2022 CMS Changes for Inpatient Diabetes Management

2022 CMS Changes for eCQM

The 2022 final rule from CMS brings the adoption of two electronic clinical quality measures (eCQMs) for the management of inpatient diabetes in the hospital setting. This rule will standardize when and how hospitals report inpatient hyperglycemia and inpatient hypoglycemia and will directly impact how hospitals publicly rank according to these quality standards.

Specifically, hospitals will now be required to report on two medication-related adverse events under the Preventable Healthcare Harm eCQM. One requires reporting on the rates of severe hyperglycemia during a hospital stay. The other requires reporting data on patients that are experiencing severe hypoglycemia, with the intention of identifying preventable medication-induced hypoglycemia.

Inpatient Diabetes Management Quality Reporting

Under the CMS Inpatient Hospital Quality Reporting (IQR) program, hospitals that do not submit quality data or fail to meet the IQR program requirements will be subject to a reduction in their annual payment under the Inpatient Prospective Payment System (IPPS).

Severe Hypoglycemia and Hyperglycemia

As hospitals consider how these new rules will impact the management of inpatient diabetes, it is important to have clarity on how CMS defines severe hypoglycemia and severe hyperglycemia in terms of reporting. All definitions are for patients 18 years and older at admission.

Severe hypoglycemia is defined as the proportion of inpatient admissions having:

• one blood glucose recorded that is <40 mg/dL collected within 24 hours of administering insulin (or other antihyperglycemic agent), AND
• no subsequent glucose test result with a result >80 mg/dL within 5 minutes of the low glucose result, during their stay.

Severe hyperglycemia is defined as the number of hospital days with a severe hyperglycemic event (defined below) per the total qualifying hospital days among inpatient encounters for patients who have either:

• a diagnosis of diabetes mellitus,
• received at least one administration of insulin or anti-diabetic medication during the hospital admission, or
• had an elevated blood glucose level (>200 mg/dL) during their hospital admission.

CMS defines a hyperglycemic event as a blood glucose result of >300 mg/dL, and/or a day in which a blood glucose value was not documented, and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL.

Treatment Protocols

For the management of inpatient diabetes in the hospital setting, it is suggested by the American Diabetes Association that each hospital set and implement a management protocol to prevent and treat hypoglycemia and hyperglycemia. Protocols should include guidelines for treatment, medical record documentation and tracking, and discharge plans that are tailored to the individuals living with diabetes.

In-Hospital Hypoglycemia Treatment

Guidelines for in-hospital hypoglycemia treatment differ based on the clinical status of the patient. For critically ill patients, insulin therapy should be initiated starting at a threshold of >180 mg/dL (10 mmol/L). One insulin therapy is started, a glucose range of 140-180 mg/dL (7.8 mmol/L) is recommended. It may also be appropriate for some patients to have a more stringent goal of 110-140 mg/dL (6.1-7.8 mmol/L) as long as the goal can be achieved without significant hypoglycemia.

In-Hospital Hyperglycemia Treatment

Guidelines for in-hospital hyperglycemia treatment also vary based on clinical status. For patients with a terminal illness, a limited life expectancy, or who are at high risk for hypoglycemia, a target of 200mg/dL (>11.1 mmol/L) may be reasonable. For non-critical status, a pre-meal glucose target of >140 mg/dL (7.8 mmol/L) and a random blood glucose of 180 mg/dL (10.0 mmol/L) is recommended. For patients who can achieve and maintain glycemic control without hypoglycemia, a lower target may be reasonable.

Antidiabetic therapy is suggested for avoidance of hypoglycemia when blood glucose values are >100 mg/dL (5.6 mmol/L). In addition, glucose-lowering treatment may need to be modified when blood glucose values are <70 mg/dL (3.9 mmol/L).

Insulin Administration Guidelines

According to the American Diabetes Association, use of only sliding-scale insulin regimen to manage diabetes in the hospital setting is strongly discouraged. In addition, insulin should be administered using validated written or preferably, computerized protocols that allow for predefined adjustments in insulin dosage based on glycemic fluctuations. For non-critically ill hospitalized patients with poor oral intake/ taking nothing by mouth, basal insulin or a basal plus bolus correction insulin regimen is suggested.

Electronic Data Management for Inpatient Severe Hypoglycemic and Hyperglycemic Treatment

A critical component to the management of diabetes in the hospital is choosing the right EHR for patient treatment and reporting of data. Beginning with the CY 2023 reporting period (FY 2025 payment determination), CMS is requiring hospitals to use a certified EHR technology that has been updated consistent with the 2015 Edition Cures Update. In addition, certified technology must support the reporting requirements for all available electronic clinical quality measures (eCQMs).

2025 CMS Hospital Inpatient Quality Reporting (IQR) Metrics and Ratings

Do You Know Your Glycemic Management Metrics?

For the measurement of both Severe Hypoglycemia and Severe Hyperglycemia eCQMs, clinical and administrative staff should use the numerator/denominator approach for calculation. It is important to note that each has specific time frame considerations for measurement and that qualifying events/days are for patients 18 years of age or older at admission.

Measuring Severe Hypoglycemia in the Hospital Setting:

Numerator = inpatient hospitalizations resulting in severe hypoglycemic event / Denominator = initial population

For the numerator, inpatient hospitalizations include each event where:

• a severe hypoglycemic event occurs during the encounter (blood glucose <40 mg/dL),
• a hypoglycemic medication was administered within 24 hours prior to the start of the severe hypoglycemic event (during the encounter), and
• no subsequent glucose test result with a result >80 mg/dL within 5 minutes of the low glucose result, during their stay.

It is important to note that only the first severe hypoglycemic event is counted per inpatient hospitalization encounter.

For the denominator, initial population is defined as inpatient hospitalizations where the patient is 18 years of age or older at admission and at least one hypoglycemic medication was administered during the encounter. This includes instances of administration in the ED or in observation at the start of hospitalization.

Measuring Severe Hyperglycemia in the Hospital Setting:

Numerator = total # of hyperglycemic days / Denominator = total # of eligible days

For the numerator, all hyperglycemic days should meet this criteria:

• All 24-hour periods with blood glucose >300 mg/dL (except the first 24-hours after admission)

OR

• All days where blood glucose was not measured and it was preceded by two consecutive days where at last one glucose value during each of the two days is >=200 mg/dL.

It is important to note that the first 24-hours after inpatient admission (including ED for observation) should not be counted. In addition, if the time period before discharge was less than 24-hours, that time should be removed.

Understanding How IQR Metrics Will Be Ranked and Reported

CMS uses the Hospital Inpatient Quality Reporting (IQR) program to provide public information about how hospitals perform so that consumers can make educated decisions about their healthcare. Subsequently, it incentivizes hospitals to improve their ranking by improving their care quality in the metrics being ranked. Prospective patients simply use the Care Compare Website via Medicare.gov to view and compare hospitals in reference to National results, getting detailed information on how hospitals rank in each category.

Managing IQR Data for Inpatient Insulin Administration

With considerations for CMS to modernize its quality measurement requirements in the future, it is critical for hospitals to focus not only on the capabilities of their current systems but the consistency in clinical treatment for their patients. Managing and treating in-patient diabetes is complex, often a moving target and remains a significant challenge for many hospitals. That is where EndoTool Glucose Management System by Monarch Medical Technologies comes in. As an FDA-cleared clinical decision support software platform, EndoTool can aid clinicians in optimizing patient outcomes, making adherence to the new CMS quality measures easy and consistent.

References

CMS.GOV Fact Sheet: Fiscal Year 2022 Medicare Hospital Inpatient Prospective Payment System and Long Term Care Hospital Rates Final Rule
eCQM Hospital Harm – Severe Hyperglycemia: Overview
eCQM Hospital Harm – Severe Hyperglycemia: Specification
eCQM Hospital Harm – Severe Hypoglycemia: Overview
eCQM Hospital Harm – Severe Hypoglycemia: Specification