eCQM Title

Hospital Harm Hyperglycemia in Hospitalized Patients

eCQM Identifier (Measure Authoring Tool) 871 eCQM Version Number 0.0.088
NQF Number Not Applicable GUID ef95493c-3f65-4440-9ccb-eaf1b9ed1210
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Developer IMPAQ International
Endorsed By None
Description
This measure assesses the number of hospital days with a hyperglycemic event (harm) per the total qualifying hospital days among inpatient encounters for patients 18 years and older at the start of the measurement period.
Copyright
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.

CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved.
Disclaimer
This measure and specifications are subject to further revisions. This performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring Ratio
Measure Type Outcome
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
Hyperglycemia, i.e., elevated blood glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Swanson, et al., 2011; Umpierrez et al., 2012). Hyperglycemia can also affect individuals with no prior history of diabetes and may be induced by medications such as steroids, or parenteral (intravenous) or enteral (tube) feeding.

Severe hyperglycemia, i.e., extremely elevated blood glucose level, is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay (Pasquel, et al., 2010; Rady, et al., 2005; Umpierrez, et al., 2002; Falciglia et al., 2009; Lee et al., 2012; King et al., 2011; Jackson et al., 2012; Umpierrez et al., 2012; Krinsley 2003). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley 2003; Newton et al., 2006; Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Swanson et al., 2011; Cook et al., 2009; Matheny et al., 2008). The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety (Maynard et al., 2015; Donihi et al., 2006).
Clinical Recommendation Statement
It should be noted that this measure does not aim to measure overall glucose control in hospitalized patients; rather, our goal is to assess the occurrence and extent of severe hyperglycemia. This measure is also intended to be used in combination with its companion measure of hypoglycemia (Hospital Harm – Hypoglycemia) to reduce unintended consequences of measurement. 

Multiple guidelines address recommended levels of glycemic control, though these do not define severe hyperglycemia:
Clinical Recommendation Statement From Section 14, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2017): 

Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold >=180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and noncritically ill patients. More stringent goals, such as <140 mg/dL (<7.8 mmol/L), may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. 

From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (Umpierrez et al., 2012):
3.1. We recommend a pre-meal glucose target of less than 140 mg/dL (7.8 mmol/liter) and a random [blood glucose] of less than 180 mg/dL (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness.

There is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >180 , >300, and >350 mg/dL, among other values (Jamesen et al., 2015; Cook et al., 2009; Donihi et al., 2011; Weinberg et al, 2010; Mendez et al, 2015). Glycemic goals may also differ among hospitalized patients. For example, in an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety.
Improvement Notation
A lower measure score indicates higher quality.
Reference
American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2017;40(Suppl 1).
Reference
Cook CB, Kongable GL, Potter DJ, et al. Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hosp Med. 2009;4(9):E7-E14
Reference
Donihi AC, DiNardo MM, DeVita MA, et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15(2):89-91.
Reference
Donihi AC, Gibson JM, Noschese ML, et al. Effect of targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011; (4)552-557.
Reference
Falciglia M, Freyberg RW, Alemenoff PL, et al. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009; 37(12):3001-3009.
Reference
Jackson RS, Amdur RL, White JC, et al. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg. 2012;214(1):68-80.
Reference
Jamesen E, Nevalainen PL, Eskelinen A, et al. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015; 86(2):175-182.
Reference
King JT, Goulet JL, Perkal MF, et al. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann surg. 2011;253(1):158-165.
Reference
Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003 Dec;78(12):1471-1478.
Reference
Krinsley JS, Jones RL. Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2016;129(3)644-650
Reference
Lee LJ, Emons MF, Martin SA, et al. Association of blood glucose levels with in-hospital mortality and 30-day readmission in patients undergoing invasive cardiovascular surgery. Curr Med Res Opin. 2012;28(1):1657-1665.
Reference
Matheny ME, Shubina M, Kimmel ZK., et al. Treatment intensification and blood glucose control among hospitalized diabetic patients. J Gen Intern Med. 2008;23(2).
Reference
Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemic reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355-367.
Reference
Mendez CE, Ata A, Rourke JM, et al. Daily inpatient glycemic survey (DINGS): A process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927-935.
Reference
Newton CA, Yong, S. Financial implications of glycemic control: Results of an inpatient diabetes management program. Endocr Pract. 2006;3:43-48.
Reference
Pasquel FJ, Spiegelman R, McCauley M. Hyperglycemia during total parenteral nutrition: An important marker of poor outcome and mortality in hospitalized patients. Diabetes Care. 2010;(33)4:739-741.
Reference
Rady MY. Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus. Mayo Clin Proc 2005;80(12):1558-1567.
Reference
Swanson CM, Potter DJ, Kongable GL, et al. Update on inpatient glycemic control in hospitals in the United States. Endocrine Practice. 2011;17(6):853-861.
Reference
Umpierrez, GE, Hellman, R, Korytkowski, MT, et al. Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97, 16-38
Reference
Umpierrez GE, Issacs DS, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endorinol Metab. 2002;87(3):978-982.
Reference
Weinberg ME, Bacchetti P, Rushakoff, RJ. Frequently repeated glucose measurements overestimate the incidence of inpatient hypoglycemia and severe hyperglycemia. J Diabetes Sci Technol. 2010;May 1;4(3):577-582.
Definition
This measure defines a severe hyperglycemic day (harm) as either (1) a 24-hour period with a blood glucose level >300 mg/dL, or (2) a day in which a blood glucose was not measured and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL. 

To determine the measure outcome, the total number of hyperglycemic days across all encounters is divided by the total number of eligible days across all encounters. Hospital days are 24-hour periods that start at the time of admission to the hospital (including Emergency Department). The measure only evaluates the first 10 days of an eligible encounter in determining eligible days (length of stay is truncated to <=10 days when an encounter’s length exceeds 10 days).
Guidance
To calculate a hospital-level measure result, total the number of hyperglycemic days across all encounters (numerator events) for each eligible day across all encounters (denominator).

To create the Measure Observation associated with the numerator, include all hyperglycemic days meeting the follow criteria:

1)	 All 24-hour periods with a blood glucose level >300 mg/dL (except those occurring in the first 24-hour period after admission to the hospital (including the Emergency Department)), 
Or,
2)	 All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL.

Do not count the first 24-hour period after admission to the hospital (including the Emergency Department) for >300 mg/dL events in order to exclude hyperglycemic events potentially due to poor glucose control outside of the hospital setting or that preceded the start of hospital care.

Remove the last time period before discharge, if it was less than 24-hours, to avoid counting a period of time that was less than 24-hours, on the day of discharge, as a full day.
Transmission Format
TBD
Initial Population
All patients 18 years or older at the start of the measurement period with a discharged inpatient hospital encounter 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 anti-diabetic medication overlaps 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 encounters that began in the Emergency Department or in observational status.
Denominator
Same as Initial Population
Denominator Exclusions
None
Measure Observations
There are two Measure Observations:
1, associated with the Denominator: The total number of eligible days across all encounters which match the initial population/denominator criteria. 

Hospital days are measured in 24-hour periods starting from the time of arrival at the hospital (including Emergency Department. Do not count the first 24-hour period after admission to the hospital (including the Emergency Department) or the last time period before discharge, if it was less than 24 hours. 

The length of stay for all eligible encounters is truncated to <=10 days when an encounter’s length exceeds 10 days.

2, associated with the Numerator: The total number of hyperglycemic days across all encounters. Days with a hyperglycemic event are defined as: 

1)	 All 24-hour periods with a blood glucose level >300 mg/dL (except those occurring in the first 24-hour period after admission to the hospital (including the Emergency Department)), 
Or,
2)	 All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL.

Do not count the first 24-hour period after admission to the hospital (including the Emergency Department),  for >300 mg/dL events, or the last time period before discharge for either numerator measure observation, if it was less than 24 hours.

The measure result is the total number of hyperglycemic days across all encounters divided by the total number of eligible days across all encounters.
Numerator
Same as Initial Population and Denominator
Numerator Exclusions
None
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and gender

Table of Contents


Population Criteria

        • "Eligible Initial Population and Denominator Encounters"
          	intersect ( "Existing Diabetes Diagnosis"
          			union "Overlapping Antidiabetic Medication"
          			union "Initial Elevated Blood Glucose Lab"
          	)
         
        • "Eligible Initial Population and Denominator Encounters"
          	intersect ( "Existing Diabetes Diagnosis"
          			union "Overlapping Antidiabetic Medication"
          			union "Initial Elevated Blood Glucose Lab"
          	)
         
        • None
         
        • "Eligible Initial Population and Denominator Encounters"
          	intersect ( "Existing Diabetes Diagnosis"
          			union "Overlapping Antidiabetic Medication"
          			union "Initial Elevated Blood Glucose Lab"
          	)
         
        • None
         
        • None
         
        • Sum (
            Min({(days between(start of Qualifying_Encounter.relevantPeriod + 24 hours)and(
          			end of Qualifying_Encounter.relevantPeriod
          		)
          	), 9 }
          )
          )
         
        • Sum (
            ( if Sum(({ 2 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 2 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 3 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 3 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 4 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 4 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 5 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 5 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 6 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 6 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 7 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 7 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 8 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 8 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 9 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 9 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          ) + ( if Sum(({ 10 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)is not null then Sum(({ 10 })Day
          			where Qualifying_Encounter.relevantPeriod includes "Encounter Day"(Qualifying_Encounter, Day)
          			return "Extreme Blood Glucose or Not Measured Day"(Qualifying_Encounter, Day)
          	)
          		else 0
          )
          )
         
  • Definitions

    Functions

    Terminology

    • valueset "Antidiabetics" (2.16.840.1.113883.3.1260.1.1978)
    • valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
    • valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
    • valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
    • valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
    • valueset "Glucose Lab Test" (2.16.840.1.113762.1.4.1045.134)
    • valueset "Observation Services" (2.16.840.1.113762.1.4.1111.143)
    • valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
    • valueset "Payer" (2.16.840.1.114222.4.11.3591)
    • valueset "Race" (2.16.840.1.114222.4.11.836)

    Data Criteria (QDM Data Elements)

    • "Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
    • "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
    • "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
    • "Encounter, Performed: Observation Services" using "Observation Services (2.16.840.1.113762.1.4.1111.143)"
    • "Laboratory Test, Performed: Glucose Lab Test" using "Glucose Lab Test (2.16.840.1.113762.1.4.1045.134)"
    • "Medication, Administered: Antidiabetics" using "Antidiabetics (2.16.840.1.113883.3.1260.1.1978)"
    • "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
    • "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
    • "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
    • "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

    Supplemental Data Elements

    Risk Adjustment Variables


    Measure Set