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Hospital Harm - Severe Hypoglycemia

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.

Denominator

Equals Initial Population

Denominator Exclusions

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure 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.

Meaningful Measure Preventable Healthcare Harm
Next Version No Version Available
Previous Version No Version Available

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Measure Information 2023 Reporting Period
Title Hospital Harm - Severe Hypoglycemia
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.

Denominator

Equals Initial Population

Denominator Exclusions 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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure 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.

Meaningful Measure Preventable Healthcare Harm
Next Version No Version Available
Previous Version No Version Available

Release Notes

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: Aug 29, 2022