Hospital Harm - Severe Hyperglycemia

Measure Information	2023 Reporting Period
CMS eCQM ID	CMS871v2
Short Name	HH-02
NQF Number	3533e
Description	This measure assesses the number of inpatient hospital days with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for that encounter for patients 18 years of age or older at admission
Initial Population	Inpatient hospitalizations where the patient is 18 years or older at the start of the admission with a 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 hospitalizations that began in the emergency department or in observation
Numerator	Inpatient hospitalizations 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 test was not done, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL
Numerator Exclusions	Not Applicable
Denominator	Equals Initial Population
Denominator Exclusions	Inpatient hospitalizations for patients with an initial blood glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter
Steward	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Ratio measure
Measure Type	Outcome measure
Improvement Notation	A lower measure score indicates higher quality
Guidance	The measure is using mg/dL as the unit of measurement for glucose results. To determine the measure outcome, the total number of hyperglycemic days during the inpatient hospitalization is divided by the total number of eligible hospital days of the inpatient hospitalization. When evaluating for days with a blood glucose level >300 mg/dL, the first 24-hour period after admission to the hospital (including the emergency department or observation) is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care. This measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions. The numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria. Blood glucose levels are determined by laboratory or point-of-care (POC) tests, including capillary/glucometer blood glucose tests. 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.
Stratification	None
Next Version	CMS871v3
Previous Version	No Version Available

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Measure Information	2023 Reporting Period	2024 Reporting Period
Title	Hospital Harm - Severe Hyperglycemia	Hospital Harm - Severe Hyperglycemia
CMS eCQM ID	CMS871v2	CMS871v3
Short Name	HH-02	HH-Hyper
NQF Number	3533e	3533e
Description	This measure assesses the number of inpatient hospital days with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for that encounter for patients 18 years of age or older at admission	This measure assesses the number of inpatient hospital days for patients age 18 and older with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for that encounter
Initial Population	Inpatient hospitalizations where the patient is 18 years or older at the start of the admission with a 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 hospitalizations that began in the emergency department or in observation	Inpatient hospitalizations for patients age 18 and older that end during the measurement period, as well as either: - A diagnosis of diabetes that starts before or during the encounter; or - Administration of at least one dose of insulin or any hypoglycemic medication during the encounter; or - Presence of at least one glucose value >=200 mg/dL at any time during the encounter
Denominator	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Inpatient hospitalizations for patients with an initial blood glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter	Inpatient hospitalizations for patients with an initial glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter
Numerator	Inpatient hospitalizations 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 test was not done, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL	Inpatient hospitalizations with a hyperglycemic event within the first 10 days of the encounter minus the first 24 hours, and minus the last period before discharge from the hospital if less than 24 hours A hyperglycemic event is defined as: - A day with at least one glucose value >300 mg/dL, OR - A day where a glucose test and result was not found, and it was immediately preceded by two contiguous, consecutive days where at least one glucose value during each of the two days was >=200 mg/dL
Numerator Exclusions	Not Applicable	Not Applicable
Measure Steward	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Ratio measure	Ratio measure
Measure Type	Outcome measure	Outcome measure
Improvement Notation	A lower measure score indicates higher quality	A lower measure score indicates higher quality
Guidance	The measure is using mg/dL as the unit of measurement for glucose results. To determine the measure outcome, the total number of hyperglycemic days during the inpatient hospitalization is divided by the total number of eligible hospital days of the inpatient hospitalization. When evaluating for days with a blood glucose level >300 mg/dL, the first 24-hour period after admission to the hospital (including the emergency department or observation) is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care. This measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions. The numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria. Blood glucose levels are determined by laboratory or point-of-care (POC) tests, including capillary/glucometer blood glucose tests. 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.	The measure is using mg/dL as the unit of measurement for glucose results. To determine the measure outcome, the total number of hyperglycemic days during the inpatient hospitalization is divided by the total number of eligible hospital days of the inpatient hospitalization. When evaluating for days with a glucose level >300 mg/dL, the first 24-hour period after admission to the hospital (including the emergency department or observation) is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care. This measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions. The “Days in Hospitalization” logic within Measure Observation 1 (associated with the denominator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hospital days (e.g., from day 2 to day 10). The “Days in Hospitalization” logic within Measure Observation 2 (associated with the numerator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hyperglycemic event days (e.g., from day 2 to day 10). Since the measure does not count any hyperglycemic events that occur in the first 24 hours, day 1 is not considered an eligible hospital day for the Measure Observations. Eligible days range from day 2 up to day 10. Although the measure does not count any hyperglycemic events that occur in the first 24 hours as a hyperglycemic event day in Measure Observation 2, the first 24 hours of the encounter is considered day 1. This is because if there was a day during the encounter where a glucose result is not found, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., day 1, to be one of the preceding days. Multiple hyperglycemic events can occur during a ‘day’, but this is still considered one hyperglycemic event day. The numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria. The specimen source for the glucose test is blood, serum, plasma, or interstitial fluid, and can be obtained by a laboratory test, a Point of Care (POC) test, or a continuous glucose monitor (CGM). 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.
Next Version	CMS871v3	No Version Available
Previous Version	No Version Available	CMS871v2

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CMS871v2.zip	89.84 KB
CMS871v2-TRN.xlsx	21.82 KB

*Note: There are known issues on CMS871v2. See issue EKI-18 and EKI-19 on the ONC eCQM Known Issues Dashboard for details.

Data Element Repository

Data Elements contained within CMS871v2

Value Sets

Value Sets to be used with CMS871v2

Release Notes

CMS871v2-TRN.xlsx

Header

Replaced 'Not Applicable' with '3533e'.

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
Added citations to reflect updated literature.

Measure Section: Rationale

Source of Change: Measure Lead
Added language regarding the treatment of patients presenting with hyperglycemic crisis.

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
Added language to clarify numerator criteria and return values.

Measure Section: Guidance

Source of Change: Measure Lead
Revised description to better align with measure intent.

Measure Section: Initial Population

Source of Change: Measure Lead
Added a denominator exclusion of inpatient hospitalizations for patients with an initial blood glucose result of >=1000 mg/dL that starts any time between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Revised formatting and punctuation.

Measure Section: Numerator

Source of Change: Measure Lead
Revised the Measure Observations description to clarify measure intent.

Measure Section: Measure Observations

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
Added logic to exclude inpatient hospitalizations for patients with an initial blood glucose result of >=1000 mg/dL that starts any time between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Replaced the numerator definition with a single definition statement for improved readability and to align with CQL Style Guide.

Measure Section: Numerator

Source of Change: Measure Lead
Replaced the 'count' operator with 'sum' to align with measure intent.

Measure Section: Measure Observations

Source of Change: Measure Lead
Revised the 'Interval To Day Numbers' function by replacing 'days' with 'duration in days' and changing the alias name of 'DayExpand' to 'DayNumber'.

Measure Section: Functions

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 Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Deleted 24 ICD-10-CM codes based on validity of code during timing of look back period.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Hypoglycemics Treatment Medications (2.16.840.1.113762.1.4.1196.394): Added 44 RxNorm codes based on terminology update. Deleted 4 RxNorm codes (261243, 1544570, 1544571, 1656705) based on terminology update. Deleted 631 RxNorm codes based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead