Hospital Harm - Severe Hypoglycemia
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| Measure Information | 2023 Reporting Period | 2024 Reporting Period | 2025 Reporting Period |
|---|---|---|---|
| Title | Hospital Harm - Severe Hypoglycemia | Hospital Harm - Severe Hypoglycemia | Hospital Harm - Severe Hypoglycemia |
| CMS eCQM ID | CMS816v2 | CMS816v3 | CMS816v4 |
| Short Name |
HH-01 |
HH-Hypo |
HH-Hypo |
| CBE ID* | 3503e | 3503e | 3503e |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| 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 |
The measure assesses the number of inpatient hospitalizations for patients age 18 and older who were administered at least one hypoglycemic medication during the encounter, who suffer the harm of a severe hypoglycemic event during the encounter |
The measure assesses the number of inpatient hospitalizations for patients age 18 and older who were administered at least one hypoglycemic medication during the encounter and who suffer the harm of a severe hypoglycemic event during the encounter |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Outcome | Outcome | Outcome |
| Stratification | *See CMS816v2.html |
None |
None |
| Risk Adjustment | *See CMS816v2.html |
None |
None |
| Rationale | *See CMS816v2.html |
This measure focuses on severe hypoglycemia as an outcome in the hospital inpatient setting. In a study published by the Office of the Inspector General (OIG), in 2018 adverse drug events represented 43% of all adverse events in hospitals among Medicare patients; of those events, hypoglycemia was among the top 5 adverse drug events (Office of the Inspector General, 2022). Inpatient hypoglycemia can be life-threatening, and is associated with longer hospital stays and increased medical costs. Severe hypoglycemia (<40 mg/dL) occurs in 2–5% of hospitalized patients with diabetes mellitus, and medication-related hypoglycemic events are common causes of adverse drug events occurring in inpatient settings. Up to half of inpatient adverse drug events may be preventable, and recent studies show that rates of severe hypoglycemia vary across hospitals, suggesting opportunities for improved care (Santos, 2020). 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., 2021). 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 (American Diabetes Association, 2022; Cruz, 2022). |
This measure focuses on severe hypoglycemia as an outcome in the hospital inpatient setting. In a study published by the Office of the Inspector General (OIG), in 2018 adverse drug events represented 43% of all adverse events in hospitals among Medicare patients; of those events, hypoglycemia was among the top 5 adverse drug events (Office of the Inspector General, 2022). Inpatient hypoglycemia can be life-threatening, and is associated with longer hospital stays and increased medical costs. Severe hypoglycemia (<40 mg/dL) occurs in 2–5% of hospitalized patients with diabetes mellitus, and medication-related hypoglycemic events are common causes of adverse drug events occurring in inpatient settings. Up to half of inpatient adverse drug events may be preventable, and recent studies show that rates of severe hypoglycemia vary across hospitals, suggesting opportunities for improved care (Santos et al., 2020). 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., 2021). 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 (American Diabetes Association, 2022; Cruz, 2020). It has been found that fasting glucose levels <100 mg/dL are predictors of hypoglycemia within the next 24 hours (ElSayed et al., 2023). |
| Clinical Recommendation Statement | *See CMS816v2.html |
From Section 16, Diabetes Care in the Hospital in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2022): 16.9 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 for quality improvement/quality assessment. 16.10 For individual patients, treatment regimens should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented. A standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be in place to immediately address blood glucose levels of <70 mg/dL (3.9 mmol/L). In addition, individualized plans for preventing and treating hypoglycemia for each patient should also be developed. An American Diabetes Association consensus statement recommends that a patient’s treatment regimen be reviewed any time a blood glucose value of <70 mg/dL (3.9 mmol/L) occurs, as such readings often predict subsequent level 3 hypoglycemia. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting, 2022: Recommendation 1.1 In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available. Recommendation 2.1 Management of patients with GC-associated hyperglycemia requires ongoing BG monitoring with adjustment of insulin dosing. All therapies require safeguards to avoid hypoglycemia when doses of GCs are tapered or abruptly discontinued. Recommendation 10.1 In adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as BG > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 POC-BG measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy. Recommendation 10.2 In adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L). Recommendation 10.3 In adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). Remarks Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG. |
From Section 16, Diabetes Care in the Hospital in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2022): 16.9 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 for quality improvement/quality assessment. 16.10 For individual patients, treatment regimens should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented. A standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be in place to immediately address blood glucose levels of <70 mg/dL (3.9 mmol/L). In addition, individualized plans for preventing and treating hypoglycemia for each patient should also be developed. An American Diabetes Association consensus statement recommends that a patient’s treatment regimen be reviewed any time a blood glucose value of <70 mg/dL (3.9 mmol/L) occurs, as such readings often predict subsequent level 3 hypoglycemia. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (Korytkowski et al., 2022) as it relates to patients at high risk of hypoglycemia: Recommendation 1.1 In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available. Recommendation 2.1 Management of patients with glucocorticoid (GC)-associated hyperglycemia requires ongoing BG monitoring with adjustment of insulin dosing. All therapies require safeguards to avoid hypoglycemia when doses of GCs are tapered or abruptly discontinued. Recommendation 10.1 In adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as BG > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 POC-BG measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy. Recommendation 10.2 In adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L). Recommendation 10.3 In adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). Remarks Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG. |
| Improvement Notation |
A lower proportion indicates better quality |
A lower proportion indicates better quality |
A lower measure score indicates higher quality |
| Definition | *See CMS816v2.html |
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 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 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 time of the glucose test. The measure does not count a severe hypoglycemic event (harm) in the numerator if there is a repeat test for glucose with a result greater than 80 mg/dL within five minutes of this initial low 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 time of the repeat hypoglycemic test. |
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 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 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 time of the glucose test. The measure does not count a severe hypoglycemic event (harm) in the numerator if there is a repeat test for glucose with a result greater than 80 mg/dL within five minutes of this initial low 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 time of the repeat hypoglycemic test. |
| 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 QDM page for more information on the QDM. |
Note the measure is currently confined to using mg/dL as the unit of measurement for glucose results. Glucose levels are determined by laboratory or point-of-care (POC) tests, including capillary/glucometer blood glucose tests, and by interstitial fluid specimens from continuous glucose monitors. Glucose test results from urine specimens are not considered. To calculate the hospital-level measure result, divide the total numerator events by the total number of qualifying inpatient hospitalizations (denominator). 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 QDM page for more information on the QDM. |
Note the measure is currently confined to using mg/dL as the unit of measurement for glucose results. Glucose levels are determined by laboratory or point-of-care (POC) tests, including capillary/glucometer blood glucose tests, and by interstitial fluid specimens from continuous glucose monitors. Glucose test results from urine specimens are not considered. 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 QDM page for more information on the QDM. |
| 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. |
Inpatient hospitalizations that end during the measurement period for patients age 18 and older 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. |
Inpatient hospitalizations that end during the measurement period for patients age 18 and older and at least one hypoglycemic medication administration starts during the encounter |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
None |
None |
None |
| 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 |
Inpatient hospitalizations where a severe hypoglycemic event occurred during the encounter, which is: - A glucose result less than 40 mg/dL AND - 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 - No subsequent repeat test for glucose with a result greater than 80 mg/dL within five minutes of the time of the initial glucose test with result less than 40mg/dL Only one 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 glucose was drawn, as this reflects the time the patient was experiencing that specific glucose level. |
Inpatient hospitalizations where a severe hypoglycemic event occurred during the encounter. A severe hypoglycemic event is: - A glucose test with a result less than 40 mg/dL AND - A hypoglycemic medication was administered within 24 hours before the start of the severe hypoglycemic event (i.e., the glucose test with a result less than 40 mg/dL) AND - There was no subsequent repeat test for glucose with a result greater than 80 mg/dL within five minutes or less from the start of the initial glucose test with a result less than 40 mg/dL Only one 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 glucose was drawn, as this reflects the time the patient was experiencing that specific glucose level. |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS816v2
Header
Replaced 'Not Applicable' with '3503e'.
Measure Section: NQF Number
Source of Change: Measure Lead
Updated measure developer from 'IMPAQ International' to 'American Institutes for Research'.
Measure Section: Measure Developer
Source of Change: Measure Lead
Replaced 'None' with 'National Quality Forum'.
Measure Section: Endorsed By
Source of Change: Measure Lead
Removed duplicative information already referenced in the definition section for clarity.
Measure Section: Description
Source of Change: Measure Lead
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards/Technical Update
Updated to remove the word 'recent'.
Measure Section: Rationale
Source of Change: Measure Lead
Updated to reflect more recent literature.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Standards/Technical Update
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Revised the numerator statement to be more concise.
Measure Section: Numerator
Source of Change: Measure Lead
Replaced 'gender' with 'sex' to provide consistent language across eCQMs.
Measure Section: Supplemental Data Elements
Source of Change: Measure Lead
Updated language for added clarity and to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
Added 'day of' timing to the Qualifying Encounter definition to clarify the timing precision level.
Measure Section: Initial Population
Source of Change: Measure Lead
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Value set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Replaced value set Glucose lab test (2.16.840.1.113762.1.4.1045.134) with value set Glucose Lab Test Mass Per Volume (2.16.840.1.113762.1.4.1248.34) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hypoglycemics Severe Hypoglycemia (2.16.840.1.113762.1.4.1196.393): Added 26 RxNorm codes based on terminology update. Deleted 256 RxNorm codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update