Average percentage of hyperglycemic hospital days for individuals with a diagnosis of diabetes mellitus, anti-diabetic drugs (except metformin) administered, or at least one elevated glucose level during the hospital stay

Limited proprietary coding is contained in the Measure specifications for user convenience. Use of these codes may require permission from the code owner or agreement to a license.  

ICD-10 codes are copyright (C) World Health Organization (WHO), Fourth Edition, 2010. The LOINC (R) codes are copyright (C) 1995-2013, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. SNOMED CT (R) was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the International Health Terminology Standards Development Organisation (IHTSDO), copyright (C) 2002-2013. All rights reserved.

Due to technical limitations, registered trademarks are indicated by (R) and copyright marks are indicated by (C).

The measure and specifications are provided as draft and subject to further revisions. This performance measure does not establish a standard of medical care and has not been tested for all potential applications.

Depending on the operational use of the measure, measure results will be stratified by:
1. Care units (intensive care unit vs. non-intensive care unit) - Hospital days will be assigned to the unit with the majority of time.
2. Type of patients (medical vs. surgical)

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This measure focuses on hyperglycemia as an intermediate outcome in the hospital inpatient setting.  The measure is aligned with national priorities with a clear focus on improved management of patients with diabetes (National Quality Forum, 2010) and improved patient safety (U.S. Department of Health and Human Services, 2012). Hyperglycemia occurs frequently in the inpatient setting, despite serious consequences, including increased risk of infection and mortality and longer lengths of stay. Estimates concerning the incidence of hyperglycemia during hospital admissions to U.S. hospitals suggest a clear quality gap and ample room for improvement in inpatient glycemic control. For example, a recent study of hospitalized patients from the VHA and the University Health System Consortium estimated that 18% and 38% of patients, respectively, experienced persistent hyperglycemia during their hospital stays (Wexler, Meigs, Cagliero, Nathan, & Grant, 2007). Hyperglycemia in the inpatient setting has been associated with a substantial increase in hospital mortality and has been a predictor of complications and serious infections (Furnary, et al., 2003; Furnary, Zerr, Grunkemeier, & Starr, 1999; Krinsley, 2003).  Interventions designed to improve glycemic control have been shown to decrease costs, lengths of stay, and complications (Furnary, Wu, & Bookin, 2004; Krinsley & Jones, 2006; Newton & Young, 2006).

The "Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians" (Qaseem et al., 2011) offers the following recommendations regarding inpatient glycemic control on page 260:

Recommendation 1: ACP recommends not using intensive insulin therapy to strictly control blood glucose in non–surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus (Grade: strong recommendation, moderate-quality evidence).

Recommendation 2: ACP recommends not using intensive insulin therapy to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus (Grade: strong recommendation, high-quality evidence).

Recommendation 3: ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients (Grade: weak recommendation, moderate-quality evidence).


The “Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: an Endocrine Society Clinical Practice Guideline” (Umpierrez et al., 2012) offers the following recommendations regarding inpatient glycemic control on pages 17:

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. (strong recommendation/low quality evidence).

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. (weak recommendation/very low quality evidence).

The "Standards of Medical Care in Diabetes--2013" (American Diabetes Association, 2013) offers the following recommendations regarding inpatient glycemic control on pages S45-S46:

For 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 (7.8–10 mmol/l) is recommended for the majority of critically ill patients. (Level of evidence=A)

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

For non-critically ill patients:
There is no clear evidence for specific blood glucose goals. If treated with insulin, the premeal blood glucose targets generally <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) are reasonable, provided these targets can be safely achieved. More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe comorbidities.(Level of evidence=E)

• Lower score indicates better quality

American Diabetes Association (ADA). (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(Suppl 1), S11-66.

Furnary, A. P., Gao, G., Grunkemeier, G. L., Wu, Y., Zerr, K. J., Bookin, S. O., et al. (2003 May). Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. Journal of Thoracic Cardiovascular Surgery, 125(5):1007-21.

Furnary, A. P., Wu, Y., & Bookin, S. O. (2004 Mar-Apr). Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: The Portland Diabetic Project. Endocrine Practice, 10(Suppl 2), 21-33.

Furnary, A. P., Zerr, K. J., Grunkemeier, G. L., & Starr, A. (1999 Feb.). Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Annals of Thoracic Surgery, 67(2):352-60; discussion 360-2.

Krinsley, J. S. (2003). Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clinic Proceedings, 78(12),1471-8.

Krinsley, J. S. & Jones, R. L. (2006). Cost analysis of intensive glycemic control in critically ill adult patients. Chest, 129(3), 644-50.

Moghissi, E. S. (2010). Reexamining the evidence for inpatient glucose control: New recommendations for glycemic targets. American Journal of Health-System Pharmacy, 67(16 Suppl 8), S3-8.

National Quality Forum. (2010, May). 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

Newton, C. A. & Young, S. (2006). Financial implications of glycemic control: Results of an inpatient diabetes management program. Endocrine Practice, Suppl 3, 43-8.

Qaseem, A., Humphrey, L., Chou, R., Snow, V., & Shekelle, M. (2011). Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med, 154(4), 260-267.

Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., Seley, J. J., Van den Berghe, G. (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.

U.S. Department of Health and Human Services. (2012). National strategy for quality improvement in healthcare: 2012 Annual Report to Congress. Washington, DC: U.S. Department of Health and Human Services.

Wexler D. J., Meigs, J. B., Cagliero, E., Nathan, D. M., & Grant, R. W. (2007). Prevalence of hyper- and hypoglycemia among inpatients with diabetes. A national survey of 44 U.S. hospitals. Diabetes Care, 30(2), 367-369.

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This section contains measure logic not currently feasible in HQMF R1.

For each admission, hospital days included in the analysis are the first 10 calendar days during the hospital stay after excluding:
• The 1st day (date of admission), if patient is admitted before noon
• The 1st and 2nd days, if patient is admitted after noon or patient is admitted before noon with the first glucose level >400 mg/dL
• The 1st, 2nd, and 3rd days, if patient is admitted after noon with the first glucose level >400 mg/dL
• The day of discharge

For cardiothoracic (CT) surgery patients, the calendar days "touching" the time period from operating room (OR) start time until OR end time plus 18 hours are removed from the analysis.

Exclude from the denominator:
1. Admissions with diagnosis of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar syndrome (HHS).
2. Admissions without any hospital days included in analysis.
3. Admissions with length of stay > 120 days.

Hyperglycemic hospital days are defined as days in which 
1. Two or more blood glucose levels were elevated (>200 mg/dL [11.1 mmol/L]), measured at least 6 hours apart; 
OR	
2. A single blood glucose level was elevated, if only one value was available that day; 
OR
3. No blood glucose level was measured that day, and it was not preceded by 2 normoglycemic days.

Eligible glucose tests: random or peri-prandial blood (capillary, serum, plasma, whole blood) glucose tests, excluding fasting or post-glucose

Final measure rate: Average of percentage of hospital days in hyperglycemia for all admissions of individuals with a diagnosis of diabetes mellitus, anti-diabetic drugs (except metformin) administered or at least one elevated glucose level during the  hospital stay.

To create the Numerator:
1. For each hospital calendar day identified for analysis in a denominator encounter, extract all glucose levels taken during the day and sort them by collection time in ascending order.
2. Count the hospital calendar day as a hyperglycemic day if there are at least two elevated blood glucose levels (>200 mg/dL [11.1 mmol/L]) at least 6 hours apart, OR if there is one single elevated blood glucose level if only one value was available, OR at least two blood glucose levels taken - all during a 6 hour period with the final blood glucose level being high, OR if there are no blood glucose levels measured and the day was not preceded by two non-hyperglycemic days.
3. For each encounter in the denominator, the average hyperglycemic rate is the number of hyperglycemic days divided by the number of hospital calendar days identified for analysis.
4. Sum all of these separate encounter hyperglycemic rate percentages up to get the numerator for the ratio measure rate. Divide this total by the denominator to get the final ratio measure rate.

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Inpatient admissions during the measurement period for patients who are at least 18 years of age at admission.

Equals all admissions in Initial Patient Population with a diagnosis of diabetes mellitus, at least one administration of insulin or any oral anti-diabetic medication except metformin, or at least one elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay.

To determine if an admission stays in the denominator, the following steps need to be followed in order validate which hospital stay days are included for analysis:
• Remove the admission day and discharge day
• Remove the 1st day following the admission date if the patient is admitted after noon or the patient is admitted before noon with the admitting blood glucose level > 400 mg/dL
• Remove the 1st and 2nd day following the admission date if the patient is admitted after noon and the admitting blood glucose level >400 mg/dL
• Of the hospital stay days that remain, keep only the first 10 days for analysis, if there are more than 10 days

The denominator is the number of admissions remaining after the previous validation and exclusion steps are completed.

1. Admissions with diagnosis of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar syndrome (HHS).
2. Admissions without any hospital days included in analysis.
3. Admissions with length of stay > 120 days.

Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator.

Hyperglycemic hospital days are defined as the presence of two or more elevated blood glucose levels (>200 mg/dL [11.1 mmol/L]) at least 6 hours apart, or one single elevated blood glucose level if only one value was available that day, or at least two blood glucose levels taken - all during a 6 hour period with the final blood glucose level being high, or a missing blood glucose level that is not preceded by 2 normoglycemic days.

For each admission, calculate the number of hyperglycemic days per day of analysis to get the percentage of hyperglycemic hospital days.

The numerator is the sum of these percentages.

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