eCQM Title | Hospital Harm - Severe Hypoglycemia |
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eCQM Identifier (Measure Authoring Tool) | 816 | eCQM Version Number | 2.0.000 |
NQF Number | 3503e | GUID | 98ee2385-0b90-40f4-859c-14f5c8d49340 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | Centers for Medicare & Medicaid Services (CMS) | ||
Measure Developer | American Institutes for Research | ||
Endorsed By | National Quality Forum | ||
Description |
Inpatient hospitalizations for patients 18 years of age or older at admission, who were administered at least one hypoglycemic medication during the encounter, who suffer the harm of a severe hypoglycemic event during the encounter |
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Copyright |
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. American Institutes for Research(R), formerly IMPAQ International, disclaims all liability for use or accuracy of any third party codes contained in the specifications. LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved. |
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Disclaimer |
This performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]. |
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Measure Scoring | Proportion | ||
Measure Type | Outcome | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
None |
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Rationale |
This measure focuses on severe hypoglycemia as an outcome in the hospital inpatient setting. Hypoglycemia events in the hospital are among the most common adverse drug events. In 2004 an estimated 888,000 adverse drug events occurred among hospitalized Medicare patients in the United States (Classen et.al., 2010; National Quality Forum, 2010). In a study published by the Office of the Inspector General (OIG), adverse drug events represent one-third of all adverse events in hospitals among Medicare patients; of those events, hypoglycemia represented the third most common adverse drug events (Office of the Inspector General, 2010). Rates of inpatient hypoglycemia events are considered an indicator of the quality of care provided by a hospital. Severe hypoglycemia events are largely avoidable by careful use of antihyperglycemic medication. Moreover, the rate of severe hypoglycemia varies across hospitals indicating an opportunity for improvement in care. The Agency for Healthcare Research and Quality (AHRQ) identified insulin and other hypoglycemic agents as high alert medications and associated adverse events to be included as a measure in the Medicare Patient Safety Monitoring System (MPSMS) (Classen et al., 2010). Hypoglycemic events are an adverse outcome that can cause patients to experience drowsiness, confusion, anxiety, irritability, sweating, weakness, increased heart rate, uncontrollable trembling, as well as loss of consciousness and seizure (Classen et al., 2010; American Diabetes Association, 2015). |
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Clinical Recommendation Statement |
From Section 15, Diabetes Care in the Hospital in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2020) two recommendations listed under goals for blood glucose levels for critically ill patients are related to hypoglycemia, and two recommendations are related to the management of hypoglycemia: Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140 - 180 mg/dL (7.8 mmol/L) is recommended for the majority of critically ill patients. More stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L) may be appropriate for selected patients, as long as they can be achieved without significant hypoglycemia. A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). There should be a structured discharge plan tailored to the individual patient with diabetes. From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (Umpierrez et al., 2012): 3.1. We recommend a premeal glucose target of less than 140 mg/dL (7.8 mmol/liter) and a random BG of less than 180 mg/dL (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness. 3.2. We suggest that glycemic targets be modified according to clinical status. For patients who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG <11.1 mmol/liter or 200 mg/dL) may be reasonable. 3.3 For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values fall below 5.6 mmol/liter (100 mg/dL). Modification of glucose-lowering treatment is usually necessary when BG values are below 3.9 mmol/liter (70 mg/dL). |
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Improvement Notation |
A lower proportion indicates better quality |
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Reference |
Reference Type: CITATION Reference Text: 'American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020;43(Supplement 1):S193-S202.' |
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Reference |
Reference Type: CITATION Reference Text: 'American Diabetes Association. Hypoglycemia (Low Blood Glucose). 2015; http://diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html. Accessed August 20, 2018.' |
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Reference |
Reference Type: CITATION Reference Text: 'Classen, D. C., Jaser, L., & Budnitz, D. S. (2010). Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf, 36(1), 12-21.' |
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Reference |
Reference Type: CITATION Reference Text: 'National Quality Forum. (2010). Prioritization of High-Impact Medicare Conditions and Measure Gaps. Measure Prioritization Advisory Committee Report. May 2010. Retrieved August 29, 2011, from http://www.qualityforum.org/projects/prioritization.aspx?section= MeasurePrioritizatinAdvisoryCommitteeReport2010-05-24' |
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Reference |
Reference Type: CITATION Reference Text: 'Office of the Inspector General. (2010). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Retrieved December 14, 2011, from http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf' |
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Reference |
Reference Type: CITATION Reference Text: 'Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., et al. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 97, 16-38.' |
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Definition |
Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. A severe hypoglycemic event (harm) is defined as a laboratory or point-of-care (POC) test for blood glucose with a result less than 40 mg/dL, where a hypoglycemic medication was given within the 24 hours prior to the start of the low blood glucose event (i.e., glucose result less than 40 mg/dL) and administered during the encounter (including emergency department and observation stays contiguous with the admission). The 24-hour timeframe extends from the end of the medication administration to the start of the blood glucose test. The measure does not count a severe hypoglycemic event (harm) in the numerator if there is a repeat test for blood glucose with a result greater than 80 mg/dL within five minutes of this initial low blood glucose test. The purpose of the repeat test within 5 minutes is to eliminate false positives that can occur in POC testing. The 5-minute timeframe extends from the start of the severe hypoglycemic test to the start of the repeat hypoglycemic test. Only one severe hypoglycemic event is counted per inpatient hospitalization encounter. |
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Guidance |
Note the measure is currently confined to using mg/dL as the unit of measurement for glucose results. To calculate the hospital-level measure result, divide the total numerator events by the total number of qualifying inpatient hospitalizations (denominator). Only the first qualifying severe hypoglycemic event is counted in the numerator, and only one severe hypoglycemic event is counted per encounter. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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Transmission Format |
TBD |
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Initial Population |
Inpatient hospitalizations where the patient is 18 years of age or older at the start of the encounter, and at least one hypoglycemic medication was administered during the encounter. The measure includes instances of administration of hypoglycemic medications in the emergency department or in observation status at the start of an inpatient hospitalization when assessing inclusion of encounters in the measure denominator. |
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Denominator |
Equals Initial Population |
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Denominator Exclusions |
None |
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Numerator |
Inpatient hospitalizations where a severe hypoglycemic event occurred during the encounter, which is: 1. A blood glucose result less than 40 mg/dL AND 2. A hypoglycemic medication administered within 24 hours prior to the start of the severe hypoglycemic event (i.e., the glucose result less than 40 mg/dL) AND 3. No subsequent repeat test for blood glucose with a result greater than 80 mg/dL within five minutes of the start of the initial blood glucose test with result less than 40mg/dL Only the first qualifying severe hypoglycemic event is counted in the numerator, and only one severe hypoglycemic event is counted per encounter. The 24-hour and 5-minute timeframes are based on the time the blood glucose was drawn, as this reflects the time the patient was experiencing that specific blood glucose level |
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Numerator Exclusions |
Not Applicable |
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Denominator Exceptions |
None |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
"Encounter With Hypoglycemic Medication Administration"
"Initial Population"
None
"Encounter With Severe Hypoglycemic Harm Event"
None
None
None
"Initial Population"
"Qualifying Encounter" InpatientEncounter with "Hypoglycemic Medication Administration" HypoglycemicMed such that Global."NormalizeInterval" ( HypoglycemicMed.relevantDatetime, HypoglycemicMed.relevantPeriod ) starts during Global.HospitalizationWithObservation ( InpatientEncounter )
"Encounter With Hypoglycemic Medication Administration" QualifyingEncounter where exists ( ["Laboratory Test, Performed": "Glucose Lab Test Mass Per Volume"] BloodGlucoseLab1 with ["Medication, Administered": "Hypoglycemics Severe Hypoglycemia"] HypoglycemicMed such that Global."NormalizeInterval" ( HypoglycemicMed.relevantDatetime, HypoglycemicMed.relevantPeriod ) starts 24 hours or less before or on BloodGlucoseLab1.relevantDatetime and Global."NormalizeInterval" ( HypoglycemicMed.relevantDatetime, HypoglycemicMed.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( QualifyingEncounter ) without ["Laboratory Test, Performed": "Glucose Lab Test Mass Per Volume"] BloodGlucoseLab2 such that BloodGlucoseLab2.relevantDatetime during Global."HospitalizationWithObservation" ( QualifyingEncounter ) and BloodGlucoseLab2.relevantDatetime 5 minutes or less after BloodGlucoseLab1.relevantDatetime and BloodGlucoseLab2.result > 80 'mg/dL' where BloodGlucoseLab1.relevantDatetime during Global."HospitalizationWithObservation" ( QualifyingEncounter ) and BloodGlucoseLab1.result < 40 'mg/dL' )
["Medication, Administered": "Hypoglycemics Severe Hypoglycemia"]
"Encounter With Hypoglycemic Medication Administration"
"Encounter With Severe Hypoglycemic Harm Event"
["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter where InpatientEncounter.relevantPeriod ends during day of "Measurement Period" and AgeInYearsAt(date from start of Global."HospitalizationWithObservation"(InpatientEncounter))>= 18
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Encounter Visit let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod sort by end of relevantPeriod ), VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod), EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED where LastED.relevantPeriod ends 1 hour or less on or before VisitStart sort by end of relevantPeriod ) return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), end of Visit.relevantPeriod]
if pointInTime is not null then Interval[pointInTime, pointInTime] else if period is not null then period else null as Interval<DateTime>
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
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