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Hospital Harm - Severe Hypoglycemia

Compare Versions of: "Hospital Harm - Severe Hypoglycemia"

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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

CBE ID 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

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.

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.

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

Equals Initial Population

Equals Initial Population

Denominator Exclusions

None

None

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.

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).

Stratification *See CMS816v2.html

None

Risk Adjustment *See CMS816v2.html

None

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.

Next Version No Version Available
Previous Version No Version Available

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

Last Updated: Mar 04, 2024