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91������ supports NQF measure #0039: “Flu Vaccinations for Adults Ages 18 and Older.” This measure represents an important clinical concept and implementation will lead to meaningful improvements in clinical outcomes. While we support this measure, we note several suggestions for the developers to consider when they submit the measure to NQF for reendorsement. First, developers should evaluate the most current performance data. The clinical impact will vary annually depending on how the vaccination matches the circulating virus. Second, developers should consider revising the specifications to include a more appropriate age-range. The highest benefit of annual vaccination is seen in patients aged >50 years. Third, while the data for self-reported influenza vaccination status has been validated as being extremely accurate, this does not appear to be the case in actual practice. A stronger measure may specify electronic data sources such as Electronic Health Records (EHRs) and state-based ISSs to confirm vaccination status and prevent overuse. Fourth, while we support implementation for health plan level analysis, it is unclear how this measure will improve care in real time at the individual clinician level of analysis. Implementation at the level of the individual clinician could penalize clinicians who treat patient who do not schedule appointments during the regular influenza season. Furthermore, primary care clinicians should not be exclusively responsible for ensuring that patients are vaccinated. Lastly, specifications should include exclusion criteria for patient refusal and patients with contraindications to therapy.