Hospital Harm – Severe Hypoglycemia

This measure assesses the proportion of encounters of patients 18 years of age or older at admission, who were administered at least one antihyperglycemic medication during the encounter, who suffer the harm of a severe hypoglycemic event during the encounter. Harm (numerator) is defined as a test for blood glucose with a result less than 40 mg/dL, where the antihyperglycemic medication was given within the 24 hours prior to the start of the low blood glucose event (and administered during the encounter). Only one severe hypoglycemic event is counted per encounter.

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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.

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.

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This measure focuses on severe hypoglycemia as an outcome in the hospital inpatient setting. Hypoglycemia events in the hospital are among the most common adverse drug events. In 2004 an estimated 888,000 adverse drug events occurred among hospitalized Medicare patients in the United States (Classen et.al., 2010; National Quality Forum, 2010). In a recent study published by the Office of the Inspector General (OIG), adverse drug events represent one-third of all adverse events in hospitals among Medicare patients; of those events, hypoglycemia represented the third most common adverse drug events (Office of the Inspector General, 2010).

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., 2010). 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 (Classen et al., 2010; American Diabetes Association, 2015).

From Section 14, Diabetes Care in the Hospital in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2018) two recommendations listed under goals for blood glucose levels for critically ill patients are related to hypoglycemia, and two recommendations are related to the management of hypoglycemia:

Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140 - 180 mg/dL (7.8 mmol/L) is recommended for the majority of critically ill patients.

More stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L) may be appropriate for selected patients, as long as they can be achieved without significant hypoglycemia.

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.

The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). There should be a structured discharge plan tailored to the individual patient with diabetes.

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 premeal glucose target of less than 140 mg/dL (7.8 mmol/liter) and a random BG of less than 180 mg/dL (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness.

3.2. We suggest that glycemic targets be modified according to clinical status. For patients who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG <11.1 mmol/liter or 200 mg/dL) may be reasonable.

3.3 For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values fall below 5.6 mmol/liter (100 mg/dL). Modification of glucose-lowering treatment is usually necessary when BG values are below 3.9 mmol/liter (70 mg/dL).

A lower proportion indicates better quality.

American Diabetes Association. 14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018;41(Supplement 1):S144.

American Diabetes Association. Hypoglycemia (Low Blood Glucose). 2015; http://diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html. Accessed August 20, 2018.

Classen, D. C., Jaser, L., & Budnitz, D. S. (2010). Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf, 36(1), 12-21.

National Quality Forum. (2010). Prioritization of High-Impact Medicare Conditions and Measure Gaps. Measure Prioritization Advisory Committee Report. May 2010. Retrieved August 29, 2011, from http://www.qualityforum.org/projects/prioritization.aspx?section= MeasurePrioritizatinAdvisoryCommitteeReport2010-05-24

Office of the Inspector General. (2010). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Retrieved December 14, 2011, from http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., et al. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 97, 16-38.

This measure defines a severe hypoglycemic event (harm) as a test (lab or point-of-care (POC)) for blood glucose with a result less than 40 mg/dL.

Additionally, the measure does not count a severe hypoglycemic event (harm) in the numerator if there is a repeat test for blood glucose with a result greater than 80 mg/dL within five minutes of this initial low blood glucose test. The purpose of the repeat test within 5 minutes is to eliminate false positives due to possible inaccurate POC test results, to ensure hospitals are not penalized for erroneous results, and therefore would be overcounting events in the numerator.

Only one severe hypoglycemic event is counted per encounter.

To calculate the hospital-level measure result, divide the total numerator events by the total number of eligible encounters (denominator). 

For each encounter, qualifying encounters (denominator) include all patients 18 years of age or older at the start of the encounter, who had at least one antihyperglycemic medication administered during the encounter.

To create the numerator, for each encounter identify: 
1. Any instance of a test for blood glucose with a result less than 40 mg/dL during the encounter (severe hypoglycemic event), with an anti-hyperglycemic medication administered within 24 hours preceding the event and during the encounter (including emergency department and observation stays contiguous with the admission).
A severe hypoglycemic event is defined as a test (laboratory or point-of-care (POC)) for blood glucose with a result less than 40 mg/dL. The 24-hour timeframe extends from the end of the medication administration to the start of the blood glucose test.
2. Do not include any severe hypoglycemic events (identified in Step 1) which were followed by a repeat test (laboratory or POC) for blood glucose with a result greater than 80 mg/dL within five minutes of the start of the initial low blood glucose test. 
Rationale: This is done to remove false positives that can occur in POC testing. The 5-minute timeframe extends from the start of the severe hypoglycemic test to the start of the repeat hypoglycemic test. 

Only the first qualifying severe hypoglycemic event is counted in the numerator, and only one severe hypoglycemic event is counted per encounter.

TBD

All encounters when the patient is 18 years of age or older at the start of the encounter, and at least one antihyperglycemic medication was administered during the encounter. Measure includes instances of administration of antihyperglycemic agents in the emergency department or in observation status at the start of an inpatient admission when assessing inclusion of encounters in the measure denominator.

Equals Initial Population

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All encounters which include:

1. A severe hypoglycemic event during the encounter, defined as a test (laboratory or point-of-care (POC)) for blood glucose with a result less than 40 mg/dL;
AND 
2. An antihyperglycemic medication administration within 24 hours prior to the start of the severe hyperglycemic event (and that was during the encounter); 
AND 
3. No subsequent repeat test (laboratory or POC) for blood glucose with a result greater than 80 mg/dL within five minutes of the start of the initial low blood glucose test. 

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.

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and gender.