Becker's Healthcare Podcast
Improving Glycemic Control - Severe Hypo and Hyper Glycemic Measures
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In this episode, Dr. Jordan Messler, Chief Medical Officer at Glytec, discusses the Hospital Inpatient Quality-Reporting (IQR) Program and the two new glycemic management eCQMs on severe hypo and hyperglycemia. Tune in to learn more about these two new quality measurements that went into effect in January 2023, how hospitals can improve their glycemic management programs before their data is reported to the public, and the top action steps a hospital or Chief Quality Officer could take now to be ready for these measures.
[00:00:00] Marcus Robertson: Hello everyone, and thank you for tuning into the Becker's Healthcare podcast series. I'm Marcus Robertson with Becker's Hospital Review. Today I am pleased to be joined by Dr. Jordan Messer, Chief Medical Officer at Glytec. Dr. Messer trained in internal medicine at Emory University in Atlanta, and subsequently served as an academic hospitalist at Emory University for several years after residency.
[00:00:28] Marcus Robertson: He's the former medical director for the Morton Plant Hospitalist Group in Clearwater, Florida. He continues to work as a hospitalist. He is the prior physician editor for the Society of Hospital Medicines Blog Hospital Leader. In addition, he previously chaired Shms Quality and Patient Safety Committee and has been active in several of their national mentoring programs, including Project Boost and Glycemic Control.
[00:00:55] Marcus Robertson: He has talked at national conferences on a variety of topics such as teamwork in the hospital, quality and patient safety, the history of hospitals and mentoring, quality improvement projects. Dr. Messer, thank you so much for being here today.
[00:01:12] Jordan Messler: Thanks for having me today. Look forward to the conversation.
[00:01:15] Marcus Robertson: Absolutely. Me too. Uh, so let's go ahead and dive. So can you first explain to our audience what the hospital inpatient quality reporting program is and what these two new glycemic management eCQMs are on severe hypo and hyperglycemia?
[00:01:38] Jordan Messler: Sure thing. Uh, the. Inpatient quality reporting program. The IQR program is, uh, part of, uh, cms.
[00:01:46] Jordan Messler: Uh, most folks in quality would be familiar with the IQR program. These, uh, regulatory, uh, metrics that come outta the program. This is specifically a pay for reporting quality program, uh, that CMS has. And, uh, really the goals of the program align with the goals that we have in quality, trying to get measurement of data.
[00:02:07] Jordan Messler: That's the way to improve quality and transparency of that data publicly. Uh, reporting on that, uh, infor information. So it's a pay for reporting quality program through CMS and, uh, excited. To talk about two of their new measures that were announced, uh, last year, and we'll go into effect, uh, in January.
[00:02:28] Jordan Messler: These, uh, two measures around glycemic control, uh, hypoglycemia and hyperglycemia measures. So we've, uh, talked in the quality space around having metrics for a glycemic control for years. The National Quality Foundation has done a lot of work on these metrics over the years, and they have finally arrived.
[00:02:46] Jordan Messler: So for those of us in the quality improvement and particularly the glycemic space, we're excited, uh, for these two measures. Uh, in brief, one of them is severe hypoglycemia measure, uh, looking at patient stays in the hospital setting of having severe hypo, less than 40 milligrams per dec. And, uh, and then the other one is severe hyperglycemia, those greater than 300, uh, and particularly those greater than 300 that are occurring after 24 hours.
[00:03:13] Jordan Messler: So excluding that, that first day where patients do come in high. And, um, and looking at patient days that, uh, that have greater than 300 after that first 24 hours. And really exciting cuz it meets those, you know, those two goals from the IQR program. Looking at measurements that we need and, and often hospitals don't have much measurements around eGlycemic control, uh, transparency, that public reporting of the data and really driving that awareness.
[00:03:38] Jordan Messler: And two important things. Severe hypoglycemia, which when related to insulin or other medications that lower blood sugar. Largely preventable and severe hyperglycemia, which is something that should be treated, certainly occurs, uh, can't prevent uh, all of the severe hyper, but when it occurs in the hospital, should be treated.
[00:03:57] Jordan Messler: And, and generally after day one, uh, we shouldn't see readings of severe hyperglycemia.
[00:04:04] Marcus Robertson: Okay, so these, these two measures are, uh, you know, kind of filling in a monitoring and reporting area that hasn't been, uh, that hasn't been filled previously. But you said they go into effect in January, so in three months. But how long do hospitals actually have to get ready for all of this?
[00:04:24] Jordan Messler: Yeah, so these, um, a little more details about the measure. They're, you know, here the abbreviation E qms, these electronic clinical quality measures under the inpatient Quality Reporting Program. Uh, there's a variety of these measures that hospitals have been familiar with.
[00:04:41] Jordan Messler: So it's not a new program, uh, but there're new measures within the program. So they have been familiar with various EC qms, uh, these eClinical quality measure. And, uh, and now I have two new ones on the list. The, some that fell off the list from CMS and now these two new ones that are, that are there. So the announcement came, uh, proposal came into effect, uh, October of last year.
[00:05:03] Jordan Messler: So I've had from last year, October, 2021, uh, until this year, January, 2023, to prepare, um, working with their electronic medical record. Vendors, um, finding ways to be able to abstract these, um, get these measures cause they're gonna be electronically abstracted as opposed to people having to abstract in the chart.
[00:05:26] Jordan Messler: So, preparation of the last year through January 23 to get the, uh, right, uh, coding with their, um, EMR systems, uh, to be able to report on these two measures. And then starting in January, the data collection period begins. So January through December of 23, uh, collect, uh, data on these two measures. And then February, 2024 will likely be when they, uh, the deadline to report that 2023 data.
[00:05:52] Jordan Messler: So the time has been going on and continues through the end of the year and need to, uh, um, be able to collect these, uh, collect, uh, data on these measure. So, just to make sure
[00:06:06] Marcus Robertson: I understand you correctly, uh, the, it goes into effect January, 2023, but, uh, data doesn't get reported until February of 2024. Is that right?
[00:06:19] Jordan Messler: Yeah. All right. So, and then it's not publicly available actually, generally until October. So, um, when you see publicly available data from CMS and then these types of programs, you're, you're looking at data that's already, in some cases over a year and a half old. So yeah, January to December, 2023. That's the data collection period.
[00:06:38] Jordan Messler: Um, so should have everything in place to be able to collect these eCQMs, the deadlines in February, 2024. And then they'll be publicly available on, uh, October, uh, 2024. And, and just a reminder as well, these are. A little more details about these eCQMs. There's about 11 of these measures and in this program, these are elective measures, so.
[00:07:01] Jordan Messler: Um, hospitals should be getting ready to report on these measures. Um, should have the data, uh, the ability to, to collect the data, but they are electives so they can choose not to report 'em this first year. We certainly recommend that they pick these two e c qms and, and pick both of them, uh, not just one or the other.
[00:07:20] Jordan Messler: Um, but hospitals can choose from a menu of about 11 different e qms. Uh, they'll have to report on four of them. One of them is an opioid related. Qm that'll be mandatory. And then they'll have three others to choose from, uh, to report, um, in February of 2024, and then the data again from January to December that they'll be collecting on that.
[00:07:45] Marcus Robertson: And so January. 2023, we're about three months away getting into crunch time on this before data starts being collected. Um, so how can hospitals go ahead and, you know, start improving their glycemic management programs before data starts getting collected and reported
[00:08:05] Jordan Messler: to the public? Yeah. Well, for me, in the glycemic management space, the time is always now, right?
[00:08:12] Jordan Messler: So , it's never soon. Um, and, and, uh, and for these particular measures, you've been collecting data in January that's a few months away, so may not see improvements, um, right away if they begin, uh, putting improvements in place today. But this is, uh, this is the long game on this. This is the beginning of, uh, CMS raising attention to glycemic measures.
[00:08:37] Jordan Messler: Um, maybe hospitals, uh, choose not to report in 2023 on glycemic. Uh, I think there's gonna be more and more intention to this, that they're gonna wanna report in 2024 if they're not reporting this year. Uh, even if they don't report, they'll have that visibility into these metrics in 2023. So they should have the ability to collect these eCQMs.
[00:08:57] Jordan Messler: Their quality team will be able to look at these metrics and then they'll decide which ones they choose to report. But the time is always now and a glycemic manage. Uh, is a, um, uh, is an important area. Obviously I'm biased working with a company, uh, in glycemic management. Uh, but we know that 10% of, uh, Americans have diabetes.
[00:09:18] Jordan Messler: Uh, yet when you get in the hospital setting, it's almost 25% of patients with diabetes in the hospital setting. And another, uh, Uh, another 10 to 15% of patients will have hyperglycemia. So almost 40% of patients in the hospital are facing glycemic issues. Uh, this is a priority, should always be a priority for hospitals to address glycemic issues.
[00:09:36] Jordan Messler: Um, and yeah, the time, the time is now, uh, look at your, uh, look at your infrastructure around glycemic management. Do you have a dedicated committee? Uh, do you have champion? Um, do you even have basic metrics, uh, outside of what you'll see from a cms, uh, to begin understanding, uh, your glycemic, uh, control around hypo and hyperglycemia?
[00:10:00] Marcus Robertson: So the time is now and I think biases aside, better safe than sorry, here. Probably, um, but you said this is a long game, even though the time is now to start working on it. It's a long game. CMS just now raising attention to the measures, kind of the beginning potentially of a movement. So are there other glycemic metrics from, uh, you know, big national organizations that hospitals should be
[00:10:28] Jordan Messler: aware of for the.
[00:10:30] Jordan Messler: Yeah, I think this is, uh, a start of seeing a lot more attention pay to glycemia, again, affecting so many patients throughout the hospital, not just one area, but throughout the hospital. Again, up to 40, 50% of patients with diabetes, hyperglycemia, Um, and hospitals often don't know where they stand with hypo and hyperglycemia or other glycemic measurements.
[00:10:51] Jordan Messler: So most hospitals have little to no data around glycem. Um, if they do have data, it's often not much. And, uh, now CMS is, uh, recognizing that there's a lot of variation around hypo and hyperglycemia. There's an opportunity to improve and we need measurements and transparency. And on the heels of this, there's certainly gonna be other measures.
[00:11:11] Jordan Messler: Um, we know that the CDCs working with the National Hospital Safety Network on measures around hypoglycemia to help drive improvement. Um, measures that hospitals may be able to get more regularly. You know, the CMS measure as mentioned, you'll see that data almost a year and a half, right? If you do things, you do in January, 2023, and you'll see data on October, 2024, Makes it hard, really improve, uh, does raise awareness and, uh, other organizations are looking how to get data back.
[00:11:38] Jordan Messler: Uh, to hospitals more timely. And that's what the CDC and National Hospital Safety Network is working on and piloting some measures this year that'll be available, um, for, for more institutions. Uh, after this pilot period. We know that national data organizations like Visient have, uh, sites that enroll with, uh, Viant have the glycemic measures that they've been reporting on.
[00:12:00] Jordan Messler: Uh, and I think we'll just see more to come and, and not only more to come, but the likely trajectory. Of measures like CMS and, and what the National Hospital Safety Network is putting together, that they start elective. And if all goes well with reporting and how they collect the data, they're likely also to be mandatory.
[00:12:17] Jordan Messler: So it's one step to have elective measures. Um, but then when you start having these mandatory measures, which we, we've seen in other disciplines that really. Really begin driving change. So, yeah, again, the time is now be prepared. Uh, glycemic improvement, um, you know, since it affects so much in the hospital, it's not, it's not, there's not an easy fix.
[00:12:36] Jordan Messler: Uh, it takes really dedicated resources to, um, improve glycemic management safely.
[00:12:43] Marcus Robertson: So not an easy fix, and most hospitals, like you said, have little to no data around glycemia, but I imagine nobody, you know, wants to be caught on their back foot here. So is there anything you have in mind as far as like maybe the top three to five action steps a hospital or a chief quality officer could go ahead and take now to begin, you know, preparing for
[00:13:09] Jordan Messler: all.
[00:13:11] Jordan Messler: Yeah, great question, right? What can you do today? What can you do tomorrow? Uh, obviously, you know, understand these measures and make sure that your institution's collecting em top to your quality team. And, um, um, you know, we, we would hope that that sites decide to, uh, elect to report on these glycemic measures and certainly report both of them.
[00:13:29] Jordan Messler: Cause they're in essence balancing measures, hypoglycemia and hyperglycemia. Uh, certainly structurally. You should really evaluate your structure around glycemic management. So do you have a committee at the hospital level? Uh, certainly at the system level. And each hospital should have a committee that's looking at glycemic management, uh, with champions in the pharmacy, nursing provider, and executive realm.
[00:13:53] Jordan Messler: So even at the minimum, certainly those four areas. And ideally, um, a certified diabetes educator as well. Often institutions don't have that, uh, position, but they should again when almost half your patients are facing diabetes or hyperglycemia and need to have those resources. So, so you know, awareness of the measures.
[00:14:12] Jordan Messler: Make sure you have that infrastructure, uh, in place and, and, and see what kind of data that you have internally. And if you don't have data, the time is to, to begin thinking about how to get better access to metrics around glycem. Or start walking the process and, and seeing what's really happening around hypo hyperglycemia, uh, processes around, uh, glycemic management.
[00:14:34] Jordan Messler: So certainly need to understand where you are, right? And then, and then the next thing is begin looking at that gap analysis. So where you are from, where you wanna be, um, uh, would be essential, uh, to understand. What improvements to make. And then the last thing to be, begin looking at those potential improvements.
[00:14:52] Jordan Messler: Certainly on the quality improvement front, Always looking to standardize care. Once you assess those gaps, see your needs, see where you can standardize care. See where you can do best practices and see if there's other, you know, solutions out there. Um, whether through the EMR or a company like ours that has insulin software to help you safely manage insulin in the hospital.
[00:15:11] Jordan Messler: Uh, begin to see what kind of technology solutions or or other solutions you can begin to. Begin to implement. Um, you know, insulin is, is the way to manage glycemia, but it's, it's certainly the, the contributing factor to hypoglycemia. So you need to manage insulin safely. And that's why, and that's why we exist at Glytec, to really help safely manage IV insulin and SubQ insulin, which is the standard of care.
[00:15:35] Jordan Messler: For hyperglycemia management in the hospital. Um, insulin is, is really the mainstay of treatment. ADA guidelines, we know, talk about IV insulin for critically ill patients, certainly for DKA, and then in the non ICU setting, SubQ insulin, basal ball therapy being, you know, standard, standard of care. And we have software to help do that safely.
[00:15:55] Jordan Messler: Uh, and if. Yeah, Software. Software. Then certainly best practices and standardizing your care to those way, to those methods using IV insulin safely, basal bowls for patients in the non ICU using insulin safely. And um, uh, yeah, continue those efforts. Okay.
[00:16:15] Marcus Robertson: A lot of really great and, uh, actionable info there.
[00:16:19] Marcus Robertson: Uh, just to recap, we've got, uh, as far as action steps, evaluate the structure you have around your glycemic management. Potentially have a committee, a certified diabetes educator, uh, then you need to be aware of the measures that are coming. And if you don't have data, you need to start working on that now so you can understand where you are and then look at that gap analysis.
[00:16:45] Marcus Robertson: And then finally, if I understood you correctly, look where you can standardize care and implement best practices. Is that an a, uh, accurate distilling of, of your advice?
[00:16:59] Jordan Messler: Yeah, that's it. Those are sort of key steps for any. Quality improvement. Um, and I think it applies here, and, uh, it's in some ways it may seem basic for folks, but those are essential elements that are often omitted, you know, have, uh, have that infrastructure in place, have that committee know where you can measure, look to standardize so you know where the variation is.
[00:17:21] Jordan Messler: And, and then continue to iterate and proof. And, and in some places where there's, uh, technology or or other solutions, uh, see if those meet. All right,
[00:17:31] Marcus Robertson: perfect. Well, there you have it. Uh, I want to thank you, Dr. Messer, for your time and the really great
[00:17:37] Jordan Messler: discussion today. I really appreciate it. Those were great questions and, uh, really excited that we're, we're getting this information out there to your listeners, thank you so much.
[00:17:47] Marcus Robertson: I'm excited as well. And I'd like to thank Glytec for sponsoring the episode. Uh, you can tune into more podcasts from Becker's Healthcare by visiting our podcast page.