The measure reports the percentage of short-stay residents or patients who are assessed and appropriately given the seasonal influenza vaccine during the most recently-completed influenza season. The influenza vaccination season (IVS) is defined as beginning on October 1, or when the vaccine first becomes available*, and ends on March 31 of the following year. This measure is based on the NQF´s National Voluntary Standards for Influenza and Pneumococcal Immunizations.
The measure is the aggregate of three separately calculated submeasures to reflect the process by which a resident or patient is assessed and appropriately given the influenza vaccination during the current or most recent influenza season.
The three submeasures are as follows:
• residents or patients who received the influenza vaccine during the most recently completed influenza season, either in the facility/hospital or outside the facility/hospital (NQF #0680a);
• residents or patients who were offered and declined the seasonal influenza vaccine (NQF #0680b);
• residents or patients who were ineligible to receive the seasonal influenza vaccine due to contraindication(s) (e.g., anaphylactic hypersensitivity to eggs or other components of the vaccine, see http://www.cdc.gov/flu/professionals/vaccination/vax-summary.htm ) (NQF #0680c).
*Note: While the IVS officially begins when the vaccine becomes available, which may be before October 1, the denominator time window for the quality measure and references to the IVS for the denominator specification is from October 1 to March 31 of the following year. The numerator time window and references to the IVS in the numerator specifications may include patients and residents who are assessed and offered the vaccine before October 1. This is based on how the influenza items were coded by the facility.
The denominator consists of patients or short-stay residents 180 days of age or older on the target date of assessment who were in the facility/hospital for at least one day during the most recently-completed influenza vaccination season (IVS). The measure is based on data from the Minimum Data Set (MDS) assessments of nursing home residents, Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) assessments for Inpatient Rehabilitation Facility (IRF) patients, and the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set Version assessments of LTCH patients.
Data are collected in each of these three settings using standardized items across the three assessment instruments. For the nursing homes, the measure is limited to short-stay residents, identified as residents who have had 100 or fewer days of nursing home care. For the LTCHs, this measure will include all patients, irrespective of a patient’s length of stay. For IRFs, this measure includes all Medicare Part A and Part C patients, irrespective of a patient’s length of stay.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.20 Testing Data Sources
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1.14 Numerator
The numerator for the overall measure (NQF #0680) is the number of residents or patients in the denominator sample who, during the numerator time window, meet any one of the following criteria: (1) those who received the seasonal influenza vaccine during the most recently-completed influenza season, either in the facility/hospital or outside the facility/hospital (NQF #0680a); (2) those who were offered and declined the seasonal influenza vaccine (NQF #0680b); or (3) those who were ineligible due to contraindication(s) (NQF #0680c). The numerator time window coincides with the most recently-completed seasonal IVS which begins on October 1 and ends on March 31 of the following year.
Each of the three submeasures numerators described above will be computed and reportedly separately, alongside the overall numerator calculated as the aggregate of the three submeasure numerators.
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1.15 Denominator
The denominator consists of patients or short-stay residents 180 days of age and older on the target date of the assessment who were in the facility/hospital for at least one day during the denominator time window. The denominator time window is defined as the most recently-completed IVS, from October 1 to March 31 of the following year. For IRF and LTCH, the QM is based on completed patient stays (have discharge assessments). An IRF or LTCH patient with multiple stays during the denominator time window (IVS) will be included more than once in the QM. If a nursing home resident has more than one episode during the denominator time window only the more recent episode is included in this QM.
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Exclusions
Residents or patients whose age is 179 days of less of age on target date of the selected influenza vaccination assessment are excluded. LTCH patients whose expired assessments are completed before April 1, 2016 are excluded. After April 1, 2016 expired patients are no longer excluded from the QM, because the influenza items were added to the LCDS expired assessments. Nursing homes with denominator counts of less than 20 residents and IRFs and LTCHs with less than 20 stays in the sample are excluded from public reporting due to small sample size.
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1.13a Data dictionary not attachedNo
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Most Recent Endorsement ActivityEndorsed Prevention and Population Health Spring Cycle 2022Initial EndorsementLast Updated
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
N/A
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)
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