HH-Hyper 24-Hour (dayPeriod) Evaluation

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for your question regarding CMS871v4: Hospital Harm - Severe Hyperglycemia. For this measure, hospital days are not defined on a calendar (midnight-to-midnight) basis. Rather, they are defined as full 24-hour periods beginning at the start of the hospitalization period (including emergency department and observation). Only complete 24-hour periods are included as eligible hospital days. If the final day before discharge is less than the full 24 hours, it is not considered an eligible hospital day. For example, if a patient is discharged at the 23rd-hour and 59th-minute mark of a day, then that day is not considered to be a full 24 hours and will not be considered an eligible hospital day for evaluation by the measure observations.

      To illustrate how this measure calculates hospital days, we have outlined each of your scenarios in a table attached below. In the assessments provided below, we have assumed that each encounter has met the initial population/denominator and numerator criteria and has not met the denominator/numerator exclusions criteria.

      Scenario 1: You are correct that measure observation 2 would return zero (0) hyperglycemic event days, as the measure does not consider day index 1 or day index 2 to be eligible hospital days. See "CQM-8431_Table1.png".

      Scenario 2: Measure observation 2 would return three (3) hyperglycemic event days (eligible days 1, 2, and 3). See "CQM-8431_Table2.png".

      Scenario 3: Measure observation 2 would return one (1) hyperglycemic event day (eligible day 1). Because the glucose test results on January 3 and January 4 both fall on day index 3, which the measure does not consider to be an eligible day, day index 3 is not a hyperglycemic event day. See "CQM-8431_Table3.png".
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      Thank you for your question regarding CMS871v4: Hospital Harm - Severe Hyperglycemia. For this measure, hospital days are not defined on a calendar (midnight-to-midnight) basis. Rather, they are defined as full 24-hour periods beginning at the start of the hospitalization period (including emergency department and observation). Only complete 24-hour periods are included as eligible hospital days. If the final day before discharge is less than the full 24 hours, it is not considered an eligible hospital day. For example, if a patient is discharged at the 23rd-hour and 59th-minute mark of a day, then that day is not considered to be a full 24 hours and will not be considered an eligible hospital day for evaluation by the measure observations. To illustrate how this measure calculates hospital days, we have outlined each of your scenarios in a table attached below. In the assessments provided below, we have assumed that each encounter has met the initial population/denominator and numerator criteria and has not met the denominator/numerator exclusions criteria. Scenario 1: You are correct that measure observation 2 would return zero (0) hyperglycemic event days, as the measure does not consider day index 1 or day index 2 to be eligible hospital days. See " CQM-8431 _Table1.png". Scenario 2: Measure observation 2 would return three (3) hyperglycemic event days (eligible days 1, 2, and 3). See " CQM-8431 _Table2.png". Scenario 3: Measure observation 2 would return one (1) hyperglycemic event day (eligible day 1). Because the glucose test results on January 3 and January 4 both fall on day index 3, which the measure does not consider to be an eligible day, day index 3 is not a hyperglycemic event day. See " CQM-8431 _Table3.png".
    • CMS0871v4

      Based on Jira CQM-5421, we understand that for the Days in Period calculation, the final minute of a 24-hour period is excluded, resulting in a day being defined as 23 hours and 59 minutes. However, if the LAST day of a hospitalization reaches the 23 hours and 59 minute mark, would that still be considered a full “day”?

      Please review the examples below and let us know whether we are calculating hyperglycemic days correctly.

      Example #1:
      Patient hospitalization is 1/1/2025 @ 11:11 am to 1/3/2025 @ 11:10
      Glucose Test result of > 300 mg/dL is documented on 1/2/2025 @ 22:46
      We currently calculate the days as:
      Day 1 1/1/2025 11:11 - 1/2/2025 11:10 - excluded (first day)
      Day 2 1/2/2025 11:11 - 1/3/2025 11:10 
      Measure observation 2 is 0, correct?

      We expect Day 1 to be excluded. Should Day 2 not be considered a hyperglycemic event because, although a “day” is defined as 23 hours and 59 minutes, the final/last day of the encounter does not represent a full 24-hour period and ends one minute short?

      Example #2 
      Patient hospitalization is 1/01/2025 @ 10:12 am to 1/06/2025 @ 20:00
      Day 1 1/1/2025 10:12 - 1/2/2025 10:11 - Skipped
      Day 2 1/2/2025 10:12 - 1/3/2025 10:11 - eligible
      Day 3 1/3/2025 10:12 - 1/4/2025 10:11 - eligible
      Glucose Test result 1. > 300 mg/dL is documented on 1/02/2025 @ 16:00
      Glucose Test result 2. > 300 mg/dL is documented on 1/03/2025 @ 10:12 am
      Measure Observation 2 equals 2

      Example #3
      Patient hospitalization is 1/01/2025 @ 10:12 am to 1/04/2025 @ 10:11 am
      Day 1 1/1/2025 10:12 - 1/2/2025 10:11 - Skipped
      Day 2 1/2/2025 10:12 - 1/3/2025 10:11 - eligible
      Day 3 1/3/2025 10:12 - 1/4/2025 10:11 - eligible but excluded because it is NOT a full 24 hours
      Glucose Test result 1. > 300 mg/dL is documented on 1/02/2025 @ 16:00
      Glucose Test result 2. > 300 mg/dL is documented on 1/03/2025 @ 10:12 am
      Glucose Test result 3. > 300 mg/dL is documented on 1/04/2025 @ 10:11 am
      Measure Observation 2 equals 2 because glucose test result #3 was documented at 10:11 a.m. and does not represent a full 24-hour period. Therefore, result #3 is considered the second result for Day 3, and only one event is counted per day. Is this correct?

        1. CQM-8431_Table3.png
          CQM-8431_Table3.png
          33 kB
        2. CQM-8431_Table2.png
          CQM-8431_Table2.png
          45 kB
        3. CQM-8431_Table1.png
          CQM-8431_Table1.png
          20 kB

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Talisa Williams
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              Updated:
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