| Measure Information | 2023 Reporting Period |
|---|---|
| CMS eCQM ID | CMS816v2 |
| Short Name |
HH-01 |
| NQF Number | 3503e |
| 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 |
| 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. |
| 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 |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Equals Initial Population |
| Denominator Exclusions |
None |
| Denominator Exceptions |
None |
| Steward | Centers for Medicare & Medicaid Services (CMS) |
| Measure Scoring | Proportion measure |
| Measure Type | Outcome measure |
| Improvement Notation |
A lower proportion indicates better quality |
| 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. |
| Next Version | |
| Previous Version | No Version Available |
Compare eCQM Versions
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Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|
| Title | Hospital Harm - Severe Hypoglycemia | Hospital Harm - Severe Hypoglycemia |
| CMS eCQM ID | CMS816v2 | CMS816v3 |
| Short Name |
HH-01 |
HH-Hypo |
| NQF Number | 3503e | 3503e |
| 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 |
| 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. |
| Denominator |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions | 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. |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| Measure Scoring | Proportion measure | Proportion measure |
| Measure Type | Outcome measure | Outcome measure |
| Improvement Notation |
A lower proportion indicates better quality |
A lower proportion indicates better quality |
| 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. |
| Next Version | CMS816v3 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
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Replaced 'Not Applicable' with '3503e'.
Measure Section: NQF Number
Source of Change: Measure Lead
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Updated measure developer from 'IMPAQ International' to 'American Institutes for Research'.
Measure Section: Measure Developer
Source of Change: Measure Lead
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Replaced 'None' with 'National Quality Forum'.
Measure Section: Endorsed By
Source of Change: Measure Lead
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Removed duplicative information already referenced in the definition section for clarity.
Measure Section: Description
Source of Change: Measure Lead
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards/Technical Update
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Updated to remove the word 'recent'.
Measure Section: Rationale
Source of Change: Measure Lead
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Updated to reflect more recent literature.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Standards/Technical Update
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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
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Revised the numerator statement to be more concise.
Measure Section: Numerator
Source of Change: Measure Lead
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Replaced 'gender' with 'sex' to provide consistent language across eCQMs.
Measure Section: Supplemental Data Elements
Source of Change: Measure Lead
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Updated language for added clarity and to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Added 'day of' timing to the Qualifying Encounter definition to clarify the timing precision level.
Measure Section: Initial Population
Source of Change: Measure Lead
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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
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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
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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
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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.
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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
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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
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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