{ "_id" : "64232951f9a010eeafc2a053", "title" : "Hospital Harm - Severe Hyperglycemia", "description" : "This measure assesses the number of inpatient hospital days for patients age 18 and older with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for that encounter", "component_hqmf_set_ids" : [ ], "measure_scoring" : "RATIO", "calculation_method" : "EPISODE_OF_CARE", "hqmf_id" : "2C928082-7FAC-C041-0180-1F512619243F", "hqmf_set_id" : "EF95493C-3F65-4440-9CCB-EAF1B9ED1210", "main_cql_library" : "HospitalHarmHyperglycemiainHospitalizedPatients", "hqmf_version_number" : "2.0.027", "cms_id" : "CMS871v2", "composite" : false, "component" : false, "calculate_sdes" : null, "value_set_ids" : [ "64232951f9a010eeafc2a046", "64232951f9a010eeafc2a047", "64232951f9a010eeafc2a048", "64232951f9a010eeafc2a049", "64232951f9a010eeafc2a04a", "64232951f9a010eeafc2a04b", "64232951f9a010eeafc2a04c", "64232951f9a010eeafc2a04d", "64232951f9a010eeafc2a04e", "64232951f9a010eeafc2a04f", "64232951f9a010eeafc2a050", "64232951f9a010eeafc2a051" ], "measure_attributes" : [ { "code" : "OTH", "value" : "871", "name" : "eCQM Identifier (Measure Authoring Tool)", "code_obj" : { "type" : "CD", "null_flavor" : "OTH", "original_text" : "eCQM Identifier (Measure Authoring Tool)" }, "value_obj" : { "type" : "ED", "value" : "871", "media_type" : "text/plain" } }, { "code" : "OTH", "value" : "3533e", "name" : "NQF Number", "code_obj" : { "type" : "CD", "null_flavor" : "OTH", "original_text" : "NQF Number" }, "value_obj" : { "type" : "ED", "value" : "3533e", "media_type" : "text/plain" } }, { "code" : "COPY", "value" : "Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. American Institutes for Research(R), formerly IMPAQ International, disclaims all liability for use or accuracy of any third party codes contained in the specifications.\n\nLOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.", "name" : "Copyright", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "COPY", "title" : "Copyright" }, "value_obj" : { "type" : "ED", "value" : "Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. American Institutes for Research(R), formerly IMPAQ International, disclaims all liability for use or accuracy of any third party codes contained in the specifications.\n\nLOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.", "media_type" : "text/plain" } }, { "code" : "DISC", "value" : "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.\n\nTHE MEASURES AND SPECIFICATIONS ARE PROVIDED \"AS IS\" WITHOUT WARRANTY OF ANY KIND.\n\nDue to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].", "name" : "Disclaimer", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "DISC", "title" : "Disclaimer" }, "value_obj" : { "type" : "ED", "value" : "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.\n\nTHE MEASURES AND SPECIFICATIONS ARE PROVIDED \"AS IS\" WITHOUT WARRANTY OF ANY KIND.\n\nDue to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].", "media_type" : "text/plain" } }, { "code" : "MSRSCORE", "name" : "Measure Scoring", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "MSRSCORE", "title" : "Measure Scoring" }, "value_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.1063", "code" : "RATIO", "title" : "Ratio" } }, { "code" : "MSRTYPE", "name" : "Measure Type", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "MSRTYPE", "title" : "Measure Type" }, "value_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.1063", "code" : "OUTCOME", "title" : "OUTCOME" } }, { "code" : "MSRADJ", "value" : "None", "name" : "Risk Adjustment", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "MSRADJ", "title" : "Risk Adjustment" }, "value_obj" : { "type" : "ED", "value" : "None", "media_type" : "text/plain" } }, { "code" : "MSRAGG", "value" : "None", "name" : "Rate Aggregation", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "MSRAGG", "title" : "Rate Aggregation" }, "value_obj" : { "type" : "ED", "value" : "None", "media_type" : "text/plain" } }, { "code" : "RAT", "value" : "Hyperglycemia, i.e., elevated glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Umpierrez et al., 2012) and account for over 30% of noncritically ill hospitalized patients (Korytkowski, 2022). Hyperglycemia can also affect individuals with no prior history of diabetes and may be induced by medications such as steroids, or parenteral (intravenous) or enteral (tube) feeding.\n\nSevere hyperglycemia, i.e., extremely elevated glucose level, is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay (Pasquel, et al., 2021; Umpierrez et al., 2012, 2015). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Bersoux et al., 2013). The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety (Leroy et al., 2020; Maynard et al., 2015).\n\nFrom the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting, 2022:\nRecommendation 1.1\nIn adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available.", "name" : "Rationale", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "RAT", "title" : "Rationale" }, "value_obj" : { "type" : "ED", "value" : "Hyperglycemia, i.e., elevated glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Umpierrez et al., 2012) and account for over 30% of noncritically ill hospitalized patients (Korytkowski, 2022). Hyperglycemia can also affect individuals with no prior history of diabetes and may be induced by medications such as steroids, or parenteral (intravenous) or enteral (tube) feeding.\n\nSevere hyperglycemia, i.e., extremely elevated glucose level, is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay (Pasquel, et al., 2021; Umpierrez et al., 2012, 2015). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Bersoux et al., 2013). The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety (Leroy et al., 2020; Maynard et al., 2015).\n\nFrom the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting, 2022:\nRecommendation 1.1\nIn adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available.", "media_type" : "text/plain" } }, { "code" : "CRS", "value" : "It should be noted that this measure does not aim to measure overall glucose control in hospitalized patients; rather, our goal is to assess the occurrence and extent of severe hyperglycemia. This measure is also intended to be used in combination with its companion measure of hypoglycemia (Hospital Harm – Hypoglycemia) to reduce unintended consequences of measurement. \n\nMultiple guidelines address recommended levels of glycemic control, though these do not define severe hyperglycemia: \n\nFrom Section 16, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2022): \n\n16.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L) (checked on two occasions). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill and noncritically ill patients. A\n\n16.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients if they can be achieved without significant hypoglycemia.\n\nFrom the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (2022): \n\nRecommendation 10.1\nIn adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as blood glucose (BG) > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy. \n\nRecommendation 10.2\nIn adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L). \n\nRecommendation 10.3\nIn adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).\n\nRemarks\nReductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG.\n\n\nThere is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >140, >180 , >300, and >350 mg/dL, among other values (American Diabetes Association, 2020; Umpierrez et al, 2012, 2015); Jamesen et al., 2015; Donihi et al., 2011; Mendez et al, 2015). BGL <180 mg/dL is associated with lower rates of mortality and stroke compared with a target glucose <200 mg/dL (Sathya, et al., 2013). Glycemic goals may also differ among hospitalized patients. For example, in an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety. Intensive insulin therapy to target glucose of 100 and 140mg/dLin the ICU didn’t significantly reduce perioperative complications compared with target glucose of 141and180mg/dLafter coronary artery bypass surgery (Umpierrez, 2015).\n\nFor patients who present with hyperglycemic crises, neurologic status must be monitored closely, with frequent re-examination. Care should be taken to prevent over-correction of hyperglycemia and hyperosmolarity following initial fluid resuscitation of these patients to prevent cerebral edema, which carries a high mortality rate. (Gosmanov et al., 2021).", "name" : "Clinical Recommendation Statement", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "CRS", "title" : "Clinical Recommendation Statement" }, "value_obj" : { "type" : "ED", "value" : "It should be noted that this measure does not aim to measure overall glucose control in hospitalized patients; rather, our goal is to assess the occurrence and extent of severe hyperglycemia. This measure is also intended to be used in combination with its companion measure of hypoglycemia (Hospital Harm – Hypoglycemia) to reduce unintended consequences of measurement. \n\nMultiple guidelines address recommended levels of glycemic control, though these do not define severe hyperglycemia: \n\nFrom Section 16, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2022): \n\n16.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L) (checked on two occasions). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill and noncritically ill patients. A\n\n16.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients if they can be achieved without significant hypoglycemia.\n\nFrom the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (2022): \n\nRecommendation 10.1\nIn adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as blood glucose (BG) > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy. \n\nRecommendation 10.2\nIn adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L). \n\nRecommendation 10.3\nIn adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).\n\nRemarks\nReductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG.\n\n\nThere is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >140, >180 , >300, and >350 mg/dL, among other values (American Diabetes Association, 2020; Umpierrez et al, 2012, 2015); Jamesen et al., 2015; Donihi et al., 2011; Mendez et al, 2015). BGL <180 mg/dL is associated with lower rates of mortality and stroke compared with a target glucose <200 mg/dL (Sathya, et al., 2013). Glycemic goals may also differ among hospitalized patients. For example, in an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety. Intensive insulin therapy to target glucose of 100 and 140mg/dLin the ICU didn’t significantly reduce perioperative complications compared with target glucose of 141and180mg/dLafter coronary artery bypass surgery (Umpierrez, 2015).\n\nFor patients who present with hyperglycemic crises, neurologic status must be monitored closely, with frequent re-examination. Care should be taken to prevent over-correction of hyperglycemia and hyperosmolarity following initial fluid resuscitation of these patients to prevent cerebral edema, which carries a high mortality rate. (Gosmanov et al., 2021).", "media_type" : "text/plain" } }, { "code" : "IDUR", "value" : "A lower measure score indicates higher quality", "name" : "Improvement Notation", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "IDUR", "title" : "Improvement Notation" }, "value_obj" : { "type" : "ED", "value" : "A lower measure score indicates higher quality", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONAmerican Diabetes Association Professional Practice Committee; 16. (2022). Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S244–S253. https://doi.org/10.2337/dc22-S016", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONAmerican Diabetes Association Professional Practice Committee; 16. (2022). Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S244–S253. https://doi.org/10.2337/dc22-S016", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONBersoux, S., Cook, C.B., Kongable, G.L., Shu, J. (2013). Trends in glycemic control over a 2-year period in 126 US hospitals. J Hosp Med. 2013;8(3):121-125. doi:10.1002/jhm.1997", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONBersoux, S., Cook, C.B., Kongable, G.L., Shu, J. (2013). Trends in glycemic control over a 2-year period in 126 US hospitals. J Hosp Med. 2013;8(3):121-125. doi:10.1002/jhm.1997", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONDonihi, A.C., Gibson, J.M., Noschese, M.L., et al. (2011). Effect of targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011; (4)552-557", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONDonihi, A.C., Gibson, J.M., Noschese, M.L., et al. (2011). Effect of targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011; (4)552-557", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONGosmanov, A.R., Gosmanova, E.O., Kitabchi, A.E. (2021). Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. [Updated 2021 May 9]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK279052/", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONGosmanov, A.R., Gosmanova, E.O., Kitabchi, A.E. (2021). Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. [Updated 2021 May 9]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK279052/", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONJamesen, E., Nevalainen, P.L., Eskelinen, A., et al. (2015). Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015; 86(2):175-182", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONJamesen, E., Nevalainen, P.L., Eskelinen, A., et al. (2015). Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015; 86(2):175-182", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONKorytkowski, M.T., Muniyappa, R., Antinori-Lent, K., Donihi, A.C., Drincic, A.T, Hirsch, I.B., Luger, A., McDonnell, M.E., Murad, M.H., Nielsen, C., Pegg, C., Rushakoff, R.J., Santesso, N., Umpierrez, G.E. (2022). Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 8, August 2022, Pages 2101–2128, https://doi.org/10.1210/clinem/dgac278", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONKorytkowski, M.T., Muniyappa, R., Antinori-Lent, K., Donihi, A.C., Drincic, A.T, Hirsch, I.B., Luger, A., McDonnell, M.E., Murad, M.H., Nielsen, C., Pegg, C., Rushakoff, R.J., Santesso, N., Umpierrez, G.E. (2022). Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 8, August 2022, Pages 2101–2128, https://doi.org/10.1210/clinem/dgac278", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONKrinsley, J.S., Jones, R.L. (2016). Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2016;129(3)644-650", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONKrinsley, J.S., Jones, R.L. (2016). Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2016;129(3)644-650", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONLeRoy, L., Richard, S. (2020). Harms Due to Diabetic Agents (Chapter 8), Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. Retrieved from: https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONLeRoy, L., Richard, S. (2020). Harms Due to Diabetic Agents (Chapter 8), Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. Retrieved from: https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONMaynard, G., Kulasa, K., Ramos, P., et al. (2015). Impact of a hypoglycemic reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355-367", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONMaynard, G., Kulasa, K., Ramos, P., et al. (2015). Impact of a hypoglycemic reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355-367", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONMendez, C.E., Ata, A., Rourke, J.M., et al. (2015). Daily inpatient glycemic survey (DINGS): A process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927-935", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONMendez, C.E., Ata, A., Rourke, J.M., et al. (2015). Daily inpatient glycemic survey (DINGS): A process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927-935", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONPasquel, F.J., Lansang, M.C., Dhatariya, K., Umpierrez, G.E. (2021). Management of diabetes and hyperglycaemia in the hospital. The Lancet Diabetes & Endocrinology. 2021; 9: 174–88", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONPasquel, F.J., Lansang, M.C., Dhatariya, K., Umpierrez, G.E. (2021). Management of diabetes and hyperglycaemia in the hospital. The Lancet Diabetes & Endocrinology. 2021; 9: 174–88", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONSathya, B., Davis, R., Taveira, T., et al. (2013). Intensity of peri-operative glycemic control and postoperative outcomes in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2013;102(1):815.10.1016/j.diabres.2013.05.003", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONSathya, B., Davis, R., Taveira, T., et al. (2013). Intensity of peri-operative glycemic control and postoperative outcomes in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2013;102(1):815.10.1016/j.diabres.2013.05.003", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONUmpierrez, G., Cardona, S., Pasquel, F., et al. (2015). Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: gluco-CABG trial. Diabetes Care. 2015;38(9):1665-1672", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONUmpierrez, G., Cardona, S., Pasquel, F., et al. (2015). Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: gluco-CABG trial. Diabetes Care. 2015;38(9):1665-1672", "media_type" : "text/plain" } }, { "code" : "REF", "value" : "CITATIONUmpierrez, G.E., Hellman, R., Korytkowski, M.T., et al. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97, 16-38", "name" : "Reference", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "REF", "title" : "Reference" }, "value_obj" : { "type" : "ED", "value" : "CITATIONUmpierrez, G.E., Hellman, R., Korytkowski, M.T., et al. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97, 16-38", "media_type" : "text/plain" } }, { "code" : "DEF", "value" : "Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. \n\nThis measure defines a severe hyperglycemic day (harm) as either (1) a day with a test (lab or point-of-care (POC)) for glucose with a result of >300 mg/dL, or (2) a day in which a glucose test with a result was not found and it was preceded by two consecutive days where at least one lab or point-of-care (POC) test during each of the two days for glucose had a result >=200 mg/dL. \n\nHospital days are not defined as midnight-to-midnight but are full 24-hour periods that start at the time of admission to the hospital (including emergency department and observation), excluding the last period before discharge from hospital inpatient if it is less than 24 hours.", "name" : "Definition", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "DEF", "title" : "Definition" }, "value_obj" : { "type" : "ED", "value" : "Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. \n\nThis measure defines a severe hyperglycemic day (harm) as either (1) a day with a test (lab or point-of-care (POC)) for glucose with a result of >300 mg/dL, or (2) a day in which a glucose test with a result was not found and it was preceded by two consecutive days where at least one lab or point-of-care (POC) test during each of the two days for glucose had a result >=200 mg/dL. \n\nHospital days are not defined as midnight-to-midnight but are full 24-hour periods that start at the time of admission to the hospital (including emergency department and observation), excluding the last period before discharge from hospital inpatient if it is less than 24 hours.", "media_type" : "text/plain" } }, { "code" : "GUIDE", "value" : "The measure is using mg/dL as the unit of measurement for glucose results.\n\nTo determine the measure outcome, the total number of hyperglycemic days during the inpatient hospitalization is divided by the total number of eligible hospital days of the inpatient hospitalization.\n\nWhen evaluating for days with a glucose level >300 mg/dL, the first 24-hour period after admission to the hospital (including the emergency department or observation) is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care.\n\nThis measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions. \n\nThe “Days in Hospitalization” logic within Measure Observation 1 (associated with the denominator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hospital days (e.g., from day 2 to day 10). \n\nThe “Days in Hospitalization” logic within Measure Observation 2 (associated with the numerator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hyperglycemic event days (e.g., from day 2 to day 10).\n\nSince the measure does not count any hyperglycemic events that occur in the first 24 hours, day 1 is not considered an eligible hospital day for the Measure Observations. Eligible days range from day 2 up to day 10.\n\nAlthough the measure does not count any hyperglycemic events that occur in the first 24 hours as a hyperglycemic event day in Measure Observation 2, the first 24 hours of the encounter is considered day 1. This is because if there was a day during the encounter where a glucose result is not found, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., day 1, to be one of the preceding days.\n\nMultiple hyperglycemic events can occur during a ‘day’, but this is still considered one hyperglycemic event day.\n\nThe numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria.\n\nThe specimen source for the glucose test is blood, serum, plasma, or interstitial fluid, and can be obtained by a laboratory test, a Point of Care (POC) test, or a continuous glucose monitor (CGM). Glucose test results from urine specimens are not considered.\n\nThis eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.\n\nThis version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.", "name" : "Guidance", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "GUIDE", "title" : "Guidance" }, "value_obj" : { "type" : "ED", "value" : "The measure is using mg/dL as the unit of measurement for glucose results.\n\nTo determine the measure outcome, the total number of hyperglycemic days during the inpatient hospitalization is divided by the total number of eligible hospital days of the inpatient hospitalization.\n\nWhen evaluating for days with a glucose level >300 mg/dL, the first 24-hour period after admission to the hospital (including the emergency department or observation) is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care.\n\nThis measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions. \n\nThe “Days in Hospitalization” logic within Measure Observation 1 (associated with the denominator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hospital days (e.g., from day 2 to day 10). \n\nThe “Days in Hospitalization” logic within Measure Observation 2 (associated with the numerator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hyperglycemic event days (e.g., from day 2 to day 10).\n\nSince the measure does not count any hyperglycemic events that occur in the first 24 hours, day 1 is not considered an eligible hospital day for the Measure Observations. Eligible days range from day 2 up to day 10.\n\nAlthough the measure does not count any hyperglycemic events that occur in the first 24 hours as a hyperglycemic event day in Measure Observation 2, the first 24 hours of the encounter is considered day 1. This is because if there was a day during the encounter where a glucose result is not found, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., day 1, to be one of the preceding days.\n\nMultiple hyperglycemic events can occur during a ‘day’, but this is still considered one hyperglycemic event day.\n\nThe numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria.\n\nThe specimen source for the glucose test is blood, serum, plasma, or interstitial fluid, and can be obtained by a laboratory test, a Point of Care (POC) test, or a continuous glucose monitor (CGM). Glucose test results from urine specimens are not considered.\n\nThis eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.\n\nThis version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.", "media_type" : "text/plain" } }, { "code" : "TRANF", "value" : "TBD", "name" : "Transmission Format", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "TRANF", "title" : "Transmission Format" }, "value_obj" : { "type" : "ED", "value" : "TBD", "media_type" : "text/plain" } }, { "code" : "IPOP", "value" : "Inpatient hospitalizations for patients age 18 and older that end during the measurement period, as well as either: \n\n - A diagnosis of diabetes that starts before or during the encounter; or \n - Administration of at least one dose of insulin or any hypoglycemic medication during the encounter; or \n - Presence of at least one glucose value >=200 mg/dL at any time during the encounter", "name" : "Initial Population", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "IPOP", "title" : "Initial Population" }, "value_obj" : { "type" : "ED", "value" : "Inpatient hospitalizations for patients age 18 and older that end during the measurement period, as well as either: \n\n - A diagnosis of diabetes that starts before or during the encounter; or \n - Administration of at least one dose of insulin or any hypoglycemic medication during the encounter; or \n - Presence of at least one glucose value >=200 mg/dL at any time during the encounter", "media_type" : "text/plain" } }, { "code" : "DENOM", "value" : "Equals Initial Population", "name" : "Denominator", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "DENOM", "title" : "Denominator" }, "value_obj" : { "type" : "ED", "value" : "Equals Initial Population", "media_type" : "text/plain" } }, { "code" : "DENEX", "value" : "Inpatient hospitalizations for patients with an initial glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter", "name" : "Denominator Exclusions", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "DENEX", "title" : "Denominator Exclusions" }, "value_obj" : { "type" : "ED", "value" : "Inpatient hospitalizations for patients with an initial glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter", "media_type" : "text/plain" } }, { "code" : "NUMER", "value" : "Inpatient hospitalizations with a hyperglycemic event within the first 10 days of the encounter minus the first 24 hours, and minus the last period before discharge from the hospital if less than 24 hours\n\nA hyperglycemic event is defined as: \n\n - A day with at least one glucose value >300 mg/dL,\n\nOR\n\n - A day where a glucose test and result was not found, and it was preceded by two consecutive days where \nat least one glucose value during each of the two days was >=200 mg/dL", "name" : "Numerator", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "NUMER", "title" : "Numerator" }, "value_obj" : { "type" : "ED", "value" : "Inpatient hospitalizations with a hyperglycemic event within the first 10 days of the encounter minus the first 24 hours, and minus the last period before discharge from the hospital if less than 24 hours\n\nA hyperglycemic event is defined as: \n\n - A day with at least one glucose value >300 mg/dL,\n\nOR\n\n - A day where a glucose test and result was not found, and it was preceded by two consecutive days where \nat least one glucose value during each of the two days was >=200 mg/dL", "media_type" : "text/plain" } }, { "code" : "NUMEX", "value" : "Not Applicable", "name" : "Numerator Exclusions", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "NUMEX", "title" : "Numerator Exclusions" }, "value_obj" : { "type" : "ED", "value" : "Not Applicable", "media_type" : "text/plain" } }, { "code" : "MSROBS", "value" : "There are two Measure Observations:\n\nMeasure Observation 1, associated with the Denominator: The total number of eligible days of the inpatient hospitalization which match the initial population/denominator criteria and did not meet the denominator exclusion criteria. \n\nMeasure Observation 2, associated with the Numerator: The total number of hyperglycemic days during the inpatient hospitalization that meet the numerator criteria. Days with a hyperglycemic event are defined as: \n\n - All days with a glucose level >300 mg/dL (except those occurring in the first 24-hour period after \nadmission to the hospital (including the emergency department and observation)), \n\nOR\n\n - All days where a glucose was not measured, and it was preceded by two consecutive days where \nat least one glucose value during each of the two days was >=200 mg/dL.\n\nThe length of stay for all eligible inpatient hospitalizations is truncated to <=10 days when the length exceeds 10 days.\n\nDo not count the last day if it was less than a 24-hour period as this is not considered a full day.", "name" : "Measure Observation", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "MSROBS", "title" : "Measure Observation" }, "value_obj" : { "type" : "ED", "value" : "There are two Measure Observations:\n\nMeasure Observation 1, associated with the Denominator: The total number of eligible days of the inpatient hospitalization which match the initial population/denominator criteria and did not meet the denominator exclusion criteria. \n\nMeasure Observation 2, associated with the Numerator: The total number of hyperglycemic days during the inpatient hospitalization that meet the numerator criteria. Days with a hyperglycemic event are defined as: \n\n - All days with a glucose level >300 mg/dL (except those occurring in the first 24-hour period after \nadmission to the hospital (including the emergency department and observation)), \n\nOR\n\n - All days where a glucose was not measured, and it was preceded by two consecutive days where \nat least one glucose value during each of the two days was >=200 mg/dL.\n\nThe length of stay for all eligible inpatient hospitalizations is truncated to <=10 days when the length exceeds 10 days.\n\nDo not count the last day if it was less than a 24-hour period as this is not considered a full day.", "media_type" : "text/plain" } }, { "code" : "SDE", "value" : "For every patient evaluated by this measure also identify payer, race, ethnicity and sex", "name" : "Supplemental Data Elements", "code_obj" : { "type" : "CD", "system" : "2.16.840.1.113883.5.4", "code" : "SDE", "title" : "Supplemental Data Elements" }, "value_obj" : { "type" : "ED", "value" : "For every patient evaluated by this measure also identify payer, race, ethnicity and sex", "media_type" : "text/plain" } } ], "measure_period" : { "type" : "IVL_TS", "low" : { "type" : "TS", "value" : "202301010000", "inclusive?" : true, "derived?" : false }, "high" : { "type" : "TS", "value" : "202312312359", "inclusive?" : true, "derived?" : false }, "width" : { "type" : "PQ", "unit" : "a", "value" : "1", "inclusive?" : true, "derived?" : false } }, "population_criteria" : { "OBSERV" : { "conjunction?" : false, "type" : "OBSERV", "hqmf_id" : "EF3028E4-3A9C-4E0C-9519-4F882EF18C0C", "aggregator" : "SUM" }, "OBSERV_1" : { "conjunction?" : false, "type" : "OBSERV", "hqmf_id" : "BADA053C-ACB6-4863-8238-F4FADEC14550", "aggregator" : "SUM" }, "IPP" : { "conjunction?" : true, "type" : "IPP", "hqmf_id" : "18CA6DFD-F20D-452D-9F10-80908239437A", "preconditions" : [ { "id" : 2, "preconditions" : [ { "id" : 1, "reference" : "HospitalHarmHyperglycemiainHospitalizedPatients__Initial_Population__33D5AB83_35E5_4DB8_B086_A149E5C12847" } ], "conjunction_code" : "allTrue" } ] }, "DENOM" : { "conjunction?" : true, "type" : "DENOM", "hqmf_id" : "5E387CCD-AB40-48EB-984E-BB88A74FA84A", "preconditions" : [ { "id" : 4, "preconditions" : [ { "id" : 3, "reference" : "HospitalHarmHyperglycemiainHospitalizedPatients__Denominator__33D5AB83_35E5_4DB8_B086_A149E5C12847" } ], "conjunction_code" : "allTrue" } ] }, "NUMER" : { "conjunction?" : true, "type" : "NUMER", "hqmf_id" : "B24F213F-485F-4C15-A644-B22AFA73C495", "preconditions" : [ { "id" : 6, "preconditions" : [ { "id" : 5, "reference" : "HospitalHarmHyperglycemiainHospitalizedPatients__Numerator__33D5AB83_35E5_4DB8_B086_A149E5C12847" } ], "conjunction_code" : "allTrue" } ] }, "DENEX" : { "conjunction?" : true, "type" : "DENEX", "hqmf_id" : "B8D56145-B6E6-4A25-8D30-A7D1F18F0587", "preconditions" : [ { "id" : 8, "preconditions" : [ { "id" : 7, "reference" : "HospitalHarmHyperglycemiainHospitalizedPatients__Denominator_Exclusions__33D5AB83_35E5_4DB8_B086_A149E5C12847" } ], "conjunction_code" : "atLeastOneTrue" } ] } }, "group_id" : "636a6a04f9a010cc10d95cd6", "updated_at" : "2023-03-28T17:52:18.009+0000", "created_at" : "2023-03-28T17:52:18.009+0000", "cql_libraries" : [ { "_id" : "64232952f9a010eeafc2a054", "is_top_level" : true, "library_name" : "HospitalHarmHyperglycemiainHospitalizedPatients", "library_version" : "2.0.027", "elm" : { "library" : { "annotation" : [ { "translatorOptions" : "EnableAnnotations,EnableLocators,DisableListDemotion,DisableListPromotion,DisableMethodInvocation", "type" : "CqlToElmInfo" }, { "type" : "Annotation", "s" : { "r" : "541", "s" : [ { "value" : [ "", "library HospitalHarmHyperglycemiainHospitalizedPatients version '2.0.027'" ] } ] } } ], "identifier" : { "id" : "HospitalHarmHyperglycemiainHospitalizedPatients", "version" : "2.0.027" }, "schemaIdentifier" : { "id" : "urn:hl7-org:elm", "version" : "r1" 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Hospitalization\" InpatientHospitalDays\r\n return Tuple {\r\n encounter: InpatientHospitalDays.encounter,\r\n relevantPeriod: InpatientHospitalDays.relevantPeriod,\r\n relevantDays: ( InpatientHospitalDays.relevantDays EncounterDay\r\n return Tuple {\r\n dayNumber: EncounterDay.dayNumber,\r\n dayPeriod: EncounterDay.dayPeriod,\r\n hasSevereResult: exists ( [\"Laboratory Test, Performed\": \"Glucose Lab Test Mass Per Volume\"] GlucoseTest\r\n where GlucoseTest.result > 300 'mg/dL'\r\n and Global.\"EarliestOf\" ( GlucoseTest.relevantDatetime, GlucoseTest.relevantPeriod ) during EncounterDay.dayPeriod\r\n ),\r\n hasElevatedResult: exists ( [\"Laboratory Test, Performed\": \"Glucose Lab Test Mass Per Volume\"] GlucoseTest\r\n where GlucoseTest.result >= 200 'mg/dL'\r\n and Global.\"EarliestOf\" ( GlucoseTest.relevantDatetime, GlucoseTest.relevantPeriod ) during EncounterDay.dayPeriod\r\n ),\r\n hasNoGlucoseTest: not exists ( [\"Laboratory Test, Performed\": \"Glucose Lab Test Mass Per Volume\"] GlucoseTest\r\n where Global.\"EarliestOf\" ( GlucoseTest.relevantDatetime, GlucoseTest.relevantPeriod ) during EncounterDay.dayPeriod\r\n )\r\n }\r\n )\r\n }\n\n/*# days with hyper events uses \"Days With Glucose Results\" to find if hyper event on each day. Skips 1st day in 'RelevantDays`. Returns boolean based on: Today high result OR Today no result AND Yesterday high result AND 2 days ago high result*/\r\n\r\ndefine \"Days with Hyperglycemic Events\":\r\n \"Days with Glucose Results\" EncounterWithResultDays\r\n let eligibleEventDays: EncounterWithResultDays.relevantDays EncounterDay\r\n where EncounterDay.dayNumber > 1\r\n return Tuple {\r\n dayNumber: EncounterDay.dayNumber,\r\n dayPeriod: EncounterDay.dayPeriod,\r\n hasHyperglycemicEvent: ( EncounterDay.hasSevereResult\r\n or ( EncounterDay.hasNoGlucoseTest\r\n and EncounterWithResultDays.relevantDays[EncounterDay.dayNumber - 2].hasElevatedResult\r\n and EncounterWithResultDays.relevantDays[EncounterDay.dayNumber - 3].hasElevatedResult\r\n )\r\n )\r\n }\r\n return Tuple {\r\n encounter: EncounterWithResultDays.encounter,\r\n relevantPeriod: EncounterWithResultDays.relevantPeriod,\r\n eligibleEventDays: eligibleEventDays\r\n }\r\n\r\ndefine \"Denominator\":\r\n \"Initial Population\"\r\n\r\ndefine \"Denominator Exclusions\":\r\n \"Encounter with First Glucose Greater Than or Equal to 1000\"\n\n/** Using the already calculated pairing of hospitalization periods with encounters, filter on ones with any elevated (>= 200) glucose reading during the hospitalization **/\r\n\r\ndefine \"Encounter with Elevated Glucose Greater Than or Equal to 200\":\r\n \"Encounter with Hospitalization Period\" Hospitalization\r\n with [\"Laboratory Test, Performed\": \"Glucose Lab Test Mass Per Volume\"] GlucoseTest\r\n such that Global.\"EarliestOf\" ( GlucoseTest.relevantDatetime, GlucoseTest.relevantPeriod ) during Hospitalization.hospitalizationPeriod\r\n and GlucoseTest.result >= 200 'mg/dL'\r\n return Hospitalization.encounter\n\n/** Using the already calculated pairing of hospitalization periods with encounters, filter on ones with \n * diabetes and return the encounter.*/\r\n\r\ndefine \"Encounter with Existing Diabetes Diagnosis\":\r\n \"Encounter with Hospitalization Period\" Hospitalization\r\n with [\"Diagnosis\": \"Diabetes\"] DiabetesCondition\r\n such that DiabetesCondition.prevalencePeriod starts before \r\n end of Hospitalization.hospitalizationPeriod\r\n return Hospitalization.encounter\r\n\r\ndefine \"Encounter with First Glucose Greater Than or Equal to 1000\":\r\n \"Initial Population\" InpatientHospitalization\r\n with \"Initial Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\" FirstGlucoseResult\r\n such that FirstGlucoseResult.result >= 1000 'mg/dL'\r\n and Global.\"EarliestOf\" ( FirstGlucoseResult.relevantDatetime, FirstGlucoseResult.relevantPeriod ) during Interval[( start of Global.\"HospitalizationWithObservation\" ( InpatientHospitalization ) - 1 hour ), ( start of Global.\"HospitalizationWithObservation\" ( InpatientHospitalization ) + 6 hours )]\r\n return InpatientHospitalization\n\n/** Create paring of encounters to hospitalization period so this calculation can be inspected and the result \n * can be reused, making the logic faster.*/\r\n\r\ndefine \"Encounter with Hospitalization Period\":\r\n \"Qualifying Encounter\" QualifyingHospitalization\r\n return Tuple {\r\n encounter: QualifyingHospitalization,\r\n hospitalizationPeriod: Global.\"HospitalizationWithObservation\" ( QualifyingHospitalization )\r\n }\r\n\r\ndefine \"Encounter with Hyperglycemic Events\":\r\n \"Days with Hyperglycemic Events\" HyperglycemicEventDays\r\n where exists ( HyperglycemicEventDays.eligibleEventDays EligibleEventDay\r\n where EligibleEventDay.hasHyperglycemicEvent\r\n )\r\n return HyperglycemicEventDays.encounter\r\n\r\ndefine \"Encounter with Hypoglycemic Medication\":\r\n \"Encounter with Hospitalization Period\" Hospitalization\r\n with [\"Medication, Administered\": \"Hypoglycemics Treatment Medications\"] HypoglycemicMedication\r\n such that Global.\"NormalizeInterval\" ( HypoglycemicMedication.relevantDatetime, HypoglycemicMedication.relevantPeriod ) starts during Hospitalization.hospitalizationPeriod\r\n return Hospitalization.encounter\r\n\r\ndefine \"Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\":\r\n from\r\n \"Initial Population\" InpatientHospitalization,\r\n [\"Laboratory Test, Performed\": \"Glucose Lab Test Mass Per Volume\"] GlucoseTest\r\n let HospitalizationInterval: Global.\"HospitalizationWithObservation\" ( InpatientHospitalization ),\r\n GlucoseTestTime: Global.\"EarliestOf\" ( GlucoseTest.relevantDatetime, GlucoseTest.relevantPeriod )\r\n where GlucoseTest.result >= 1000 'mg/dL'\r\n and GlucoseTestTime during Interval[( start of HospitalizationInterval - 1 hour ), ( start of HospitalizationInterval + 6 hours )]\r\n return GlucoseTest\r\n\r\ndefine \"Glucose Tests Earlier Than Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\":\r\n from\r\n \"Initial Population\" InpatientHospitalization,\r\n \"Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\" GlucoseResult1000,\r\n [\"Laboratory Test, Performed\": \"Glucose Lab Test Mass Per Volume\"] EarlierGlucoseTest\r\n let HospitalizationInterval: Global.\"HospitalizationWithObservation\" ( InpatientHospitalization ),\r\n GlucoseTest1000Time: Global.\"EarliestOf\" ( GlucoseResult1000.relevantDatetime, GlucoseResult1000.relevantPeriod ),\r\n EarlierGlucoseTestTime: Global.\"EarliestOf\" ( EarlierGlucoseTest.relevantDatetime, EarlierGlucoseTest.relevantPeriod )\r\n where GlucoseTest1000Time during Interval[( start of HospitalizationInterval - 1 hour ), ( start of HospitalizationInterval + 6 hour )]\r\n and EarlierGlucoseTestTime during Interval[( start of HospitalizationInterval - 1 hour ), GlucoseTest1000Time )\r\n and EarlierGlucoseTest.id !~ GlucoseResult1000.id\r\n return GlucoseResult1000\r\n\r\ndefine \"Initial Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\":\r\n \"Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\" GlucoseResult1000\r\n where not ( GlucoseResult1000.id in \"Glucose Tests Earlier Than Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start\".id )\r\n\r\ndefine \"Initial Population\":\r\n \"Encounter with Existing Diabetes Diagnosis\"\r\n union \"Encounter with Hypoglycemic Medication\"\r\n union \"Encounter with Elevated Glucose Greater Than or Equal to 200\"\r\n\r\ndefine \"Measurement Population\":\r\n \"Denominator\"\r\n\r\ndefine \"Numerator\":\r\n \"Encounter with Hyperglycemic Events\"\r\n\r\ndefine \"Qualifying Encounter\":\r\n [\"Encounter, Performed\": \"Encounter Inpatient\"] InpatientEncounter\r\n where InpatientEncounter.relevantPeriod ends during day of \"Measurement Period\"\r\n and AgeInYearsAt(date from start of InpatientEncounter.relevantPeriod)>= 18\r\n\r\ndefine \"SDE Ethnicity\":\r\n [\"Patient Characteristic Ethnicity\": \"Ethnicity\"]\r\n\r\ndefine \"SDE Payer\":\r\n [\"Patient Characteristic Payer\": \"Payer\"]\r\n\r\ndefine \"SDE Race\":\r\n [\"Patient Characteristic Race\": \"Race\"]\r\n\r\ndefine \"SDE Sex\":\r\n [\"Patient Characteristic Sex\": \"ONC Administrative Sex\"]\n\n/** Creates a list of integers from 1 to how many days are in the interval. Note, this wont create an index for\n * the final day if it is less than 24 hours. This also includes the first 24 hour period.*/\r\n\r\ndefine function \"Interval To Day Numbers\"(Period Interval):\r\n ( expand { Interval[1, days between start of Period and \r\n end of Period]} ) DayExpand\r\n return \r\n end of DayExpand\n\n/**\n * Crops an interval to a maximum length of 10 days.*/\r\n\r\ndefine function \"Hospital Days Max 10\"(Period Interval):\r\n Interval[start of Period, Min({ \r\n end of Period, start of Period + 10 days }\r\n )]\n\n/**\n * Creates a list of 24 hour long intervals in an interval paired with the index (1 indexed) to which 24 hour interval it is.*/\r\n\r\ndefine function \"Days In Period\"(Period Interval):\r\n ( \"Interval To Day Numbers\"(Period)) DayNumber\r\n let startPeriod: start of Period + ( 24 hours * ( DayNumber - 1 ) ),\r\n endPeriod: if ( hours between startPeriod and \r\n end of Period < 24\r\n ) then startPeriod \r\n else start of Period + ( 24 hours * DayNumber )\r\n return Tuple {\r\n dayNumber: DayNumber,\r\n dayPeriod: Interval[startPeriod, endPeriod )\r\n }\n\n/**\n * Counts the number of eligible days in an encounter. 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\"Encounter Inpatient\"] EncounterInpatient\n where \"LengthInDays\"(EncounterInpatient.relevantPeriod)<= 120\n and EncounterInpatient.relevantPeriod ends during day of \"Measurement Period\"\n\n/*@description: Returns an interval of date values extracted from the input interval of date-time values\n@comment: This function returns an interval constructed using the `date from` extractor on the start\nand end values of the input date-time interval. Note that using a precision specifier as part of a\ntiming phrase is preferred to communicate intent to perform day-level comparison, as well as for\ngeneral readability.*/\ndefine function \"ToDateInterval\"(period Interval ):\n Interval[date from start of period, date from end of period]\n\n/*calculates the difference in calendar days between the start and end of the given interval.*/\ndefine function \"LengthInDays\"(Value Interval ):\n difference in days between start of Value and end of Value\n\n/*returns list of all locations within an encounter, including locations for immediately prior ED visit.*/\ndefine function \"HospitalizationLocations\"(Encounter \"Encounter, Performed\" ):\n Encounter Visit\n \tlet EDVisit: Last([\"Encounter, Performed\": \"Emergency Department Visit\"] LastED\n \t\t\twhere LastED.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t)\n \treturn if EDVisit is null then Visit.facilityLocations \n \t\telse flatten { EDVisit.facilityLocations, Visit.facilityLocations }\n\n/*Returns the arrival time in the ED for the encounter.*/\ndefine function \"EmergencyDepartmentArrivalTime\"(Encounter \"Encounter, Performed\" ):\n start of First((\"HospitalizationLocations\"(Encounter))HospitalLocation\n \t\twhere HospitalLocation.code in \"Emergency Department Visit\"\n \t\tsort by start of locationPeriod\n ).locationPeriod\n\n/*Returns admission time for an encounter or for immediately prior emergency department visit.*/\ndefine function \"HospitalAdmissionTime\"(Encounter \"Encounter, Performed\" ):\n start of \"Hospitalization\"(Encounter)\n\n/*Returns earliest arrival time for an encounter including any prior ED visit.*/\ndefine function \"HospitalArrivalTime\"(Encounter \"Encounter, Performed\" ):\n start of First((\"HospitalizationLocations\"(Encounter))HospitalLocation\n \t\tsort by start of locationPeriod\n ).locationPeriod\n\n/*Hospitalization returns the total interval for admission to discharge for the given encounter, or for the admission of any immediately prior emergency department visit to the discharge of the given encounter.*/\ndefine function \"Hospitalization\"(Encounter \"Encounter, Performed\" ):\n Encounter Visit\n \tlet EDVisit: Last([\"Encounter, Performed\": \"Emergency Department Visit\"] LastED\n \t\t\twhere LastED.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t)\n \treturn Interval[Coalesce(start of EDVisit.relevantPeriod, start of Visit.relevantPeriod), \n \tend of Visit.relevantPeriod]\n\n/*Returns the length of stay in days (i.e. the number of days between admission and discharge) for the given encounter, or from the admission of any immediately prior emergency department visit to the discharge of the encounter*/\ndefine function \"HospitalizationLengthofStay\"(Encounter \"Encounter, Performed\" ):\n LengthInDays(\"Hospitalization\"(Encounter))\n\n/*Returns the latest departure time for encounter including any prior ED visit.*/\ndefine function \"HospitalDepartureTime\"(Encounter \"Encounter, Performed\" ):\n end of Last((\"HospitalizationLocations\"(Encounter))HospitalLocation\n \t\tsort by start of locationPeriod\n ).locationPeriod\n\n/*Hospital Discharge Time returns the discharge time for an encounter*/\ndefine function \"HospitalDischargeTime\"(Encounter \"Encounter, Performed\" ):\n end of Encounter.relevantPeriod\n\n/*Hospitalization with Observation and Outpatient Surgery Service returns the total interval from the start of any immediately prior emergency department visit, outpatient surgery visit or observation visit to the discharge of the given encounter.*/\ndefine function \"HospitalizationWithObservationAndOutpatientSurgeryService\"(Encounter \"Encounter, Performed\" ):\n Encounter Visit\n \tlet ObsVisit: Last([\"Encounter, Performed\": \"Observation Services\"] LastObs\n \t\t\twhere LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t),\n \tVisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),\n \tEDVisit: Last([\"Encounter, Performed\": \"Emergency Department Visit\"] LastED\n \t\t\twhere LastED.relevantPeriod ends 1 hour or less on or before VisitStart\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t),\n \tVisitStartWithED: Coalesce(start of EDVisit.relevantPeriod, VisitStart),\n \tOutpatientSurgeryVisit: Last([\"Encounter, Performed\": \"Outpatient Surgery Service\"] LastSurgeryOP\n \t\t\twhere LastSurgeryOP.relevantPeriod ends 1 hour or less on or before VisitStartWithED\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t)\n \treturn Interval[Coalesce(start of OutpatientSurgeryVisit.relevantPeriod, VisitStartWithED), \n \tend of Visit.relevantPeriod]\n\n/*Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter*/\ndefine function \"HospitalizationWithObservation\"(Encounter \"Encounter, Performed\" ):\n Encounter Visit\n \tlet ObsVisit: Last([\"Encounter, Performed\": \"Observation Services\"] LastObs\n \t\t\twhere LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t),\n \tVisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),\n \tEDVisit: Last([\"Encounter, Performed\": \"Emergency Department Visit\"] LastED\n \t\t\twhere LastED.relevantPeriod ends 1 hour or less on or before VisitStart\n \t\t\tsort by \n \t\t\tend of relevantPeriod\n \t)\n \treturn Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), \n \tend of Visit.relevantPeriod]\n\n/*Hospitalization with Observation Length of Stay returns the length in days from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter*/\ndefine function \"HospitalizationWithObservationLengthofStay\"(Encounter \"Encounter, Performed\" ):\n \"LengthInDays\"(\"HospitalizationWithObservation\"(Encounter))\n\n/*First Inpatient Intensive Care Unit returns the first intensive care unit for the given encounter, without considering any immediately prior emergency department visit.*/\ndefine function \"FirstInpatientIntensiveCareUnit\"(Encounter \"Encounter, Performed\" ):\n First((Encounter.facilityLocations)HospitalLocation\n where HospitalLocation.code in \"Intensive Care Unit\"\n and HospitalLocation.locationPeriod during Encounter.relevantPeriod\n sort by start of locationPeriod\n )\n\n/*Given a datetime and a period, returns the period (if a period is provided) or the interval beginning and ending on the datetime (if a datetime is provided)*/\ndefine function \"NormalizeInterval\"(pointInTime DateTime, 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