Health Affairs Blog
Angela K. Shen Elizabeth Sobczyk
September 20, 2019
Meaningfully measuring adult influenza and pneumococcal vaccination is a vital public health intervention. Ninety percent of deaths from influenza occur in older adults, often those with chronic co-morbid conditions. Pneumococcal disease is also responsible for thousands of deaths annually. In adults age 65 and older, pneumococcal pneumonia kills about 1 in 20 infected; pneumococcal bacteremia and pneumococcal meningitis each kill about 1 in 5 infected. These diseases are expensive, too: In 2015, common vaccine- preventable diseases in adults cost the US $9 billion, over 80 percent of which was spent on un-vaccinated individuals. Until recently, quality performance measures were only available for these adult vaccines (i.e. influenza and pneumococcal). Newly available composite measures, however, account for all vaccinations routinely recommended by the Advisory Committee on Immunization Practices (ACIP), and have the potential to ensure that all patients receive the standard of care when it comes to immunization coverage.
New Adult Immunization Measures In HEDIS
Last year, the National Committee for Quality Assurance (NCQA) introduced two new adult immunization composite measures. The first—Prenatal Immunization Status (PRS)—seeks to ensure that pregnant women receive influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccinations to protect both themselves and their infants. The second composite measure—Adult Immunization Status (AIS)—seeks to ensure that adults receive recommended routine vaccines, including influenza, tetanus and diphtheria (Td) or Tdap, herpes zoster and pneumococcal vaccinations. These measures became available in HEDIS®2019 and have just completed their first year of voluntary reporting.
The prenatal and adult immunization composite measures come at a time when providers are under increased pressure to improve health outcomes. The PRS and AIS were developed by NCQA as electronically-reported measures using the HEDIS Electronic Clinical Data Systems (ECDS) method, which seeks to inspire innovative use of electronic clinical data to document patient care and demonstrate evidence-based practice. Moreover, reporting ECDS for HEDIS® encourages sharing and interoperability of health data systems and marks a step towards adapting measurement to accommodate the expansive electronic information available for quality improvement.
As incentives and health care spending shift from volume- to value-based care, measurement is increasingly being used to drive performance improvement throughout the continuum of care. However, even with a clinical data ecosystem emerging around immunization registries and cloud-based applications for measurement, concerns over feasibility have limited adoption of these new measures. Electronic measurement overcomes the limitations of paper-based survey measures that rely on patient recall (e.g., Removal of the Pneumococcal Vaccination Status for Older Adults measure from the Medicare Shared Savings Program). Standardizing electronic reporting will make it possible to tailor meaningful metrics to each user instead of using a generic set of core measures. As the United States invests tremendous resources in the limited view of the clinical world, clinicians are missing the ability to fully capture the needs of each individual patient and focus energy on real outcomes.
Vaccinations Across The Lifespan And Measures Of System Performance In Prevention
Services like immunizations (featuring influenza and pneumococcal vaccination measures) and breast and cervical cancer screenings are often included in measure sets and measurement programs (e.g., NCQA HEDIS® Measure set, Hospital Inpatient Quality Reporting Program, Long-term Care Hospital Quality Reporting Programs, Medicare Advantage Star Ratings Program, Medicaid Core Set) that assess health system performance around preventive health services. However, the number of quality measures developed by external entities such as Medicare, Medicaid, and private health insurance plans has increased rapidly in the last decade. Implementing new adult immunization measures will be challenging as the general consensus is that there are too many measures. On average physicians and staff spend 785 hours annually – equaling $15.4 billion – tracking and reporting measures for Medicare, Medicaid, and private health insurers. The cost to a practice is more than $40,000 per physician per year.
Immunizations and other preventive interventions compete among a litany of adult patient needs for precious time during a clinical encounter. Importantly, clinicians struggle to strike a balance between offering preventive care and managing chronic diseases (such as coronary artery disease and diabetes), which is where most spending occurs. However, clinicians may fail to realize that immunizations indirectly mitigate chronic conditions. For example, influenza vaccination has been shown to reduce the risk of heart attack by 19-45 percent. In addition to being recommended for routine use, pneumococcal vaccinations are specifically recommended for adults with chronic conditions, who are at greater risk for pneumococcal disease.
The two new adult composite measures represent a new model of measures that simplify, streamline, and comprehensively assess immunization status across multiple vaccines.These measures include an unprecedented range of immunization status measures (going beyond influenza and pneumococcal vaccinations). Like the Childhood Immunization Status and Immunizations for Adolescents composite measures, which have been a staple of measurement for child health and wellness since they were first published in 1994 (Childhood Immunization Status) and 2010 (Immunizations for Adolescents), the new measures include all ACIP recommended vaccines for adults. Altogether, this suite of measures addresses the benefits of immunization across the lifespan rather than through the lens of an individual disease-specific focus.
Supporting System Performance In Immunization Through The 21st Century
While immunization measures assess a process (i.e., adherence to recommended clinical practice guidelines), vaccination also affects other significant health outcomes, particularly among patients with complex co-morbid conditions such as heart disease and diabetes. For example, influenza vaccination has become increasingly important given the link between influenza disease and thromboembolic events such as heart attack and stroke. This makes it even more vital that practitioners and policymakers support the AIS and PRS measures.
Even before NCQA developed the AIS and PRS measures, the National Adult and Influenza Immunization Summit (a public-private partnership that aims to increase adult immunization coverage rates) solicited extensive stakeholder feedback on the measures. Through this partnership, testing of an adult immunization composite measure in the Indian Health Service health care delivery system demonstrated the composite measure’s capacity to improve system performance and increase vaccination coverage. Having new measures that better reflect system performance – alongside a more robust reporting system – lays the foundation for the next generation of meaningful measures.
Immunizations are one of the greatest achievements in the 20th century. Composite measures go beyond vaccine-specific measures and provide a systems-wide view of preventive care performance. Focusing on system performance makes it possible to highlight and address coverage gaps by identifying patients, including racial and ethnic populations, who have not yet received specific preventive services (namely, recommended vaccinations). Having new measures that better reflect improved health outcomes, the processes that lead to them, and systems of care delivery epitomize the next generation of measures.
Electronic Reporting Of Measures Now And For The Future
CMS is currently considering adopting the AIS into the Medicare Shared Savings Program. While this is a promising sign for the adoption of the adult composite measure, wide-spread implementation remains an uphill battle. In a July 2019 draft report by an expert working group to CMS on recommendations to the Medicaid adult and child core sets neither the AIS or PRS were recommended to CMS for inclusion into the next cycle, though the working group did recommend state coordination between Medicaid and public health registries, especially immunization registries. The annual core sets are designed to highlight gaps in existing quality measures, strength the quality of care in gap areas, and evaluate state- specific Medicaid and CHIP initiatives. The unfortunate lack of inclusion of either the AIS or PRS into the Medicaid core sets, in part due to concerns about the ability to collect the necessary data, emphasizes the need to focus all available efforts on strengthening the electronic domain, which is central to the next generation of measures.
As the new composite measures become more utilized, the information available in electronic health records, clinical registries, health information exchanges, administrative claims systems, electronic laboratory reports, electronic pharmacy systems, immunization information systems (IIS), and disease/case management registries can be leveraged to alleviate the burden of reporting data and improve the feasibility, accuracy, and validity of measure calculations. Notably, NCQA is aiming to add standardized clinical language to HEDIS® measures over the course of the next several years as part of a strategic priority to improve measurement.
Increasingly, measures will need to be electronically submitted through a standardized process (e.g., HL7 format) to make reporting easier for health plans and providers. If NCQA can adapt long-standing childhood and adolescent immunization measures to ECDS as a complement to the new adult composite measures, the HEDIS dataset will feature a complete package of immunization measures that use the wide range of electronic data sources available today. This uniformly designed set of immunization measures would span the life course and help paint a more accurate and complete picture of vaccine utilization and disease prevention in the United States. Moreover, prioritizing efforts to improve electronic reporting will facilitate the use of new immunization and other measures to support immunization efforts and preventive care from birth to older adulthood.