States 2008, with chartbook. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2009. 589 p.

National Quality Forum measure information: percent of residents assessed and appropriately given the seasonal influenza vaccine (long stay). Washington (DC): National Quality Forum (NQF); 2016 Jan 13. 12 p.

Nichol KL, Goodman M. Cost effectiveness of influenza vaccination for healthy persons between ages 65 and 74 years. Vaccine. 2002 May 15;20 Suppl 2:S21-4. PubMed External Web Site Policy

Office of Disease Prevention and Health Promotion (ODPHP). Healthy people 2010. [internet]. Washington (DC): U.S. Department of Health and Human Services (HHS); 2000. 

Smith DB, Feng Z, Fennell ML, Zinn JS, Mor V. Separate and unequal: racial segregation and disparities in quality across U.S. nursing homes. Health Aff (Millwood). 2007 Sep-Oct;26(5):1448-58. PubMed External Web Site Policy

Extent of Measure Testing

A joint RAND/Harvard team engaged in a deliberate iterative process to incorporate provider and consumer input, expert consultation, scientific advances in clinical knowledge about screening and assessment, Centers for Medicare & Medicaid Services (CMS) experience, and intensive item development and testing by a national Veteran's Health Administration (VHA) consortium. This process allowed the final national testing of Minimum Data Set (MDS) 3.0 to include well-developed and tested items.

The national validation and evaluation of the MDS 3.0 included 71 community nursing homes (NHs) (3,822 residents) and 19 VHA NHs (764 residents), regionally distributed throughout the United States. The evaluation was designed to test and analyze inter-rater agreement (reliability) between gold-standard (research) nurses and between facility and gold-standard nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

Analysis of the test results showed that MDS 3.0 items had either excellent or very good reliability even when comparing research nurse to facility-nurse assessment. In most instances these were higher than those seen in the past with MDS 2.0. In addition, for the cognitive, mood and behavior items, national testing included collection of independent criterion or gold-standard measures. These MDS 3.0 sections were more highly matched to criterion measures than were MDS 2.0 items.

Improvements incorporated in MDS 3.0 produced a more efficient assessment: better quality information was obtained in less time. Such gains should improve identification of resident needs and enhance resident-focused care planning. In addition, including items recognized in other care settings is likely to enhance communication among providers. These significant gains reflect the cumulative effect of changes across the tool, including use of more valid items, direct inclusion of resident reports, improved clarity of retained items, deletion of poorly performing items, form redesign, and briefer assessment periods for clinical items.

Refer to Development & Validation of a Revised Nursing Home Assessment Tool: MDS 3.0. for additional information.

Evidence for Extent of Measure Testing

Saliba D, Buchanan J. Development & validation of a revised nursing home assessment tool: MDS 3.0. Baltimore (MD): Quality Measurement and Health Assessment Group, Office of Clinical Standards and Quality, Centers for Medicare & Medicaid Services; 2008 Apr. 263 p.

State of Use

Current routine use

Current Use

Decision-making by consumers about health plan/provider choice

Internal quality improvement

National reporting

Measurement Setting

Skilled Nursing Facilities/Nursing Homes

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age greater than 179 days

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

The most recently completed influenza vaccination season, which begins on October 1 and ends on March 31 of the following year

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Diagnostic Evaluation

Institutionalization

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All long-stay* residents with a selected influenza vaccination assessment, except those with exclusions

*Long-stay: An episode with cumulative days in facility (CDIF) greater than or equal to 101 days as of the end of the target period.

Exclusions
Resident's age on target date of selected influenza vaccination assessment is 179 days or less

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Residents meeting the following criteria on the selected influenza vaccination assessment:

  1. Resident was ineligible due to contraindication(s) (e.g., anaphylactic hypersensitivity to eggs or other components of the vaccine, history of Guillain-Barré syndrome within 6 weeks after a previous influenza vaccination, bone marrow transplant within the past 6 months).

Note:

  • This measure is only calculated once a year with a target period of October 1 of the prior year to June 30 of the current year and reports for the October 1 through March 31 influenza vaccination season.
  • Refer to the original measure documentation for details.

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Center for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) - Resident Assessment Instrument (Version 3.0)

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Does not apply to this measure

Standard of Comparison

External comparison at a point in, or interval of, time

Internal time comparison

Original Title

Percent of residents who did not receive, due to medical contraindication, the seasonal influenza vaccine (long-stay).

Measure Collection Name

Nursing Home Quality Initiative Measures

Measure Set Name

Long-stay Quality Measures

Submitter

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Developer

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

RTI International - Nonprofit Research Organization

Funding Source(s)

United States (U.S.) Government

Composition of the Group that Developed the Measure

United States (U.S.) Government Staff, Clinical Experts, Researchers, and Statisticians

Financial Disclosures/Other Potential Conflicts of Interest

No conflicts of interest exist.

Endorser

National Quality Forum

NQF Number

0681

Date of Endorsement

2015 Jan 6

Adaptation

This measure was adapted from the following source:

  • Influenza vaccination for all nursing home residents and pneumococcal vaccination of residents age 65 or older (Centers for Disease Control and Prevention [CDC])

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Annual and (every three years) endorsement

Date of Next Anticipated Revision

Quarter 2 2016

Measure Status

This is the current release of the measure.

This measure updates a previous version: RTI International. MDS 3.0 quality measures user's manual. v8.0. Baltimore (MD): Center for Medicare & Medicaid Services (CMS); 2013 Apr 15. 80 p.

Source(s)

RTI International. MDS 3.0 quality measures user's manual, v9.0. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2015 Oct 1. 80 p.

Measure Availability

Source available from the Centers for Medicare & Medicaid Services (CMS) Web site External Web Site Policy.

For more information, refer to the CMS Web site at www.cms.gov External Web Site Policy.

Companion Documents

The following is available:

  • Saliba D, Buchanan J. Development & validation of a revised nursing home assessment tool: MDS 3.0. Baltimore (MD): Quality Measurement and Health Assessment Group, Office of Clinical Standards and Quality, Centers for Medicare & Medicaid Services; 2008 Apr. 263 p. Available from the Centers for Medicare & Medicaid Services (CMS) Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on August 15, 2013. The information was verified by the measure developer on December 3, 2013.

This NQMC summary was updated by ECRI Institute on May 31, 2016. The information was not verified by the measure developer.

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