Contributor: CMS Has Decided to Put Its Muscle Behind Glycemic Management—Why Now?

CMS recently completed its annual update of payment policies and rates for hospitals and long-term care facilities and outlined new rules for the upcoming fiscal year. This included revisions to the Hospital Inpatient Quality-Reporting (IQR) Program, which requires health care facilities to capture and report electronic clinical quality measures (eCQMs), with the goal of “driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care.”

CMS introduced 3 new eCQM metrics this year, 2 of which are reporting requirements for glycemic management. The first rule requires reporting rates of severe hyperglycemia during a hospital stay and the second mandates data on patients experiencing severe hypoglycemia, which is intended to identify preventable medication-induced hypoglycemia. These new rules are significant because this is not a small problem. One-third of all hospitalized patients—not just the 34 million Americans living with diabetes and 84 million with prediabetes—require insulin therapy to regulate high blood sugar during their stay.

This is a striking development for health systems because CMS has thrust glycemic management into the spotlight as an indicator of patient safety. The eCQM reporting data will be publicly available, therefore anyone can access the information and compare how each hospital manages its patient safety. These new rules signal a strong commitment from CMS to shine a light on this often-overlooked area of inpatient care.

The question is, why now?

Decades in the Making

The American Diabetes Association (ADA) and glycemic management leaders have long known and spoken of the dangers of inadequate glycemic management in the hospital, and until now it has often been low on the list of priorities. But the environment is changing and the mountain of data and research highlighting the impact of poor glycemic management has become too large to ignore. In addition, as CMS pushes the industry towards value-based care and more shared risk, the financial costs of untreated or poorly treated hyperglycemia are also getting more attention.

Decades of clinical research has shown that optimal glycemic management in the hospital positively impacts patient outcomes. Lower rates of hyperglycemia and hypoglycemia improve rates of mortality and morbidity, reduce lengths of stay, readmissions, and costs of care. Poor glucose control leads to patient stays that are up to 3 days longer than those with effectively managed hyperglycemia. In addition, a single episode of severe hypoglycemia can cost a hospital up to $10,000.

This cuts across disease states, reasons for admission, and impacts every hospital department. Hyperglycemia is not only a concern for patients with diabetes, as it oftentimes occurs in patients after surgery as a result of a complex pathophysiology and the body’s response to stress. This can be worsened by the fact that hundreds of medications affect blood glucose levels. For example, steroids – like dexamethasone, one of the most common treatments for COVID-19 – are known to cause insulin resistance.

The Complexities of Addressing the Problem

The reality is change management can be difficult and a lack of standardization across the health care industry is a challenge. The ADA recommends using written or computerized dosing protocols for care in the hospital that allow for predefined adjustments in insulin dosage based on glycemic fluctuations. Algorithmic insulin dosing decision support has been on the market since 2006 but has not been as widely adopted as it should have been. Properly managing blood glucose is complex and needs to be personalized for every patient based on their insulin sensitivity, caloric intake, and a number of other fluctuating patient-specific factors. As a result, most hospitals struggle to adequately manage their patients’ blood sugars given their reliance on manual or simplistic protocols.

Across the 6000 hospitals in the United States, many clinicians still calculate insulin doses manually, using tools like paper protocols or digitized calculators built into electronic medical records that are simple but cannot provide personalized recommendations for each patient. These protocols require multiple steps or calculations, which often lead to dosing errors. These methods are a big part of the reason that insulin is involved in 16.3% of medication error reports for high-alert medications in acute care settings, more than any other medication type.

Another common issue with insulin dosing in the hospital is the over reliance on sliding scale alone to manage insulin dosing. This is simple to implement but is a reactive approach that may contribute to more hyperglycemia and hypoglycemia, and has never been shown to effectively achieve optimal outcomes.

Answering the Call

These new CMS glycemic management measures finally answer the calls the ADA and others like National Quality Forum (NQF) have been making for 2 decades to hold hospitals to the standards of care for glycemic management. Currently, nearly one-third of all hospitals have no glucose management metrics and 59% do not have an automated method of pulling data on rates of hyperglycemia and hypoglycemia. These new measures will uncover rates of key glycemic outcomes that hospitals weren’t aware of, or lacked comparisons to, in order to understand whether their rates were good or bad. Hospital leadership will be forced to implement solutions to improve glycemic management and develop a standardized approach to the management of diabetes and hyperglycemia in the hospital.

With these 2 new CMS measures, hospitals will finally be incentivized to prioritize glycemic management initiatives, overcome the challenges of optimal glycemic management, and improve value to improve patient safety and reduce costs.