Is your hospital ready for CMS' glycemic management measures? Here's your guide.
Danielle Scheurer, MD, MSRC, SFHM | Medical University of South Carolina
Jordan Messler, MD, SFHM, FACP | Glytec
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Hi, everyone, and welcome to today’s webinar, Is Your Hospital Ready for CMS’s Glycemic Management Measures? Here’s Your Guide. On behalf of Becker’s Healthcare, thank you for joining us today.
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With that, I am pleased to welcome today’s speakers, Dr. Danielle Scheurer, hospitalist, physician, and chief quality officer for the Medical University of South Carolina Hospital, and Dr. Jordan Messler, chief medical officer at Glytec. Thank you both so much for being here today. Dr. Messler, I’ll turn the floor over to you.
JORDAN MESSLER: Great, thanks so much. Welcome, everybody. Thanks for joining us this afternoon. For those of us in the glycemic space, we’ve been talking about some measures for a while, and here they are. They’ve been announced in a final rule from CMS. And today, this afternoon, we’ll see if we can help answer this question – are you prepared? Are you ready for CMS’s glycemic management measures?
I’m happy to be joined here today with Danielle, chief quality officer at MUSC. Again, Jordan Messler. I’m the chief medical officer for Glytec, which has Glucommander insulin management software. I’m a practicing hospitalist medicine physician as well down in the Tampa Bay area. I was running a hospital medicine group here for about 10 years. During that time, got a lot of interest in patient safety/quality improvement. I have done a lot of work with the Society of Hospital Medicine with mentored implementations and various programs locally and nationally to help sites work through quality improvement, in particular diabetes, inpatient glycemic management, and that work over the years helped bring me to Glytec a few years ago.
For this afternoon’s session, we are going to talk about some basic elements of a best-in-class glycemic management program, review some of the challenges of inpatient glycemic management which really set the foundation for why these types of measures have made it through CMS’s final rule. We’ll discuss the role of CMS in driving clinical quality improvement and go through some of the details of these two glycemic measures. And then for a good portion of this afternoon, hear from Danielle a chief quality officer perspective for these types of measures for CMS, review how they handle these eCQMs at a place like MUSC, and a case study for similar-type measures. And then we’ll end up just talking about how Glytec thinks about this and how we can help partner on change management.
I just want to talk briefly about my company, Glytec. It was founded in 2006, and we have Glucommander insulin management software, FDA-cleared solution that has insulin modules for IV insulin, transition IV to subQ, subQ insulin, and an outpatient solution where we integrate with sites’ EMRs to try to assist in insulin management and safely and effectively managing glycemic in the hospital. Our eGMS system personalizes insulin dosing. And with numerous studies that we’ve done independently, done with sites, and many sites themselves have done independently to show the efficacy of the product in various settings and patient populations, we’re really aiming towards our mission of treating hyperglycemia safely and preventing hypoglycemia.
When we think about glycemic management in the hospital – and one of the reasons I wound up at Glytec is I had spent a lot of time working through processes and working on various teams and felt there was a piece that was really missing to help get us over the top. So really partnering with technology, with the processes that we implement in the hospital – order sets, various workflows, and working with our multidisciplinary team and frontline clinicians to achieve what’s in the center there, glycemic management success.
One of the things we’ll talk about this afternoon is one of the barriers to glycemic management success has often been the lack of metrics – lack of clear national standards. What is success? And we know that we can’t improve if we can’t measure.
So let’s talk to some of the challenges of inpatient glycemic management and why we feel these two measures are so important and really just the start to better understanding inpatient glycemic management. We know the challenges of hyperglycemia and diabetes are common, costly, and many instances, we’ll talk about hypoglycemia – largely preventable. We know one in three Americans have glycemic control issues – diabetes or prediabetes – and these numbers are continuing to grow.
We know in the hospital setting, 30%, 40%, and in some cases, up to 50% of patients have diabetes and/or stress hyperglycemia and will require insulin during their hospital stay. Insulin’s standard of care for managing hyperglycemia in the hospital, but is one of our high alert medications. Our top three high alert medications – very common – opioids, anticoagulants, and up there is insulin that’s involved in, in some cases, 16% of medication error reports.
And then looking at this right number here, 59%, so almost two-thirds of hospitals, do not have an automated capability to extract and analyze glucose data. This is the real challenge with improving if we can’t really measure, and many institutions don’t have reliable ways to measure. Even if they have ways to measure, it’s very difficult to benchmark and understand what success means.
Part of the challenges in the management of glycemic today – not just the measurements, but often doing protocols that are a bit outdated or not really following standard of care. On the ICU side, IV insulin is the standard of care to manage hyperglycemia, and most institutions have paper protocols that may have been proven effective in research, but in the real world, they’re very challenging. They require multiple steps. Sometimes, they involve calculations. And the frontline nurses, with so many things that really take up their cognitive load and tasks, certainly looking to find ways to reduce that is important. So these methods can certainly be prone to error, require multiple steps.
And then on the non-ICU setting, there’s been numerous studies for really 50, 60 years now showing that sliding-scale insulin alone is not the way to manage hyperglycemia in the non-ICU setting. Our journal for hospitalists, The Journal of Hospital Medicine, they published this article a few years ago in the things we do for no reason category, and sliding-scale insulin alone as monotherapy for glycemic control is something that we do for no reason. The standard of care, the ADA guidelines for the inpatient setting, is basal-bolus management, a proactive approach – getting patients on basal, baseline insulin, and bolus insulin, mealtime insulin to really manage hyperglycemia proactively and not this reactive, sliding-scale insulin approach.
We know these things, but they’re often challenging to do. And again, if we’re not really measuring success, it’s very difficult to really know what’s happening. So what’s happening when you’re doing these kind of methodologies? Well, one, if you don’t have a way to recognize if somebody’s having persistent hyperglycemia, there are sometimes delays in care.
If we look at this graph for a simulated patient, you see these red dots, red line on the day one, when the patient wasn’t recognized to be severely hyperglycemic, delaying getting started treatment. Eventually did get started on a paper protocol, had a time where they were getting in range, but slow to range, longer time to target. You see some bouncing around dots. That’s that glycemic variability.
And then when transitioned over to the right, IV to subQ, if not using a standard protocol, you often get rebound hyperglycemia. So you had a patient in range. Now, they’re out of range. If you’re using sliding-scale insulin alone, not using a proactive approach, you’ll again see that persistent glycemic variability, higher incidence of hyperglycemia, and also hypoglycemia. All this compounded can lead to longer lengths of stay and costlier care.
So that’s the situation that we’re in at many institutions. Let’s talk about these measures. Those are, again, the drivers for why these measures have come about and why they’re so important. We know the big role that CMS, the Center for Medicare and Medicaid Services, plays in our country. CMS pays out to hospitals – it really accounts for 58% of hospital payments, the rest largely with private insurance. But CMS is a big driver for these kind of measures, a big driver what private insurance will do. We know when these kind of regulatory measures come out, it does drive change. I was thinking about all the different ways over the last few years – we paid attention to readmissions. We pay attention to sepsis because of many of these measures.
This particular glycemic program we’re going to talk about, the IQR program, and the details here. This is the Inpatient Quality Reporting program where these measures come in, and it’s a pay-for-reporting quality program. If hospitals do not submit the quality data or fail to meet all the program requirements, they are subject to a payment penalty, a one-fourth reduction in annual payment.
And what we’ll be talking about under the IQR program is these eCQMs, these electronic clinical quality measures. CMS is trying to move to more of these types of measures. They can be electronically captured instead of abstracted manually. They’re updated regularly every year with a final rule. There may be some new measures and some measures that are taken away.
They’re operating under this goal here in the green box, driving quality improvement through measurement. Transparency – publicly displaying the data to help consumers make more informed decisions about their healthcare. Those are certainly the goals that we aspire to as we try to drive change – be transparent and measure.
So the final rule was announced in August by CMS, and these eCQMs, these two glycemic eCQMs, will fall under a list of about 11 eCQMs for fiscal year ’23, and hospitals will have to report on four of them. So they’ll choose which eCQMs that they’ll report of the four. One of them will be mandated, an opioid measure, and then can electively choose the other three. Hospitals will need to start collecting data on this as of January 1, 2023. So we do have some time, and we’ll talk through the timeline here in a minute.
Let’s talk about these two measures, though. We have two glycemic measures. There’s a severe hypoglycemia measure and a severe hyperglycemia. Ideally, if hospitals report on them, you would report on both, because they’re really nice balancing measures, and really how they’ve been designed over the years is to report on both of them. But hospitals will have the option to report neither, one, or both of them. Certainly, recommend reporting on both.
Some of the details of the severe hypoglycemia measure – this is going to be calculated on percent patient stays with BG, blood glucose, less than 40 and really try and relate it to those preventable situations in the hospital, within 24 hours of the administration of insulin or an anti-hyperglycemic agent. The intention here is to measure events that are potentially triggered by things we do in the hospital – use of insulin incorrectly. CMS here we think is really making it clear that severe hypoglycemia related to insulin is largely preventable. It should really be a never event. And hospitals should be working towards that goal.
On the right side, severe hyperglycemia. This is going to be measured in percent hospital days with one or more blood sugar greater than 300. There’ll be some exclusions – exclude that first period of time, the first 24-hour period when a patient’s coming in potentially with hyperglycemia, didn’t have a chance to really treat it yet. But the intention is to measure it after that period, when we do have an opportunity to treat.
There’s been numerous studies on the ICU side. With the use of IV insulin, we know we can get patients under control in a matter of hours. In the non-ICU setting, with the use of basal-bolus therapy, we can get patients controlled in a matter of two to three days and certainly can get them controlled less than 300 fairly promptly if we’re using the right standards of care and getting patients on the right treatment. So the intention here is to measure that untreated and prolonged hyperglycemia that we know, even in a short hospital stay, really can inhibit a patient’s ability to recover. Clearly here with hyperglycemia, emphasizing that patients are going to need to prioritize early treatment, guideline-based treatment, optimal management of severe hyperglycemia.
So we mentioned that there are 11 eCQMs, these e-clinical quality measures, in this IQR program. Here are the 11 that will be there by fiscal year ’23. In the bottom in green are the two we just mentioned, the severe hypo and the severe hyper measure. You’ll recognize many of these measures. The STK ones are the stroke measures related to anticoagulants. There’s a couple of VTE, venous thromboembolism, prophylaxis measures. Measures over time are going to be removed. The three in orange we highlight – by calendar year 2024, there’ll be three that are removed. So over time, there will really even be less, at least as of now, unless CMS adds more. But there may be by 2024 really just eight measures, and you can see that picking glycemia measures is certainly going to be very likely.
We wanted to take a second to review the timelines to understand when this is going into place here. This is, again, announced over the summer. Fiscal year for CMS starts in October 2021 – is fiscal year 2022. So the new proposal goes into effect by October 2021. During that time from October to January 2023, hospitals will work with their electronic health record providers to implement the reporting packages. Again, the goal here is that these are to be electronically abstracted, no manual abstracts. So working with the EHR to get the right tools in place to be able to automatically abstract this information. And then from January to December 2023, that’s the data collection period. When you’ll be reporting this to CMS will be generally deadlines around February. This past year, that was extended for COVID-related issues – may be extended. That’s the time that the hospital and executive teams will review the data and decide which eCQMs to report.
I think it’s important in this box at the top here – even if the hospital chooses not to report these measures under these elective conditions to report them, there will be greater visibility internally. We’ll hear more from Danielle how a CQO approaches these eCQMs.
So by October 2024, the data will be available publicly based on 2023. I know 2023 may seem like it’s far away, but you can see how the time to act – and we know for glycemic improvement, it doesn’t happen in a matter of weeks. It’s certainly projects that happen in a matter of months. So the time to act is always now. And then by fiscal year 2025, that’ll begin the financial penalties for those who don’t report on the measure.
So really, as we’re thinking about these measures, I think there’s a few key things. One is that, yes, they’re elective now, but these types of measures over time do become mandatory. Yes, it’s pay for reporting currently, but these types of measures over time may become pay for performance. And in particular, when you think these glycemic measures, these are perfect measures to report on over time, because we know there’s a lot of variation. We know it’s going to be very challenging for sites to hit 0%. So these very well will be likely measures that last for a long time, because that’s certainly the intent – to try to really show variation and drive change and drive improvement.
Really, I mentioned some of these points here why these measures are really very important. They’re establishing meaningful metrics. As alluded to, many sites really have no insight to how they’re doing around glycemia. So now, we’re going to have – once the reporting begins, really be able to see how others are doing and compare ourselves and certainly raise that awareness about glycemic management. Thinking about 30%, 40%, upwards of 50% of our patients affected with diabetes hyperglycemia, we need that awareness. It affects every unit in the hospital. And with that awareness, we know we’re all going to be looking for solutions to drive improvement.
So with that, I will hand it over to Dr. Scheurer.
DANIELLE SCHEURER: Great. Thanks for having me. So I’m Danielle Scheurer. I’m chief quality officer at MUSC Health as well as a hospitalist, so I have been very involved in all things public reporting of quality measures and certainly the eCQM program as well as our glycemic management team. I just wanted to share a little bit of the story of how this has evolved at MUSC.
Just a little bit of background – MUSC is South Carolina’s only academic health science center. We have currently about 25,000 team members, 14 hospitals, 2,500 beds throughout several locations, a little over 750 total care locations, 300 telehealth sites, and have long been a flagship hospital with the Joint Commission Advanced Inpatient Diabetes Care certification for over 10 years. Again, we’ve had a longstanding multidisciplinary care team that’s been very devoted to glycemic management for well over a decade.
A little bit more about eCQMs – our team has actually been big fans of eCQMs for all the benefits listed on the left, just to name a few. They’re a very efficient way to extract good-quality information from the EMR. As Jordan mentioned, there is ongoing pretty significant federal support for transitioning from the traditional abstracted method of quality measurement and public reporting to eCQMs. For obvious reasons, it can substantially reduce the burden of reporting and requires far fewer human resources. We all know the cost of medical care has unfortunately gone up over time, and a lot of the regulatory burdens, such as abstracting medical records, simply adds to the cost of care, which we just can’t afford to continue.
The other advantage is it doesn’t need sampling. Many of the complex abstracted measures – one of the many problems with that is you end up with very small sample sizes because of the time required to abstract. With eCQMs, you essentially get a holistic picture of performance, because there’s no need to sample. You can get the full population.
Really, the only big challenge, I would say, is this obviously requires very structured data entry and often falls to already overburdened clinicians. So in the build portion of these eCQMs, I think the key – and we’ll go through this in a minute – is to really understand the definitions so that you can build the workflow into the daily life of a clinician such that it’s not overly burdensome in what they’re already doing.
Some other challenges – the eCQM program I think just nationally – adoption has been relatively slow. I think we all envisioned it was going to be a little bit faster than it has. Some of this is just related to national EMR adoption, local and federal IT resources, and then just competing priorities. It did take a little bit of a backseat over COVID, as many other things did as well. And then it does take a little bit of a challenge from the perspective – that slide that Jordan showed earlier with the red and green boxes – they do change every year or so, so it does take a constant agility in build and reporting and transparency, but not dissimilar to what we’ve been used to for decades in quality programs, and really no different than the abstracted measures.
Obviously, hospitals and the quality teams – they already do and will continue to collect these eCQM data. I mentioned a little bit about the workflow – the quality and/or IS teams typically build and report on all these eCQM measures and then holistically look at the performance typically with an executive team, and then they decide which measures to publicly report. But the good news is that it does give you pretty good insight into, obviously, the performance of all those measures, which is also nice. So even if you don’t report, say, on the VTE measures, it gives you really good insight into how things are actually happening, as opposed to what you think is happening.
Hospitals will definitely need more emphasis on reviewing and benchmarking performance. As Jordan mentioned, obviously, with the evolution of all these programs, they typically start with pay for reporting and move to pay for performance. So we obviously have to be very mindful of how good can you get and benchmark against other organizations that are similar in size and complexity to make sure that our performance is at standard.
Also of note – we’ve been talking a lot about CMS and Joint Commission, but obviously hypo- and hyperglycemia as a clinical quality metric is in a broader scope than just federal programs. So as a notable example, for those organizations that participate in Vizient, which is a very large benchmarking organization, Vizient does use a hypoglycemic measure in their quality and accountability rankings.
So we do think that these performance measures will likely gain more popularity in rankings outside of federal programs as well as in value-based payment programs, primarily because the measures are really important. We know that both hyper- and hypoglycemia in hospitalized patients, as Jordan mentioned earlier, is associated with outcomes, and the complexity of the definition is actually relatively low. So I do think these are going to gain popularity over time.
At MUSC, the way we tackle eCQMs, similar to really any other key performance indicator, is through a series of what we call our QAPI program, which stands for quality assessment/performance improvement. This is just a kind of high-level diagrammatic scheme of how our QAPI program works.
At MUSC, similar to lots of other places, we have a whole host of service lines that we call ICCE, integrated centers of clinical excellence – very similar to service lines, but follow patients throughout the spectrum of care, so not just focused on inpatient. We have some ICCE that are what we call patient-focused ICCE, so these are things like musculoskeletal and cancer. We have some ICCE that we call collaborative ICCE that sort of cut across multiple different service lines or ICCE. These are things like radiology and laboratory medicine. And then obviously a whole bunch of what we call support departments, so these are things like HR and IS and admit transfer centers, so anything falling outside a patient-centered or a collaborative ICCE.
And the way we run our QAPIs – so each one of these pICCE, cICCE, and support departments has a QAPI, and we have a QAPI support team which consists of subject-matter experts primarily, but not exclusively, in the quality department – so directors of areas such as risk management, patient safety, even clinical documentation integrity teams, patient experience, etc., that support each one of these QAPIs in a very structured manner.
This is not an inclusive list, but just to give you an idea of all of the different QAPIs, you can see, again, a smattering of some that are very patient-focused, while others such as scheduling, information solutions, environmental services, etc., are more indirect patient care, but extremely important as it relates to producing good outcomes.
And then each one of our QAPIs reports ultimately to the board of trustees, but a couple of layers through several different senior leader teams to make sure that all of our performance is very transparent and gets to senior leaders to remove any barriers.
As an example of how historically an eCQM has been able to drive change – two examples. One is stroke and one is VTE. This is a couple of bar charts over the course of time as we transitioned from abstracted over to eCQMs. You can see the blue and orange bars are two of our stroke measures, and you can see going all the way back to 2018 – fortunately, our performance was actually pretty good, and we used our stroke/neuro QAPI program to make sure that we sustained those very high performance measures over the course of time. Similarly with VTE, we are now forming a PI project to make sure that our VTE measures both for patients in and out of the ICU – that we can collateralize on that QAPI program similar to how we’ve done with stroke to make sure that our performance improves over the course of time.
So a couple of next steps that I think most organizations are probably in some degree of evolution already. But obviously, step one is you got to figure out how you’re going to report and get your data, which again usually requires a combination of a quality and IS team. Balance the measures – so look at both hypo- and hyperglycemia together. Obviously, to get a big picture, you don’t want to get imbalanced and get very aggressive on hyperglycemia, only at the expense of hypo, etc. If you don’t already have one, obviously form a multidisciplinary glycemic team, typically consisting of nursing, pharmacy, providers, quality, and likely others. Then do a gap analysis of the current program and where your gaps are and then deeply look at the processes driving those outcomes to see where improvement is needed.
With that, I’ll turn it back over to Jordan.
MESSLER: Great, thanks. I think a really important overview of really understanding how one site is thinking about this. You can see the importance of having that infrastructure and knowing you’ll be really prepared when these types of measures come to light.
A little quick housekeeping – as we’re moving forward, certainly as we’re going along here, feel free to type questions into the Q&A box. We’re seeing a lot come through about the slides, so I just wanted to highlight that for a second. Feel free to type that you would request a copy of the slides into the Q&A box now, and we’ll make sure you get a copy of them. Or you could email us at any time at Glytec. So that would be the marketing team at glytecsystems.com, and we can get that in the Q&A as well, where to email us. But certainly feel free to type in the Q&A to request slides.
I see some questions going through. We’ve just got a few more slides, and we should have time to get to most of these questions.
I wanted to talk a little bit about our solution here at Glytec and thinking through glycemic management and our perspective of improvement here. Again, I don’t think I can highlight enough the importance of having metrics. I think for many institutions, they have not been paying attention to glycemic management – not willfully, it’s just that you don’t really have good metrics. They haven’t been pulling data, and it’s really hard to know where you are. So this is really going to create a new layer of visibility to understand how you’re doing and how you’re comparing to others.
You could see that when these measures come out, this is recognized as an issue that needs to be evaluated and worked on. So CMS is saying this is a problem. We have certainly many examples of variation of hypo- and hyperglycemia. We certainly have numerous studies showing the impact on morbidity and mortality for severe hypoglycemia as well as persistent hyperglycemia on the inpatient study. It’s a problem, and there’s opportunity to improve. So there’s an urgency. There’s a visibility here to the metrics.
And then I think the real thoughtful piece, as you heard from Danielle, as we share about what we have at Glytec, is how are you going to improve? Do you have that infrastructure? Do you have that glycemic team? Do you have the processes – and us at Glytec, that added layer of technology to reach that layer of improvement?
Now, this is by no means to go through in detail what we have at Glytec, but I wanted to touch briefly on the suite of solutions that we offer to help drive improvement, reductions in hyperglycemia, prevent severe hypoglycemia. I mentioned Glucommander in the top left there. Glucommander is our insulin dosing software, FDA-cleared solution to provide dosing decision support at the point of care. But there’s much more that we have to really help improve.
In particular, in the middle, we have a team that really works closely with your team. You need to have a glycemic management team not just for implementing these kind of solutions like Glucommander, but longitudinally to drive change and sustain improvement. So we certainly work with hospitals’, institutions’ glycemic team. Our software on the top here is cloud-hosted to be able to do installations and upgrades remotely. On the right, again, we’re talking about the CMS measures here, but having measurements in various ways, either outcomes measures or process measures to how you’re doing around glycemia is certainly very important for improvement and an area where we give sites real-time data and regular feedback on how they’re doing.
GlucoSurveillance – a big piece of improvement is identifying in real time, so we have a tool to help see in real time who’s having persistent hyperglycemia.
On the bottom, SmartClick, our solution to really have this seamless integration with your EMR, so for the end user, they’re clicking within the EMR – within Epic, within Cerner, to get to our cloud-based solution, and for the end user, it appears as though it’s in the EMR.
And then circling around to GlucoView, our solution to provide those timely alerts to know, particularly on IV insulin, when you need follow-up blood sugar checks. So a really high-level overview of what we have at Glytec.
When you put a solution like this in place and have that glycemic team and tracking this over time, getting patients in target sooner, we start seeing the results that you want to see. So we have numerous studies at our website. I’ll highlight a few here. This is an IV Glucommander study at Grady – 99.8% reduction in severe hypoglycemia when compared to a prior process with paper protocols. We’ve seen 90-plus percent reductions repeatedly when switching to IV Glucommander looking at severe hypo events.
And then on the basal-bolus side – BBI, basal-bolus insulin – so on the non-ICU setting, managing patients with hyperglycemia with Glucommander subQ, getting patients in that target range. In this particular institution, able to get 81% of blood sugars in target range with no severe hypoglycemia, safely managing on basal-bolus and getting patients on the right basal-bolus doses, adjusting daily, and having some guardrails to help minimize the risk for hypoglycemia.
When you do this over and over, you see those cost savings. This was a site, Kaweah Delta, that really had a lot of sliding-scale insulin only, went with Glucommander IV and subQ whole house, and really went from very little basal-bolus to almost 95% basal-bolus insulin use, and over a year, saw almost $10 million in savings, because they were getting patients in target sooner, shorter lengths of stay, reductions in hypo, reductions in hyperglycemia.
And to do this, it’s not just implementing the solution. We really want to be that partner in change management. I think whether with our solution or as you’re thinking through any solutions, I think this diagram, again, that I showed earlier is very important. It’s not just looking at one thing. You’re not just implementing a technology. But really, having the right people at the table, the right experts, that glycemic management team – in this case, with the right processes, trying to standardize care as best you can, evaluating your workflows constantly, and with an added technology to really help put those safety guardrails in place. Again, thinking about severe hypoglycemia on insulin or other oral diabetic agents, it’s largely preventable. And if you do all this right and you have the right measurements, we think that you could see in the middle there that glycemic (audio cuts out; inaudible).
So that really gets us close to the end of what Danielle and I had to share, and I know a lot of questions coming through. I did want to take a minute to highlight – and we’ll get to some of these questions here, but if you have further questions, more to come on these metrics at our conference. We’re having our first conference and have invited a lot of terrific speakers that I’ll share on the next slide – some of the speakers that will join us to talk about getting to target, about patient safety around glycemic management. This will be a virtual conference, free to register – glytectimetotarget.com. It’s on October 26th and 27th. And wanted to highlight some of the national colleagues that are going to join us, folks like Dr. Umpierrez, a national leader on inpatient glycemic management, talking about the latest in inpatient diabetes management. Dr. Maynard, who’s been one of our national leaders on metrics and data and will talk more about the CMS measures. And some other experts – Dr. Rolih, endocrinology at Novant, Dr. Rogers, hospitalist, and Dr. Bode, endocrinologist in Atlanta that’s really been a leader as well in diabetes technology. So I wanted to highlight that coming as well.
If you have further questions, this will take us – I really wanted to make sure we get to the content and get through your questions. So thank you so much for listening, and it looks like we’ll have a bit of time here to get through some of these questions.
F: Definitely. Thank you both so much for that great presentation today. We can now begin today’s question-and-answer session, since there are a lot of questions coming in. So you can submit any questions by typing them into your Q&A chat box on your webinar console.
I’d love to get started with the first question. It looks like it’s directed towards Danielle. What do you anticipate the biggest barrier or barriers to successful performance within the new glycemic eCQMs?
SCHEURER: Sorry, I had that on mute there. I think it will probably end up being around true performance. I think most hospitals are used to figuring out how to do the build and even the workflows required to get good information, but as everyone knows, what Jordan had shared in some of the statistics is just the volume of patients with diabetes on a whole host of different medications on admission requiring very good medication reconciliation, etc. But within 24 hours, getting them within control, that takes a lot of work. It just takes a good, coordinated clinical team of multidisciplinary nature to really get them on the right medications extremely quickly and to manage them effectively. That’s probably the biggest challenge is just going to be actually performing well, so keeping them out of the hyper- and hypoglycemic ranges.
F: Thanks, Danielle. Our next question is directed more towards Jordan. What are some of the details of severe hypo and severe hyper measures?
MESSLER: Yeah, thanks. I thought someone might ask that. We touched on the measures and certainly can read through the 2,000-page federal registry, but we thought we would do some of that for you. There’s a lot of stuff in the final rule from CMS. These measures are in there, but there’s numerous things in there. And I thought this was a good time to take a couple of minutes, then – just a little more details about these two measures for those that are curious. Again, obviously, being electronically abstracted, you’ll get this right, and I’m sure there’ll be a period of validation to be sure that you have it right. But it’s good to understand how they’re going to capture this measure.
So for those not familiar with glycemic metrics, there are generally three different ways that you hear about glycemic metrics – either an event level, where the denominator is all BGs. Like all POC, for instance, could be the denominator. Patient stays would be the number of patients that are included as your denominator. And then for severe hyperglycemia, it’s going to be patient day, where the denominator is patient days. And you’ll have vastly different outcomes, obviously, because you’ll have different denominators.
For the severe hypo, it’s a patient stay metric, and again, it’s for patients receiving insulin or any other hypoglycemic medication, any other medication that can reduce blood sugar. So it’s really trying to go after those preventable hypoglycemias to measure, as we know that some patients with severe sepsis, organ failure, may have severe hypoglycemia that’s really not preventable. Looking at adults greater than 18, looking at inpatients, which generally is the case with CMS – so inpatient designation by Medicare – and having at least one blood sugar. So as soon as they hit a blood sugar less than 40, they’re in the numerator. It doesn’t matter if they have multiple recurrences, that’s a one. During their hospital stay and within 24 hours of a anti-hyperglycemic medication. So if they had a less than 40, and you can see within the prior 24 hours that they had administration of insulin or anti-hyperglycemic. And really just one exclusion to think of here is that you really try to be mindful that it wasn’t a false less than 40. So if there was a subsequent retest within five minutes greater than 80, then that less than 40 won’t be counted. So really trying to get the number of patients that are having severe less than 40 that received insulin or another anti-hyperglycemic agent in the prior 24 hours.
And then the severe hyper gets a little more confusing. This is patient day, but you can again envision that we’re trying to see how we’re doing treating hyperglycemia, so looking at the days greater than 300, knowing that we can treat successfully if we get patients on the right therapy quickly. So it’s a little more complicated here. I’ll go through this. Again, we can get you some more information if you want more insight.
But it’s the number of hyperglycemic days, including lab and point-of-care testing, and they’re looking at 24-hour periods with at least one blood sugar greater than 300 – again, as mentioned earlier, not including that first 24 hours. And then there’s a second caveat to help include some of those. If a blood sugar’s not measured one day, but the two prior days, there were multiple readings greater than 200, that would also count in the numerator. So again, even though it’s greater than 300, if you have a day where blood sugar was not measured, they’re making an assumption and trying to see, well, why wasn’t that measured? We don’t want to miss out that you’re just not measuring, and that patient was having multiple hyperglycemic days.
And then the denominator is going to be that number of eligible days for a variety of patients to put in there. They just didn’t want to capture any patient that’s getting point-of-care testing, so those ones that we really want to pay attention to – inpatient status, patients that have diabetes before or during the encounter, receiving at least one dose of insulin or another medication to lower blood sugar, and had any blood sugar greater than 200. So that’s the inclusion bucket, the denominator, which will be the number of eligible days for this bucket, and really trying to get to those days greater than 300. And they’ll exclude, again, that first 24 hours, and if at the end of a patient stay, it was a partial day, they’ll exclude a bit of that last day as well if it’s just a partial day.
So a little more added detail. I hope that helps to really try to understand these measures in more detail.
F: Dr. Messler, an audience member wants to know if the hyperglycemia measures include patients on high-dose steroids.
MESSLER: The denominator, again, is we’re looking at patients that have diabetes that have readings greater than 200. The medication is medications that are lowering blood sugar. Yes, those patients on steroids can wind up hyperglycemic. Then they’ll be in there. But the list of medications will be patients that are receiving insulin or a medication that’s lowering blood sugar. Certainly, if patients on steroids wind up greater than 300, they’ll be in there. But if they’re just on steroids and they never have a greater than 300, and they don’t have diabetes and don’t have a greater than 200, they wouldn’t fall in there.
F: Another audience member would like to know if Glucommander is for both IV and subQ insulin therapies.
MESSLER: Yeah, thanks. Glucommander – here at Glytec, our insulin software, the FDA clearance for – we have an IV Glucommander module, transition IV to subQ, and subQ Glucommander, yes, to help manage basal and mealtime insulin safely.
F: Thanks, Dr. Messler. Another audience member is curious if Glytec can be layered onto an existing EHR system.
MESSLER: Yes. Short answer is yes, that we’re in over 300 hospitals and have sites that are Cerner, Epic, and really various other EMRs. And really to the end user, it appears seamless. We do integrations with EMRs.
F: Great, thank you. We have lots of audience questions, so we’ll try to get through as many as we possibly can. Another audience member would like to know, do the glycemic management eCQM metrics have a goal range – for example, like what percent of the patient days at a certain level is an acceptable percentage?
SCHEURER: That’s a good question that really gets to benchmarking. Because it’s a new measure, we probably won’t have benchmarks until we start reporting. Presumably you’ll have some number that are over 300 and less than 40. Obviously, lower is going to be better. But as far as what is optimal performance, I think that remains to be seen when we have benchmarks.
F: Great. Thanks, Danielle. Go ahead, Dr. Messler.
MESSLER: No, I agree. I think someone else asked will it ultimately be zero would be what we’re aiming for? Sure. That’s going to be difficult to achieve. But yeah, zero would be the goal for both of those. And it is a challenging piece, because you can start trying to look at the literature and see in other studies where they’ve looked at patient stay less than 40 or patient day greater than 300, but it won’t exactly line up with this in terms of within 24 hours of insulin, other aspects of this measurement. So it’ll be very hard to see exactly. You can try to see where you are internally by trying to sort of reconstitute this measure a bit. But yeah, we won’t know benchmarks until they’re reported.
F: Thanks for those responses, you two. Another audience member would like to know if you know why CMS chose 40 mg as their hypoglycemia level versus 50 or 54.
MESSLER: I don’t know that I know specifically why. We know severe hypoglycemia – it’s hard to argue with really reducing severe hypoglycemic events. We know that that really is less than 54 physiologically, ADA definition. Less than 40 really is one associated with those more severe events. I don’t know. Danielle, do you have anything else to add to that?
SCHEURER: Yeah, I agree. I think it’s hard to argue against whether or not 40 is bad. (laughter) When you get higher thresholds, I think you would just get more arguments about whether they are or not tolerating those numbers. But I think 40’s pretty straightforward, and it defines severe.
F: Another viewer asked if a system doesn’t choose these measures, does the data still get reported on Care Compare?
SCHEURER: No, they would not. Again, what most centers do is go ahead and pull all of them, see where they’re performing best, and then they can pick which ones they want to publicly report. But only if you push the button to send to CMS will they end up being publicly reported.
F: There were a couple questions about the implementation, but one audience member would like to hear a little bit more about how hospitals should approach glycemic control in pre-op, intra-op, PACU, and when transferred to the floor.
MESSLER: Yeah, I can begin to answer that. That’s certainly a talk, a paper, a book in itself there. But I think you saw from Danielle the pearls and how they approach it, and that’s where you start. You have a glycemic team and really design some aims for that area of the hospital – really try to understand current state, get those subject-matter experts to understand the guidelines to operate in that space pre-op, peri-op, post-op – or pre-op, intra-op, post-op – and be sure that you have standards to try to reduce variation. So see what current state is, see what the processes are, and begin to think through the different clinical scenarios. You want to have situations – what to do with oral agents, what to do with managing insulin, what to do with shorter procedures, longer procedures, how to manage indications for when to start IV insulin intra-op and how to manage subQ insulin.
So you’re going to want to really go through those steps, like you do a quality improvement project, get that team, get those subject-matter experts, have those clear aims, understand the current state, and then really look through the literature to understand the standards and guide towards that.
F: The next question is somewhat related, so let me know if you feel like you’ve already spoken to it. But it says for large healthcare systems, would you recommend next steps starting at the local level or the system level – for example, collecting data, developing multidisciplinary teams, gap analysis, etc.?
SCHEURER: Yeah, there’s definitely no right or wrong way to do it, but it probably would make sense to develop a team at the system level just to get kind of the basic building blocks in place. And then obviously there’s going to be some nuances at each site. But to really try to standardize that care across sites, I do worry if each site is developing their own program, you’re going to have a lot of inconsistencies and variation in process and outcome across sites. So I would recommend starting at the system level.
F: Thanks, Danielle. Another audience member (audio cuts out; inaudible) how much of the burden is on medical staff, especially for places without residents, for data entry? Can you share an example of a workflow that is successful?
SCHEURER: Yeah, that really gets into one of the slides. It was sort of on the con list of eCQNs. You have to be very mindful of how you build the workflow to get the structured data elements in the medical record so they can be pulled out of the back end. And as best you can, while you’re doing that analysis and build, you want to be very mindful of clinicians’ time and data entry burdens. If there’s any way to offload those to non-clinicians or other disciplines, that is always going to be best-case scenario.
F: Another audience member would like to know what’s the potential impact of crossover use of anti-diabetic agents for other conditions, such as heart failure, on hypoglycemia risk.
MESSLER: I missed a word in there. Can you state that question again?
F: Yeah, this question says what is the potential impact of crossover use of anti-diabetic agents for other conditions, such as heart failure, on hypoglycemia risk?
MESSLER: I would guess – and I’m not entirely clear on the question, but I think you’re referring to that we’ve got newer oral agents in the hospital that are being used for cardiovascular conditions to help prevent heart failure hospitalizations – SGLT2 inhibitors and a lot of literature supporting their use. I think we’ve got to certainly be mindful for new data and new evidence and how to use them. The current ADA guidelines for inpatient management certainly recommend stopping most oral agents, because most of them have contraindications in the hospital – patients with renal failure, liver failure, risk for lactic acidosis in some situations. Even the SGLT2 inhibitors, there’s a risk for euglycemic DKA, risk for dehydration. So there’s a lot of risks that most of our patients that are in the acute setting will have a lot of those risk factors and potential relative contraindications for those oral medications.
I can say briefly for the SGLT2 inhibitors, right now, again, the ADA guidelines recommend holding oral agents, maybe resuming close to discharge, really managing in the non-ICU setting basal-bolus. And if you need them, because the evidence is terrific to help reduce heart failure hospitalizations, other good outcomes, but maybe that’s closer to discharge or soon after discharge, those oral agents get started. But certainly thinking of ways to get those instituted given that they certainly have benefits. But you’re going to have to weigh the risk of knowing that patients, really, with hyperglycemia and many of those other hypoglycemia risk factors benefit from being on basal-bolus insulin.
F: Thanks, Dr. Messler. Yeah, that was great. We have a few minutes left to squeeze in a few more questions. So this audience member would like to know if you could briefly review the impact, if any, of the new guidelines on PPS-exempt hospitals.
MESSLER: I’m not sure I know what PPF-exempt hospitals are. If you’re reporting on CMS measures and eCQMs currently, then you’ll be asked to report them – oh, PPS, Prospective Payment System. If you’re reporting on these eCQMs currently, you’ll be reporting them – I’m not sure of the exemptions that are new because of these measures. Danielle, is there another –
SCHEURER: Yeah, I think the short story is that there’s no requirement for reporting, that it’s more voluntary than required for payment. I do think if the hospital has the infrastructure and resources to report, I think they would benefit. I think their patients would benefit, because obviously you’re going to have more transparency and visibility on the performance of glycemic management, unless you already have an easier way to do it. It obviously wouldn’t affect payment, but it can certainly improve the clinical care of the diabetic patient in your hospital.
F: Great, thank you both. And just know if you feel like something is not clear, we can always follow up via email afterwards as well.
Another audience member wants to know if there is an incentive for big EMR companies to build or push to all sites, or will each site need to engage with a local build?
MESSLER: I’ll defer that one to you, Danielle, on how work with EMRs on creating –
SCHEURER: Yeah, it always sounds really easy and enticing that if you have, say, Epic or Cerner or one of the bigger national companies as an EMR that it seems like you could just take an off-the-shelf build and plop it in, and that almost never works. (laughter) Many times, it’s because our workflows are customized. So as we determine how things are actually happening, instead of changing the way people work, we try to build the EMR to support the clinicians and not the other way around. In my experience, unfortunately, having a big national EMR does not necessarily help with structured workflows or the build or reporting.
F: Thanks, Danielle. And thank you both again. Unfortunately, that is all the time we have today, but I just want to thank Dr. Scheurer and Dr. Messler for the excellent presentation and also Glytec for sponsoring today’s webinar. To learn more about the content presented here today, please check out the resources section on your webinar console. Thank you again for joining us, and we hope you have a wonderful day.
SCHEURER: Thank you.
MESSLER: Thanks, everyone.
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