Glycemic Control - Hypoglycemia

The rate of severe hypoglycemic events following the administration of an anti-diabetic agent.

The rate is defined as:
The total numer of severe hypoglycemic events / total number of days where at least one anti-diabetic medication was administered.

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" 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 subject to further revisions. This performance measure does not establish a standard of medical care and has not been tested for all potential applications.

None

None

None

This measure focuses on severe hypoglycemia 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). Hypoglycemia was the third most frequently occurring adverse drug event with the highest percentage of events classified as preventable in the Office of the Inspector General’s (2010) publication concerning adverse events in hospitals. Hypoglycemia is associated with increased in-hospital mortality (Curkendall et al., 2009; Krinsley & Grover, 2007; Turchin et al., 2009), longer hospital stay (Curkendall et al., 2009; Krinsley et al, 2011; Turchin et al., 2009), and higher medical costs (Curkendall et al., 2009).

From Section IX.A, “Diabetes Care in the Hospital” in the “Standards of Medical Care in Diabetes—2013” by the American Diabetes Association (American Diabetes Association, 2013), two recommendations listed under “Goals for blood glucose levels” for “critically ill patients” are related to 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 (7.8–10 mmol/L) is recommended for the majority of critically ill patients. (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 they can be achieved without significant hypoglycemia. (C)


From “Guidelines for the Use of an Insulin Infusion for the Management of Hyperglycemia in Critically Ill Patients” by the Society of Critical Care Medicine (Jacobi et al., 2012):

We suggest that a BG ?150 mg/dL should trigger initiation of insulin therapy, titrated to keep BG <150 mg/dL for most adult ICU patients and to maintain BG values absolutely <180 mg/dL using a protocol that achieves a low rate of hypoglycemia (BG ?70 mg/dL) despite limited impact on patient mortality. [Quality of evidence: very low]


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. (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)

Lower Score = Better Quality

American Diabetes Association (ADA). (2013). Standards of Medical Care in Diabetes. IX. Diabetes care in specific settings. Diabetes Care, 36(Supplement 1), S45-S49.

Curkendall, S. M., Natoli, J. L., Alexander, C. M., Nathanson, B. H., Haidar, T., & Dubois, R. W. (2009). Economic and clinical impact of inpatient diabetic hypoglycemia. Endocr Pract, 15(4), 302-312.

Jacobi, J., Bircher, N., Krinsley, J., Agnus, M., Braithwaite, S., Deutschman, C., . . . Schunemann, H. (2012). Guidelines for the Use of an Insulin Infusion for the Management of Hyperglycemia in Critically Ill Patients. Crit Care Med, 40(12), 3251-3276.

Krinsley, J. & Grover, A. (2007). Severe hypoglycemia in critically ill patients: Risk factors and outcomes. Critical Care Medicine, 35(10), 2262-2267.

Krinsley, J., Schultz, M. J., Spronk, P. E., van Braam Houckgeest, F., van der Sluijs, J. P., Melot ,C., & Preiser J. (2011). Mild hypoglycemia is strongly associated with increased intensive care unit length of stay. Annals of Intensive Care, 1, 49.

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

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

Turchin, A., Matheny, M. E., Shubina, M., Scanlon, J. V., Greenwood, B., & Pendergrass, M. L. (2009). Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care, 32(7), 1153-1157.

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.

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.

None

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

For each admission stay, count the number of calendar days during the hospital stay where at least one anti-diabetic medication was administered.
The denominator is the sum of the calendar days where at least one anti-diabetic medication was administered.

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

To create the numerator:
1.For each hospital calendar day identified for analysis in the denominator, extract all glucose tests except fasting tests 
2.Extract the glucose tests with result <40 mg/dL.
3.Only keep the glucose tests, if there was a rapid/short-acting insulin administered within 12 hours or if there was an anti-diabetic medication (other than rapid/short-acting insulin) administered within 24 hours before the glucose test was taken.
4.Remove the glucose tests if they were followed by another glucose test with result >80 mg/dL within five minutes.
5.Sort the glucose tests for each admission in the denominator by collection time, and remove any glucose test that occurred within 20 hours of the preceding test.
6.Sum all the glucose tests (hypoglycemic events) to get the numerator for the measure rate. Divide this total by the total number of calendar days where at least one anti-diabetic medication was administered to the get final measure rate.

None

Inpatient admissions during the measurement period for patients who are at least 18 years of age at admission, admitted and discharged during the measurement period, and with length of stay is less than or equal to 120 days.

Equals all hospital days in Initial Patient Population with at least one anti-diabetic agent administered.

1. Include the admissions with at least one administration of an anti-diabetic medication during the hospital stay.

2. For each admission, count the number of days during the hospital stay where at least one anti-diabetic medication was administered.

3. The denominator is the total number of hospital days with at least one anti-diabetic agent administered.

None

Total number of severe hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than rapid/short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within five minutes, and were at least 20 hours apart

To calculate the numerator for the measure rate, follow the steps outlined below:

1. Include all glucose tests except fasting tests for admissions that were a part of the denominator. 

2. Only keep the glucose tests (with result <40 mg/dL), if there was rapid/short-acting insulin administered within 12 hours before the glucose test was taken
OR
 If there was an anti-diabetic medication (other than rapid/short-acting insulin) administered within 24 hours before the glucose test was taken.
3. Remove the glucose tests, if they were followed by another glucose test with result >80 mg/dL within 5 minutes.
4. Sort the glucose tests for each admission by collection time, and remove any glucose test that occurred within 20 hours of the preceding test.

The numerator is the sum of the severe hypoglycemic events (i.e. glucose tests < 40 mg/dl).

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

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

Medication Measures 2011-2012