CMS Glycemic Management Measures – Complete Overview

Maintaining appropriate glycemic control in hospitalized patients is imperative to promote optimal health outcomes and prevent complications. CMS glycemic measures are several of the established clinical quality measures (eCQMs) assessed via inpatient quality reporting (IPR). This complete overview of the CMS glycemic management measures will underscore the importance of ensuring glycemic control to not only improve patient outcomes but also to ensure standardization of glycemic management across health systems and to improve resource utilization.

Understanding CMS Glycemic Management Measures

Understanding the context of Centers for Medicare and Medicaid Services (CMS) glycemic measures and reviewing the importance of prioritizing inpatient glycemic management sets the stage for how these metrics can be successfully used to achieve optimal patient care outcomes and sustain hospital financial viability, as most hospitals rely heavily upon CMS reimbursement.

What Are CMS Glycemic Measures?

CMS glycemic measures are performance metrics established by the Centers for Medicare & Medicaid Services (CMS) to improve blood glucose management in hospitalized patients. These metrics are included in the Hospital Inpatient Quality Reporting (IQR) Program, which encourages hospitals to prioritize improving clinical outcomes and ensuring patient safety through appropriate quality improvement efforts.

The CMS glycemic measures focus on appropriately tracking and optimizing inpatient glycemic management. This emphasizes addressing the potential risks associated with severe hypoglycemia and hyperglycemia. CMS utilizes specific electronic clinical quality measures (eCQMs) as criteria to evaluate hospitals on their abilities to mitigate preventable complications, like severe hypoglycemia and hyperglycemia, both of which are linked to increased length of hospital stay, higher in-hospital mortality rates, and adverse patient safety outcomes.

The CMS metrics can enhance the use of evidence-based guidelines for optimal insulin dosing, appropriate use of non-insulin anti-diabetic medications, and successful reliance upon real-time glycemic management systems. The goal of all CMS quality measures are to standardize hospital care, reduce variation and ensure hospitals continue to strive to achieve the best patient health outcomes.  Hospitals are also motivated to improve their metrics due to public reporting of them and also financial incentives. By aligning their recommendations with those from nationally-recognized organizations (like the American Diabetes Association), the best glycemic outcomes can be achieved.

The Importance of Prioritizing Glycemic Management

Glycemic Management and Patient Outcomes

Prioritizing glycemic management in hospitalized patients is crucial for optimal health outcomes. Uncontrolled hyperglycemia has been linked to increased morbidity and higher in-hospital mortality rates amongst inpatients. And, on the other hand, hypoglycemia can lead to permanent cognitive impairment, fatal cardiac dysrhythmias, severe organ dysfunction and even death.

The importance of prioritizing glycemic management in hospitalized patients is well-supported. According to available reported data from the National Diabetes Statistics Report, about 11.3% of the US population (which is an estimated 37.3 million Americans) have diabetes. Furthermore, a notable percentage of those have either undiagnosed or poorly-controlled diabetes-related complications. Hospitalized patients with uncontrolled blood glucose levels are at an even higher risk for complications from poor glucose management, which can lead to longer lengths of hospital stays, higher in-hospital mortality rates, and other overall poor outcomes.

Glycemic Management and Resource Utilization

In addition, 25-50% of hospitalized patients who have diabetes include unstable blood glucose control, which demonstrates the imperative role of careful inpatient glycemic management. Along with the improvements in patient care outcomes, maintaining appropriate glycemic control also reduces resource utilization and overall healthcare costs. Approximately 25% of national healthcare costs related to diabetes are due to hospitalizations resulting from diabetic complications.

Resource utilization can be reduced through accurate and precise glucose monitoring, adherence to standard, evidenced based treatment protocols and sufficient hospital inpatient quality reporting. Such efforts align with CMS glycemic management measures aimed at improving care standards and reducing healthcare disparities.

Glycemic Control Challenges in Hospital Settings

Inpatient glycemic management brings significant challenges in the hospital setting.

Hospitalized patients experience fluctuating glucose levels based on various factors, including:

• Critical illness
• Infection
• Sepsis
• Renal failure
• Heart failure
• Dehydration
• Steroid use
• Variable caloric intake

Prevalence and Risks

Hyperglycemia is defined as a blood glucose level ≥ 140 mg/dL, and it often occurs in about 25-50% of non-critically ill hospitalized patients. The prevalence of hypoglycemia in a hospital stay is slightly lower and can range from 10-45%. Knowing that as many as 50% of hospitalized patients who have diabetes mellitus experience diabetes-related complications or poor glycemic control while they are hospitalized, statistics indicate that the prevalence of hypoglycemia and hyperglycemia are high.

Uncontrolled hyperglycemia has been linked to increased morbidity and mortality rates during hospital admissions. Hypoglycemia presents its own patient safety risks, as it can lead to permanent cognitive impairment, fatal cardiac dysrhythmias, and severe organ dysfunction.

Both hyperglycemia and hypoglycemia can delay wound healing and recovery in patients with diabetes undergoing cardiac and noncardiac surgery. In critically ill patients, severe hyperglycemia and severe hypoglycemia are significant threats to overall patient safety. In non critically ill patients in acute care settings, the American Diabetes Association still emphasizes optimal glycemic management to improve patient outcomes.

Poor Glycemic Management and Consequences

Poor inpatient glycemic management in patients who have diabetes causes increased in-hospital mortality and requires increased resource utilization.

Dangers of Severe Hyperglycemia

Severe hyperglycemia can increase morbidity and mortality in several ways. Elevated blood sugar during hospitalization is associated with the following adverse effects:

• Increased length of hospital stay
• Elevated healthcare costs
• Higher infection risk
• Impaired wound healing
• Greater protein-energy malnutrition
• Increased overall mortality

Effects of Hypoglycemia

In addition to preventing severe hyperglycemia, avoiding hypoglycemia must also be a priority to improve clinical outcomes.

In many cases, hospitalized patients have decreased oral intake, and the concurrent use of insulin therapy or other anti diabetic medications can cause severe hypoglycemia. This presents an opportunity to avoid preventable medication-induced hypoglycemia, which is also important for the severe hypoglycemia eCQM.

Hypoglycemia can cause cognitive impairment, leading to falls, aspiration, and organ dysfunction. Hypoglycemia can also affect catecholamine release, potentially leading to fatal cardiac arrhythmias. There are many factors that increase the risk of severe hypoglycemia:

• Other ongoing medical problems
• Advanced age
• Impaired kidney function
• Insulin-dependent diabetes
• History of hypoglycemia
• Poor nutrition status
• Lower body mass index

Preventing severe hypoglycemia during inpatient admissions is a crucial part of the glycemic management metrics.

Achieving Optimal Glycemic Management

In order to optimize patient outcomes and to meet hospital electronic clinical quality measures, achieving optimal glycemic management during inpatient hospitalizations is imperative, yet complex. This requires collaboration between hospital leadership (including the chief medical officer and other decision makers), physicians, nurses, and other members of the healthcare team.

Identifying High-Risk Patients

Certain patients are at higher risk of poor glycemic control. The first step in meeting glycemic management metrics is to identify the hospitalized patients with diabetes mellitus who are on insulin therapy, who take hypoglycemic medications, who have poor disease control, or even who have undiagnosed diabetes.

Actively Managing Blood Glucose Values

After identifying the hospitalized patients at greatest risk for suboptimal blood glucose results, the next step is to prioritize glycemic management in these patients, aiming for quality improvement by the use of an E-glycemic management system.

The use of a glycemic management software such as EndoTool Insulin Dosing Software has proven to reduce the incidences of hyperglycemia in inpatient settings while keeping hypoglycemia rates minimal. EndoTool’s unique algorithm models each patient’s clinical characteristics and response to insulin to provide optimal dosing recommendations, and reduce the risk of severe hypoglycemia to virtually zero.

Connecting Patient Care with Inpatient Quality Reporting (IPR)

While ensuring optimal treatment and patient safety are the highest priorities, following CMS glycemic management measures (read: receiving payment from Medicare and Medicaid Services) requires integrating health care (the care of the patient) with inpatient quality reporting (IPR) so that the reported data reflects adherence to the electronic clinical quality measures (eCQMs).

In the past, reported data was optional, but now it is required for hospitals to receive full reimbursement from CMS for Medicare patients. Review the original announcement and initial measures here, and more information regarding the CMS program requirements can be found here.

Ensuring Electronic Clinical Quality Measures Are Met

Ensuring that electronic clinical quality measures are met should be a priority for health systems and hospital leadership. The eCQMs change over time (usually yearly), yet the most common clinical conditions with the largest impact on patient outcomes remain as eCQMs year after year. Some common examples include diabetes mellitus, anticoagulant therapy, venous thromboembolism prevention, maternal health, and opioid use.

Current Diabetes-Related eCQMs

Based on reported data from the eCQI Resource Center and CMS, these are the current diabetes-related eCQMs for 2024:

• Hospital Harm – Severe Hyperglycemia
• Hospital Harm – Severe Hypoglycemia

Hospital Harm – Severe Hyperglycemia

Specifically, this assessment of glycemic control looks at the number of inpatient hospital admissions for patients ages 18 years and older that included a hyperglycemic event (harm), as compared to the total qualifying inpatient hospital admissions for that hospital stay. While this assessment does not measure the overall glycemic control in hospitalized patients, the aim is to review the occurrences and extents of severe hyperglycemic events.

Hospital Harm – Severe Hypoglycemia

This electronic clinical quality measure is focused on severe hypoglycemia related to medication use. It assesses the number of inpatient hospitalizations for patients ages 18 years and older who were administered at least one hypoglycemic medication during the encounter, and who also experienced the harm of a severe hypoglycemic event during that hospital stay. The definition of a severe hypoglycemic event is having a blood glucose value < 40 mg/dL after having taken a hypoglycemic medication within the preceding 24 hours.

For more information on CMS glycemic measures and how they are calculated, refer to this ebook.

Hospital Inpatient Quality Reporting Requirements

In order for electronic clinical quality measures to be reviewed, health systems are required to submit quality data via hospital inpatient quality reporting programs (IPR). Hospital inpatient reporting guidance is available through the Quality Reporting Center. Part of inpatient quality reporting programs is that information publicly displaying data on a national quality forum (like Care Compare) emphasizes patient safety and encourages quality health care.

Reporting Timeline

Reporting submissions are open quarterly, although all data must be submitted by the end of each calendar year, based on the annual timeline.

Key Takeaways

Maintaining appropriate glycemic control in hospitalized patients is crucial in promoting optimal health outcomes and in preventing complications. CMS glycemic management measures are an established way to require inpatient quality reporting in aims of elevating patient care, quality improvement, and care standardization across health systems. These electronic clinical quality measures prioritize glycemic management, aiming to benefit patient safety in acute care settings. However, understanding and implementing the CMS glycemic management measures requires a collaborative approach between E-glycemic management strategies at the point of care and hospital leadership for inpatient quality reporting. EndoTool is uniquely poised to not only capture the data regarding blood glucose levels but also to advise swift and effective diabetes mellitus treatment within the inpatient setting.

About EndoTool

Made by Monarch Medical Technologies, EndoTool is the only patient-specific insulin dosing system which simplifies the complex task of glycemic management in hospital environments. The recommended dosing is different for each patient based on multiple clinical characteristics. The FDA-cleared platform is utilized in hundreds of hospitals across the United States and is fully integrated with all major electronic medical records. To see how EndoTool can support your health system, get in touch today.