Hospital Harm - Severe Hyperglycemia

This measure assesses the number of hospital days with a hyperglycemic event (harm) per the total qualifying hospital days among inpatient encounters for patients 18 years and older at the start of the measurement period.

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CPT(R) contained in the Measure specifications is copyright 2004-2018 American Medical Association. LOINC(R) copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 World Health Organization. All Rights Reserved

This measure and specifications are subject to further revisions. 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.

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Hyperglycemia, i.e., elevated blood glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Swanson, et al., 2011; Umpierrez et al., 2012). Hyperglycemia can also affect individuals with no prior history of diabetes and may be induced by medications such as steroids, or parenteral (intravenous) or enteral (tube) feeding.

Severe hyperglycemia, i.e., extremely elevated blood glucose level, is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay (Pasquel, et al., 2010; Rady, et al., 2005; Umpierrez, et al., 2002; Falciglia et al., 2009; Lee et al., 2012; King et al., 2011; Jackson et al., 2012; Umpierrez et al., 2012; Krinsley 2003). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley 2003; Newton et al., 2006; Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Swanson et al., 2011; Cook et al., 2009; Matheny et al., 2008). The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety (Maynard et al., 2015; Donihi et al., 2006).

It should be noted that this measure does not aim to measure overall glucose control in hospitalized patients; rather, our goal is to assess the occurrence and extent of severe hyperglycemia. This measure is also intended to be used in combination with its companion measure of hypoglycemia (Hospital Harm – Hypoglycemia) to reduce unintended consequences of measurement. 

Multiple guidelines address recommended levels of glycemic control, though these do not define severe hyperglycemia:
Clinical Recommendation Statement From Section 14, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2017): 

Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold >=180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and noncritically ill patients. More stringent goals, such as <140 mg/dL (<7.8 mmol/L), may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. 

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 pre-meal glucose target of less than 140 mg/dL (7.8 mmol/liter) and a random [blood glucose] of less than 180 mg/dL (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness.

There is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >180 , >300, and >350 mg/dL, among other values (Jamesen et al., 2015; Cook et al., 2009; Donihi et al., 2011; Weinberg et al, 2010; Mendez et al, 2015). Glycemic goals may also differ among hospitalized patients. For example, in an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety.

A lower measure score indicates higher quality.

American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2017;40(Suppl 1).

Cook CB, Kongable GL, Potter DJ, et al. Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hosp Med. 2009;4(9):E7-E14

Donihi AC, DiNardo MM, DeVita MA, et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15(2):89-91.

Donihi AC, Gibson JM, Noschese ML, et al. Effect of targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011; (4)552-557.

Falciglia M, Freyberg RW, Alemenoff PL, et al. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009; 37(12):3001-3009.

Jackson RS, Amdur RL, White JC, et al. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg. 2012;214(1):68-80.

Jamesen E, Nevalainen PL, Eskelinen A, et al. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015; 86(2):175-182.

King JT, Goulet JL, Perkal MF, et al. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann surg. 2011;253(1):158-165.

Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003 Dec;78(12):1471-1478.

Krinsley JS, Jones RL. Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2016;129(3)644-650

Lee LJ, Emons MF, Martin SA, et al. Association of blood glucose levels with in-hospital mortality and 30-day readmission in patients undergoing invasive cardiovascular surgery. Curr Med Res Opin. 2012;28(1):1657-1665.

Matheny ME, Shubina M, Kimmel ZK., et al. Treatment intensification and blood glucose control among hospitalized diabetic patients. J Gen Intern Med. 2008;23(2).

Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemic reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355-367.

Mendez CE, Ata A, Rourke JM, et al. Daily inpatient glycemic survey (DINGS): A process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927-935.

Newton CA, Yong, S. Financial implications of glycemic control: Results of an inpatient diabetes management program. Endocr Pract. 2006;3:43-48.

Pasquel FJ, Spiegelman R, McCauley M. Hyperglycemia during total parenteral nutrition: An important marker of poor outcome and mortality in hospitalized patients. Diabetes Care. 2010;(33)4:739-741.

Rady MY. Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus. Mayo Clin Proc 2005;80(12):1558-1567.

Swanson CM, Potter DJ, Kongable GL, et al. Update on inpatient glycemic control in hospitals in the United States. Endocrine Practice. 2011;17(6):853-861.

Umpierrez, GE, Hellman, R, Korytkowski, MT, et al. Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97, 16-38

Umpierrez GE, Issacs DS, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endorinol Metab. 2002;87(3):978-982.

Weinberg ME, Bacchetti P, Rushakoff, RJ. Frequently repeated glucose measurements overestimate the incidence of inpatient hypoglycemia and severe hyperglycemia. J Diabetes Sci Technol. 2010;May 1;4(3):577-582.

This measure defines a severe hyperglycemic day (harm) as either (1) a 24-hour period with a test (lab or point-of-care (POC)) for blood glucose with a result of >300 mg/dL, or (2) a day in which a test for blood glucose was not measured and it was preceded by two consecutive days where at least one lab or point-of-care (POC) test during each of the two days for blood glucose had a result >=200 mg/dL. 

To determine the measure outcome, the total number of hyperglycemic days across all encounters is divided by the total number of eligible days across all encounters. Hospital days are 24-hour periods that start at the time of admission to the hospital (including Emergency Department). The measure only evaluates the first 10 days of an eligible encounter in determining eligible days (length of stay is truncated to <=10 days when an encounter’s length exceeds 10 days).

To calculate a hospital-level measure result, total the number of hyperglycemic days across all encounters (numerator events) for each eligible day across all encounters (denominator).

To create the Measure Observation associated with the numerator, include all hyperglycemic days meeting the follow criteria:

1)	 All 24-hour periods with a blood glucose level >300 mg/dL (except those occurring in the first 24-hour period after admission to the hospital (including the Emergency Department)), 
Or,
2)	 All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value during each of the two days is >=200 mg/dL.

Do not count the first 24-hour period after admission to the hospital (including the Emergency Department) for >300 mg/dL events in order to exclude hyperglycemic events potentially due to poor glucose control outside of the hospital setting or that preceded the start of hospital care.

Remove the last time period before discharge, if it was less than 24-hours, to avoid counting a period of time that was less than 24-hours, on the day of discharge, as a full day.

Blood glucose levels are determined by laboratory or point-of-care (POC) tests, including capillary/glucometer blood glucose tests.

Note the measure is currently confined to using mg/dL as the unit of measurement for glucose results.

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5.  Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All encounters where the patient is 18 years or older at the start of the measurement period with an inpatient hospital discharge during the measurement period, as well as either: 
1.	a diagnosis of diabetes that starts before or during the encounter; or 
2.	administration of at least one dose of insulin or any hypoglycemic medication during the encounter; or 
3.	presence of at least one blood glucose value >=200 mg/dL at any time during the encounter. 

The measure includes inpatient encounters that began in the Emergency Department or in observational status.

Equals Initial Population

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There are two Measure Observations:
1, associated with the Denominator: The total number of eligible days across all encounters which match the initial population/denominator criteria. 

Hospital days are measured in 24-hour periods starting from the time of arrival at the hospital (including Emergency Department. Do not count the first 24-hour period after admission to the hospital (including the Emergency Department) or the last time period before discharge, if it was less than 24 hours. 

The length of stay for all eligible encounters is truncated to <=10 days when an encounter’s length exceeds 10 days.

2, associated with the Numerator: The total number of hyperglycemic days across all encounters. Days with a hyperglycemic event are defined as: 

1)	 All 24-hour periods with a blood glucose level >300 mg/dL (except those occurring in the first 24-hour period after admission to the hospital (including the Emergency Department)), 
Or,
2)	 All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL.

Do not count the first 24-hour period after admission to the hospital (including the Emergency Department),  for >300 mg/dL events, or the last time period before discharge for either numerator measure observation, if it was less than 24 hours.

The measure result is the total number of hyperglycemic days across all encounters divided by the total number of eligible days across all encounters.

All encounters with a hyperglycemic event within the first 10 days of the encounter minus the first 24 hours, and minus the last period before discharge if less than 24 hours.

A hyperglycemic event is defined as: 
1.	A day with at least one blood glucose value >300 mg/dL; OR
2.	A day where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL.

Not Applicable

For every patient evaluated by this measure also identify payer, race, ethnicity and gender