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Hospital Harm - Severe Hyperglycemia

Measure Information 2023 Reporting Period
CMS Measure ID CMS871v2
Short Name HH-02
NQF Number 3533e
Measure 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

Denominator Statement

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

Numerator Statement

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

Measure 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

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.

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

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Measure Information 2023 Reporting Period
CMS Measure ID CMS871v2
Short Name HH-02
NQF Number 3533e
Measure 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

Denominator Statement

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
Numerator Statement

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

Measure 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

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.

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

Release Notes

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

Last Updated: May 04, 2022