MPOG Glycemic Management Workgroup

Meeting Minutes

August 13, 2026 | 3:00-4:00 PM EST | Zoom

Meeting Details

Meeting name

Glycemic Management Workgroup

Date / time

August 13, 2026; 3:00-4:00 PM EST

Location

Zoom

Facilitator / chair

Nirav Shah, MPOG

Prepared by

Megan Charette, MPOG

Attendance

Bollini, Mara (WUSTL)

Gonzalez, Marbelia (Dartmouth Health -

Hitchcock)

Shah, Nirav (MPOG)

Buehler, Kate (MPOG)

Henson, Patrick (VUMC)

Wade, Meridith (MPOG)

Calabio, Meilou (MPOG)

Janda, Allison (MPOG)

Wilson, Blake (MyMichigan Health)

Charette, Megan (MPOG)

Kirkham, Kyle (UHN)

Yee, Branden (WUSTL)

Duggan, Beth (University of Alabama at

Birmingham)

Lopacki, Kayla (Trinity)

Georgiadis, Paige (UVM)

Pennington, Bethany (WUSTL)

Meeting Start

Meeting start: 15:00

Agenda

Purpose and proposed framework for the Glycemic Management Workgroup

Current glycemic management measures across MPOG

Proposal to simplify measures while preserving phase-of-care visibility

Review of proposed and released measures: GLU-15, GLU-16, GLU-17, and GLU-18

Data definitions and measure specification considerations

Summary and next steps

Meeting Summary

The Glycemic Management Workgroup reviewed a proposed framework for simplifying and aligning MPOG glycemic

management measures. The discussion focused on consolidating legacy intraoperative and perioperative measures

while preserving phase-of-care visibility, separating monitoring and treatment domains, updating recheck and

treatment intervals, and incorporating recommendations from May 2026 Quality Committee measure reviews and

subspecialty guidance. Participants supported the direction of the framework while identifying specification issues for

further refinement, including PACU glucose checks for patients with diabetes, treatment and recheck timing after

subcutaneous insulin, ASC versus outpatient classification for GLU-17, and dashboard views that distinguish phases

of care and case context.

Discussion by Agenda Topic

1. Purpose and proposed framework for the Glycemic Management Workgroup

Key discussion:

Nirav Shah, MPOG explained that the meeting was intended to consolidate recommendations from the prior

ambulatory glycemic management workgroup, May 2026 measure reviews, and Coordinating Center discussions.

The proposed framework organized measures into two domains: Monitoring and Treatment.

The group supported simplifying the measure set while preserving details about where failures occur across

phases of care.

2. Current glycemic management measures across MPOG

Key discussion:

Nirav Shah, MPOG described the need to simplify existing and newly developed glycemic management measures

and make specification language more consistent.

The group discussed retiring intraoperative-only measures where they overlap with perioperative measures while

retaining phase-of-care information.

3. GLU-15: Appropriate Glycemic Monitoring, Perioperative

Key discussion:

Bethany Pennington, WUSTL asked whether users could identify which phase of care a flag occurred in; Nirav

Shah, MPOG described phase-of-care distribution and case-list detail.

Patrick Henson, VUMC supported hourly-oriented rechecks but noted the need to distinguish monitoring from re-

dosing after subcutaneous insulin.

Blake Wilson, MyMichigan Health asked whether subcutaneous insulin rechecks could be handled without

unintentionally penalizing appropriate care.

Marbelia Gonzalez, Dartmouth Health - Hitchcock clarified that the proposed diabetic-patient trigger required a

preoperative glucose check only and noted her institution asks providers to check every 90 minutes for patients

with diabetes.

Beth Duggan, University of Alabama at Birmingham raised concern that the measure could unintentionally

message that one normal preoperative value is enough for the rest of the perioperative day.

Kyle Kirkham, UHN advocated adding at least one additional check for patients with diabetes, potentially as a

PACU or post-procedure check.

Paige Georgiadis, UVM wrote via chat that she agreed with adding a PACU check for all patients with diabetes

regardless of initial value and that her group also asks for an intraop re-check for diabetic patients with case length

longer than 2 hours.

Kate Buehler, MPOG noted that if PACU time is missing, MPOG may default to anesthesia end, prompting

discussion about whether such cases should be excluded.

Outcome: The proposed GLU-15 specification requires further refinement, coordinating center to revise the measure

specification to include glucose level recheck for diabetic patients in PACU and intraoperatively for cases greater than

2 hours.

4. GLU-16: Hyperglycemia Treatment, Perioperative

Key discussion:

Nirav Shah, MPOG stated that the treatment window was proposed to change from 90 minutes to 60 minutes

based on Dr. Henson’s prior review.

Blake Wilson, MyMichigan Health asked whether removing the outpatient less-than-4-hour exclusion meant

outpatient cases would be included; Nirav Shah, MPOG clarified that GLU-16 would include essentially every case

and overlap with GLU-17.

Cesarean delivery and labor epidural populations were noted as excluded and expected to be discussed

separately through the OB subcommittee.

Outcome: The proposal remained to move treatment from 90 minutes to 60 minutes and remove the outpatient less-

than-4-hour legacy exclusion, with additional refinement expected. The group also noted the value of adding measure-

summary visualizations that allow GLU-16 performance to be reviewed by location or site context.

5. GLU-17: Hyperglycemia Treatment, Outpatient

Key discussion:

Nirav Shah, MPOG asked whether the measure should apply to ambulatory surgical center cases or all outpatient-

class cases.

Beth Duggan, University of Alabama at Birmingham stated that the SAMBA recommendation better fits

freestanding ambulatory surgery centers than long or complex outpatient cases performed in inpatient centers.

Nirav Shah, MPOG proposed modifying GLU-17 from outpatient class to ambulatory surgical center cases; Beth

Duggan, University of Alabama at Birmingham agreed that approach was appropriate.

Blake Wilson, MyMichigan Health noted that this creates different thresholds by location: 180 mg/dL in GLU-16

for hospital outpatient cases and 250 mg/dL in GLU-17 for ASC cases.

Kyle Kirkham, UHN expressed concern that an ASC-only definition may not fit organizations where ambulatory

surgery occurs primarily in full inpatient hospitals.

Beth Duggan, University of Alabama at Birmingham explained that ambulatory-community pushback was driven

largely by short, high-throughput cases such as cataracts, endoscopy, and colonoscopy.

Outcome: The reported next step was to modify GLU-17 toward ASC cases instead of outpatient class while

considering site context and dashboard stratification needs.

6. GLU-18: Hypoglycemia Treatment, Perioperative

Key discussion:

Nirav Shah, MPOG stated that the plan was to implement what Beth Duggan proposed, and the Quality Committee

reviewed in May.

Nirav Shah, MPOG noted that the related hypoglycemia recheck component remains a future consideration, after

focusing first on treatment.

Outcome: No additional questions or comments were raised during this segment.

7. Dashboard visualization and phase-of-care analytics

Key discussion:

Nirav Shah, MPOG described proposed dashboard enhancements including flagged-event distribution, phase-of-

care analysis, time-to-treatment distribution, and case characteristics.

Blake Wilson, MyMichigan Health said the visualization would help because ACQRs and site leads spend

substantial time reviewing failed cases to identify where improvement work should focus.

Bethany Pennington, WUSTL and Mara Bollini, WUSTL wrote via chat that the visualization would be helpful.

Outcome: The visualization approach was positively received, with additional feedback invited after the meeting.

Decisions, Action Items, and Follow-up Items

Topic

Decision / action

Owner

GLU-11

Maintain GLU-11 as

specified through the

2027 P4P/VBR

measurement period.

MPOG / Coordinating

Center

GLU-15 / GLU-16 /

GLU-17 / GLU-18

Refine glucose

measure specifications

with feedback from the

Glycemic Management

Workgroup.

MPOG / Coordinating

Center

GLU-17

Modify GLU-17 to

include ASC cases

instead of outpatient

class, based on

feedback from the

Glycemic Management

Workgroup.

MPOG / Coordinating

Center

Quality Committee

review

Present finalized

measure specifications

to the Quality

Committee.

MPOG / Coordinating

Center

Dashboard release

Build and release

glucose measures to

the Dashboard for site

validation.

MPOG / Coordinating

Center

Glycemic Management

Workgroup

Regroup with the

Glycemic Management

Workgroup for

measure feedback, if

needed.

MPOG / Coordinating

Center

Adjourned

Adjourned: 16:00

Next Meeting

Next meeting date/time: Not specified. The workgroup may be reconvened for measure feedback if needed; otherwise,

follow-up information will be shared by email.

Full Transcript

The transcript below is a cleaned transcript derived from the meeting recording transcript. Timestamps are shown in

HH:MM format from the source transcript. Filler words, repeated words, and obvious transcription artifacts were

removed when doing so improved readability without changing meaning. Chat comments were inserted where they

clearly belonged with the surrounding discussion.

[00:15] Nirav Shah, MPOG: And we'll start in just a minute, another minute. Folks, folks can hear me right, Blake, I know you

could before, but other folks, okay, great, thank you. Oh. All right, let us go ahead and get started. Thank you, everyone. Thank

you for joining, making the time, to participate in our Glycemic Management Workgroup. I think there may be a few other folks

that join in, over the next hour or so, and so, which is totally fine, and so, we may, harken back to things previously, if we need

to reiterate things for folks, as we move on. But, so the… we've got a packed agenda, so I will… I will dive in. We've had a lot

of… very good discussion over the past year or so on Glycemic management. We had two really, really excellent reviews. Dr.

Henson, Dr. Duggan, thank you both for joining as well, today. And as we've thought about, both implementing the results

what was formerly the Ambulatory Glycemic Management Workgroup, and now is the, just, Glycemic Management

Workgroup, implementing the recommendations from that. plus also the measure reviews that we had in May. And also some

thoughts we've had at the Coordinating Center, we, I wanted to basically consolidate all those recommendations, share it

back with the group, see if it resonates with this group, and then, either, finalize, crystallize some of it at one of the upcoming

Quality Committee meetings, or, provide enough direction for us at the Coordinating Center to just… to just go ahead and

move ahead with some of these. So that's the context Of this meeting, which is really to share all that, that consolidated,

perspective with this group, and then figure out what next steps are. So, as we move ahead, what I thought we would do in the

interest of time, I think most folks know each other, there may be some folks that are new, but as… maybe as folks have

comments and thoughts and ideas, if, and as you guys all pipe in, maybe just quickly, introduce yourself at that time, just to

save a little bit of time in the intros. So… Again, I talked a little bit about the purpose, but, specifically the goals for this hour,

or next 55 minutes or so, we wanted to explore this concept of organizing the measures into two core domains into monitoring

and treatment. I know we've talked about that before, talked about it at the measure review back in May, we talked about it at

the previous work groups, so… but I wanted to, like… we wanted to share with you, specifically how that… how that would

look in the context of MPOG measures. We wanted to talk a little bit about consolidating, these… some of our legacy

measures, specifically, anytime we had an intraop and a periop measure, to consolidate that into a single measure, and talk

about our plans to do that. And then we want to make sure that we can… that we… all of this happens in the context of

aligning both with the recommendations from our measure reviewers on the quality committee, during our measure reviews,

and also with, subspecialty recommendations, i.e. SAMBA, the whole purpose for having the, the initial ambulatory Glycemic

management work group. So anyway, so that's what we were thinking, is there… Anything else? Any other… Areas that we

wanted to delve into, anyone on this… on this call wanted to delve into, with the time that we have for this hour. Okay,

awesome. Before we begin, I did want to, provide a quick shout out to Megan Charette. Megan, put all these slides and all

these analysis together, so Megan, thank you, thank you very much. Hope everyone, is ready to dive in. Okay, so just as a bit

of background, we have a bunch of measures, legacy measures, measures that have worked in a variety of different

scenarios, for those in the state of Michigan, from our, Blue Cross Blue Shield incentive programs. Other folks are using it as

part of their quality improvement initiatives. We have, I think, talked about simplifying, and rationalizing a little bit our bundle

of Glycemic measures. And so. And then for those of us at the coordinating center, we've also talked about, on our end. Trying

to make the language more consistent across all the measure specifications, and so that's just, one more perspective or

angle that we have, when it comes to looking at these glycemic management measures. Okay, so specifically, I think I

mentioned some of this before. We wanted to consolidate measures by retiring the intraoperative-only measures, and so we

have measures that look only from anesthesia start to anesthesia end, and then we have measures that look at from pre-op

start to PACU end. And one, one thing that we talked about in the past, but we wanted to bring up again, is we want to

consolidate, these measures into, a single perioperative measure. But not necessarily lose the information about the phase

of care. So still provide details about whether a flag occurred in the pre-op phase, the intra-op phase, or the PACU phase. And

Megan, I think, has put together a really nice mock-up of how that could look, and I'll share that later on. So that's one… one

specific thing. The second thing, again, this probably isn't new information for those that were able to attend the Quality

Committee Meeting or the previous workgroup. We wanted to separate monitoring into treatment into separate measures.

And so the legacy MPOG measure, as many of is both a monitoring and a treatment measure combined. So it looks to see,

within, 90 minutes of a high blood glucose, Did you either recheck or administer insulin? And then we went on later on to

create this new measure on, if you have high blood glucose, did you treat? And so those were overlapping measures. And the

thought is that we could separate the measures into monitoring and treatment, and that would then also enable us to really

expand on the monitoring component, and And Liz, you mentioned this during your review for hypoglycemia, that you would…

you would to see, is rechecking of blood glucose happening at the right intervals for a patient with low blood glucose? also,

obviously, it makes sense to perhaps do that in patients with high blood glucose as well, and we had shared some thoughts

around what we thought appropriate glucose monitoring would be at previous meetings, and so we'll dive into that, but

conceptually, it gives us much more flexibility On making sure monitoring happens, in, in, in all the ways that we want.

Patrick, you had, in your review, brought up this concept of reducing, the timeframe for checking from 90 minutes to 60

minutes. You mentioned that in the concept of treatment. And our thought was to align that with, with monitoring as well. And

so, we'll share, a proposal related to that. And then finally, of course, the last thing we wanted to bring up is, Dr. Dugan's,

approved, proposals around, updating the hypoglycemia measures as well, and so I thought we'd spend a few minutes on

that as well. Okay, so this, I believe, is, the money slide for the hour, and this… going to just let it sit for a few minutes, one,

because it's a busy slide, and also because this is pretty much everything that we're proposing, you know? So what this is

saying is that, I'll just go line by line. So what the first row is saying is that we're going to take our existing GLU-09 and GLU-10

measures. That's… Intraoperative. and perioperative hyperglycemia management. It's the measure that looks at, did you

either recheck an elevated glucose, or did you administer insulin, and turn that into a single new measure Related to did you

monitor, blood glucoses appropriately in patients who had, either high blood glucose or have a history of diabetes? And then

go into a little bit more detail on specifically what we mean with that, but that's… that's the first row. The second row is taking,

the, treatment of high glucose, so… So, if a patient had a high glucose level, did you treat with insulin? And then make two

specific changes. One is, make the treatment time within 60 minutes, that was based on Patrick's review in May, and then

also remove the exclusion for out… for outpatient cases less than 4 hours. And so that's been this, like. exclusion that we had

when we didn't have this ambulatory measure, for blood glucose that was recommended by this group earlier. Now that we

have that measure, and we have some feedback from the group about, the applicability of… of the measure to this… to this

outpatient, class, we thought we would remove the exclusion. Importantly, and I'll bring this up again, We're going to maintain

the existing GLU-11 measure. through this year, mainly for our Michigan sites, because many of our Michigan sites have GLU-

11 as part of their, incentive payment program, so VBR, P4P. So I think that's probably an important point to note for our

Michigan sites. The third row is, to implement the, ambulatory measure for, treatment of hyperglycemia, and that's at a blood

glucose level of 250. That was recommended by this group earlier. That measure is Ready to be published, and may have

already be, or will be very soon, on the dashboard. And this is the treatment of blood glucose greater than 250 within 60

minutes, for outpatient cases. Now, there is a nuance to that, which we'll talk about in a little bit, of outpatient versus the

concept of an ambulatory surgical center patient, and we'll delve into that in a little bit. And then the final row. Here is to

implement, the updates for the, hypoglycemia. Cases. So, blood glucose less than 70, within 30 minutes, treatment, and then

for blood glucose less than 54 within 15 minutes. Before we go into some of those, the specific measures that we've

proposed, any… At a high level, or even at a low detail level, any comments from the group? Bethany, I see your hand up.

[00:27] Bethany Pennington, WUSTL: Yeah.

[00:28] Nirav Shah, MPOG: Hold on one second. Before you comment, does anyone mind if I… am I recording this meeting?

Okay, yes, I am. Thank you. Please, go ahead.

[00:28] Bethany Pennington, WUSTL: Thanks. Hi everyone, Bethany Pennington from WashU Clinical Pharmacist in the

Department of Anesthesiology. First of all, Nirav, this is awesome, I love it. I was just curious, for the ones for GLU-15 and 18,

the periopic combination, I'm assuming it would be, in the raw data, where you would actually identify which phase of care it

occurred? If you wanted to drill down to that detail.

[00:28] Nirav Shah, MPOG: Yeah, yeah, here, let me, let me… Let me just show you… I'm going to…

[00:28] Bethany Pennington, WUSTL: Sorry to jump ahead.

[00:28] Nirav Shah, MPOG: No, no, no, no.

[00:28] Bethany Pennington, WUSTL: can wait.

[00:28] Nirav Shah, MPOG: Yeah, not here. No, this is… so, Let me do one thing here. This was a reminder to me, more than

anything. Okay, so yeah, so this is… this is one way of thinking about it. One is updating the measure summary screen. To be

able to show phase of care, both, in terms of, the, the distribution of the flat cases, what percentage are in each, but also the

raw numbers, and then also to see it on specific, case lists as well. So, whether you, for example, downloaded a measure

case report, or whether you went to a case list here in the reporting tool to be able to look at it both, both, from a visual

perspective, but also into raw details if you were interested in analyzing it further. Does that… Did that answer your question?

Okay.

[00:29] Bethany Pennington, WUSTL: Yeah, thank you, appreciate that.

[00:29] Nirav Shah, MPOG: Alright, thanks. Patrick, and then Blake?

[00:29] Patrick Henson, VUMC: Yeah, thanks. Patrick Henson Vanderbilt. So, the… glucose rechecks, we did advocate for

changing those times, being in more alignment, with a safer, on the hour, which is what I think we're asking our people to do.

The question comes with subcutaneous treatment, so we're going to ask our people to continue to recheck on the hour, but

not re-dose before that 2-hour window, so that's a little bit… I can't remember if we discussed that in the moment, but that

subcutaneous 120-minute recheck is, I think, appropriate from a treatment standpoint. You wouldn't treat before then, but

we're also going to be asking our group to check every hour. Okay, okay. So I don't know if that's a way to work that in here,

and obviously we could parse that out on our side if, as we evaluate, but I think the context might be important there.

[00:30] Nirav Shah, MPOG: Yeah.

[00:30] Patrick Henson, VUMC: Yeah, just curious what other… if anyone else has an opinion. The sub-Q, we're finding it's so

rare that people are using it, but I think we're going to encourage it in some of these cases where insulin drip may not be

appropriate either. I'm just curious.

[00:30] Nirav Shah, MPOG: Yeah. Yeah, I see your… I see your point. So, for you, if someone… if you've given someone sub-Q

insulin, you still want them… is what you're saying? You're still asking them to check every hour, but not re-dose.

[00:31] Patrick Henson, VUMC: I think that's going to be easier for our, quality workflow, too, is just ensuring if people are

getting insulin, that we're checking every hour, and then in that subset of patients getting sub-Q, we would ask them for a little

bit more granularity or nuance there, but yeah, I think splitting that out… so, just throwing that out there, not sure if that works

from a metric perspective, or how that works.

[00:31] Nirav Shah, MPOG: Yeah. Okay, thank you. Blake?

[00:31] Blake Wilson, MyMichigan Health: Yeah, thanks. All this looks great, and I agree with, Patrick. We've had problems,

in the past, because of… some reluctance not to check every hour, so… which has led us to use a lot of IV, insulin rather than

sub-Q insulin. So I don't know if there's a way that we could, essentially, only have that metric essentially require treatment. If

treatment is given, then… a recheck, greater than a specific period of time, so say 90 minutes or, 180 minutes or something

after that first treatment, if it is, sub-Q, maybe doesn't, count towards the measure or gets excluded. The other, question that

I had, if you go back to the original, overall slide of proposed changes, could you just clarify, GLU-16, the exclusion of the

outpatient less than 4-hour?

[00:32] Nirav Shah, MPOG: Yeah,

[00:32] Blake Wilson, MyMichigan Health: Does that mean outpatient cases… less than 4 hours will be included? Does that

mean inpatient cases? Like.

[00:33] Nirav Shah, MPOG: Yeah, yeah.

[00:33] Blake Wilson, MyMichigan Health: There's a couple different ways to, like…

[00:33] Nirav Shah, MPOG: Totally. Yeah.

[00:33] Blake Wilson, MyMichigan Health: To see that.

[00:33] Nirav Shah, MPOG: Totally, yeah, no, it is slightly confusing. So, when we first built this measure, there was feedback,

I think very appropriate feedback, saying, hey, Out… outpatient… for outpatient cases, we have different, standards for

glycemic management, so we… we're not asking folks to… to treat, when a blood glucose necessary was greater than 180. It

may have been 250 or some other number, and so… and so, So we… initially, we were should we just exclude all outpatient

cases? And then folks are well, that's, like. most of the cases. And so, the thought was that if there are, maybe certain

outpatient cases would be more likely, should be more likely to follow these recommendations, 180 treat within, or recheck

within 90 minutes, and the thought is that if it was, a longer or more complex outpatient case, you would want to follow, the

standard Glycemic management algorithms, and, the very blunt Parameter we used for that if… was… was case duration.

[00:34] Blake Wilson, MyMichigan Health: Sure.

[00:34] Nirav Shah, MPOG: And so this is now just removing that very, very blunt parameter, given that it looks protocols,

typically around the country have essentially aligned on, you know. what our updates are for these new measures, which is

blood glucose greater than 180 milligrams per deciliter, and treatment, or within 60 minutes, or monitoring within 60 minutes

as well. So the thought is, we no longer need that exclusion. And also, because we're building this new ambulatory-focused

measure, and so it's more of eliminating, a legacy component of.

[00:35] Blake Wilson, MyMichigan Health: Sure. So, just from my understanding, GLU-16 then would cover only inpatients.

Glucose 17 would cover all outpatients, regardless of duration. Is that correct?

[00:35] Nirav Shah, MPOG: No, no, the thought is that glucose… so there would still be some overlap. Glucose 16 would

essentially be… Every case, and then… and then glucose… 17 would essentially align with the samba. Okay.

[00:35] Blake Wilson, MyMichigan Health: Sure enough.

[00:35] Nirav Shah, MPOG: aligned with the SAMBA recommendation for those that wanted, for those that participate in

SAMBA, for those that want to align with the SAMBA measure.

[00:35] Blake Wilson, MyMichigan Health: Okay. Thanks.

[00:35] Nirav Shah, MPOG: Marbelia?

[00:35] Marbelia Gonzalez, Dartmouth Health - Hitchcock: Okay, let me just print this out. So, I have a question. Glucose

15, when we are monitoring diabetic patients. That means that in the intra-op phase, it's going to fire my… my… my trigger, it's

going to be 60 minutes to recheck, regardless.

[00:36] Nirav Shah, MPOG: No, no, thank you for bringing that up. Yeah, so that is… that is… yeah, that is a great point. So,

the only thing that we're looking at diabetic patients for is, did you check a blood sugar in pre-op?

[00:36] Marbelia Gonzalez, Dartmouth Health - Hitchcock: Okay, so no one… so no one is… none of these measures, it's

going to be, advising the providers to recheck a blood sugar on the diabetic patient that has a normal blood sugar pre-op, but

now we are 2 hours into the case, and it's going to be 3 more hours into the case, and so that's… I want to make sure that that

is what… none of these are going to be looking at those. Okay. Yeah.

[00:36] Nirav Shah, MPOG: Yeah, yeah, we have not, and mainly because when I'm looking at protocols that we… I mean.

Clearly open to feedback, but the thought was that, that, only, that trigger should apply only if you check a blood sugar and a

patient's blood sugar is greater than 180. in terms of, all these other things that you're seeing. If you… if folks have seen or

have protocols for different testing protocols for in diabetic patients, either in intraop or in the PACU, then, we can, can

definitely discuss if it makes sense to add one of those components in, but, we haven't.

[00:37] Marbelia Gonzalez, Dartmouth Health - Hitchcock: at least here, that's what I'm asking people to do, because most

of the times, if I'm asking them to check a glucose impact, which is what I think the metric speaks about. If you check one pre-

op, whatever the result of that is, you're asking also in the metric to… to recheck one in PACU, so… it's okay. I think we… I

think we'll continue to do what we do, which is our… our thing triggers every 90 minutes a check of blood sugar on any

diabetic patient, regardless of what the previous blood sugar was all about. There was… can you go back into your slide for

one second? Okay. And then, in regards to that sub-Q, everyone, 20 minutes, I'm just going to say that it will be… I mean, for

us, it's very difficult to treat hyperglycemia in the OR with sub-Q insulin, just because, it's that little vial that has to travel with

the patient and that everyone forgets in the pre-op area. But, it has those downsides of Oof. How much we really are treating

someone with…

[00:39] Nirav Shah, MPOG: Totally.

[00:39] Marbelia Gonzalez, Dartmouth Health - Hitchcock: queue insulin while we are in the operating room, but it doesn't

really matter. But thank you for the clarification of the…

[00:39] Nirav Shah, MPOG: Yeah, no, it's interesting. I think at Michigan Medicine, we've seen, we have this, dichotomy, if

you're in the ambulatory surgical centers now, we're seeing folks essentially get treated with, sub-Q insulin. But if you're in

the… on the inpatient hospitals, even if you're an outpatient, in an inpatient, then… then you get an insulin infusion. And

that's, that's been interesting to see that. that, difference in practice pattern based on where you're… where you happen…

even… could be the exact same procedure, exact same time, same, still going home. Just, if you're at… on the Hill, you get

insulin infusion. If you're at East Ann Arbor, you get sub-Q insulin.

[00:39] Marbelia Gonzalez, Dartmouth Health - Hitchcock: No, I mean, it's very interesting for us, because I gotta tell you

that our… our EP procedures are all of them outpatients. But, you know. But that's, it could be a 4-hour procedure with a 2-

hour PACU because of growing, checks and all that stuff, so those patients end up being with us for sometimes 7 hours. In the

hospital, it's just that we don't want to admit them. So it's funny how it's considered an outpatient, but we treat them as an

inpatient because there's nothing sleep in them.

[00:40] Nirav Shah, MPOG: Yeah, totally. Thank you. Any other comments before I… before I move on?

[00:40] Beth Duggan, University of Alabama at Birmingham: I don't want to throw a wrench in the system, but… now that

I'm reading these, and you just made that point, it is interesting to me that we are telling people, as long as your patient

landed in pre-op with 178, You have no obligation to treat them for the rest of their perioperative day. I'm sorry, not treat,

check.

[00:41] Nirav Shah, MPOG: Yeah, treat or check, I mean, according to our measures, yeah, both.

[00:41] Beth Duggan, University of Alabama at Birmingham: Right? if you catch them at 180, now you're on the path. But if

you didn't catch them, because we know that blood sugar rises typically in the first 2 hours, right? We know that, especially

after we've given some Decadron, we're helping them out, right? The average type 2 diabetic's blood sugar rises 55 milligrams

per deciliter with a dose of 4 of Decadron that we all give at the beginning of the case before incision. I don't know, I don't

want to throw in a wrench in it, but food for thought, because that is a lot that, we're maybe missing this.

[00:41] Nirav Shah, MPOG: I mean, you are, with these measures, you are going to miss, or let's say you are imposing a major

surgical stress. On a patient. so if you're a non-diabetic. don't have a diagnosis of diabetes, but you have… you're undergoing

major surgery, or, I do a lot of head and neck, where we give 10 milligrams of dexamethasone as standard, essentially, for

many of our cases, and I, I'm we're just going to… and for a freight club, I'm we're just going to check every hour, because I

know at some point. no matter what your diagnosis is, your blood sugar. And so, we are definitely missing some case… some

edge cases, which I believe, over time, we should absolutely address. It gets very hard. You end up getting a lot of false

negatives. That… that's the… the issue that we found. And so, you know. Open to thoughts on whether we should address it

now, or folks are okay with, building in some of this nuance over time as we, first of all, maybe get better at, figuring out, what

are actually the high-risk cases to go after and things that. Patrick?

[00:42] Patrick Henson, VUMC: Yeah, thanks. I have to hop off for a clinical meeting, but I appreciate this, and I'm really

invest… we all are really invested in this work. We've struggled with that very thing as well, so asking, in a diabetic patient

who's normal Glycemic, or in a non-diabetic with hyperglycemia, how frequently should you recheck if you're not treating

them? And I think that 180 threshold is important, it's what's been established here, and as we work back from that, we're

adding a lot of new measures. how to work that nuance in of check if you're diabetic and also recheck at X time interval, when

societies can't really agree on what the proper recheck. So I think if you were using evidence bases, I don't really know what

the strong evidence is for rechecking diabetic or a hyperglycemic patient? Is it every 2 hours? Is it every 4 hours? Is it every

hour? I would imagine Dr. Duggan knows more But we all have suspicions on this, but it's been hard, at least locally, for me to

integrate my suspicions with what everybody else believes, and how we can actually do it. So, just to say that, that definitely

agree with… with those thoughts, and not sure how to, market this and that. But I think these approaches are a great start,

especially as we're integrating a lot of new ideas here.

[00:43] Nirav Shah, MPOG: Yeah, yeah, thank you. Thanks for joining. Yeah, Bethany, My… the way that at least we've

historically done is made sure we get… we put out a measure that we can get broad agreement on. And then, incrementally

over time, ratcheted up the, the, either the threshold or, some components of the measure to make it, cover more and more

scenarios that we want to. So that's what we've done. I don't…

[00:44] Beth Duggan, University of Alabama at Birmingham: That's the wrong thing.

[00:44] Nirav Shah, MPOG: implementation science component, yeah.

[00:44] Beth Duggan, University of Alabama at Birmingham: Yeah, to Patrick's point, we don't… nobody's ever shown us

data, right? We're checking at some frequent interval is more likely to pick up. hyperglycemia or stress hyperglycemia, right?

We're guessing at best. So perhaps the… I guess I'm… the only thing I'm afraid of is we're messaging, check it once and ignore

it. That's the message I don't want us to send. But I think.

[00:45] Nirav Shah, MPOG: Yeah, for diabetic patients that are normal glycemic, and preop.

[00:45] Beth Duggan, University of Alabama at Birmingham: Exactly. Yeah. But I completely agree with you. This is the

opportunity to perhaps find the cases And the types of patients that are highest risk to develop hyperglycemia, whether that's

steroid-related, or certain steroid dose-related, or, is it… patients… I mean, with the GLPs, I mean, everything's changed in

diabetes anyway. these patients that used to be diabetic are not diabetic. So, again, we may… we may learn a whole slew of

things in the next year or two that can guide us into when to check. I mean, maybe this is the group that actually writes the

first paper that says, hey, this is who you should be checking and when you should be checking. Yeah. Because we don't

know. I just think when we message this. We should… we should make sure that it doesn't say… you don't need to check

diabetics in the office. if you didn't detect hyperglycemia the first time around, I think all of the people here are saying they're

just stalled. Yours included says, I know in this type of patient, in this type of case. that's how our cardiac anesthesiology

friends discovered that stress hyperglycemia in non-diabetic patients was a disaster, so… Food for thought. I love your idea.

And maybe the messaging just counts a little bit.

[00:46] Nirav Shah, MPOG: Yeah. I am going to write that down. Okay, yeah, no, I think that makes a lot of sense. Any other…

Kyle.

[00:46] Kyle Kirkham, UHN: I'm just going to push on that a little bit further and say, especially if you're presenting the phases

of care and we're able to drill down and view where these metrics fail. why we don't include at least some second check, in

the patients that come in with a previous diagnosis. And it doesn't have to be necessarily time-based. We could make it

phase of care. You could say you expect a post-procedure glucose check, which I think most centers are probably doing, even

if they're not rechecking in the OR, they're probably doing something to impact you. And… I don't think that would be too

onerous, to the detriment of the metric. And I think that, given that you have the phases of care, it might provide some of that

information that we're talking about in terms of saying, well, where do these patients fail? we can tighten that further over

time, and start to narrow that window. But I think this is the opportunity to put it in there, honestly.

[00:47] Nirav Shah, MPOG: So, so then, how does this sound? If a patient is diabetic, then, they should have at least one blue

blood glucose measured during the PACU phase. Kyle…

[00:48] Kyle Kirkham, UHN: Yeah, I mean, I would advocate for that, I think, and irrespective of what the initial value is,

because, then the time window doesn't matter, so much in between those two checks. you're not going to have a 15-minute

case that's creating a big problem there, but, I think that's a fairly open way of dealing with it.

[00:48] Nirav Shah, MPOG: Okay.

[00:48] Marbelia Gonzalez, Dartmouth Health - Hitchcock: Nirav, you meant intraop, not in PACU. Paige is already in the

measure, correct?

[00:48] Nirav Shah, MPOG: Not… not if you have a diagnosis of diabetes. PACU check is only right now, if you have insulin

administered in the intraoperative phase, did you check at least one blood glucose in the PACU. As it's built right now, as it's

proposed, nothing is built, is all… all words right now. there's nothing about, if you're a diabetic, Check in the PACU.

[00:48] Kyle Kirkham, UHN: Which is why I'm advocating that should be added, because otherwise it's one time, as Beth has

said, and then it's open…

[00:49] Paige Georgiadis, UVM (via chat): I agree with adding a PACU check for all diabetic patients regardless of initial

glucose value.

[00:49] Nirav Shah, MPOG: Yeah.

[00:49] Kyle Kirkham, UHN: Season on however long you're in the hospital, right?

[00:49] Nirav Shah, MPOG: Yeah. So, Beth, is that… would that… would you agree with that?

[00:49] Beth Duggan, University of Alabama at Birmingham: I think it's consistent with a lot of practices, so we're not asking

people to make major changes, which is nice. Yeah, I think that's very reasonable. And frankly, I think… I mean, I know SAMBA

actually, I think, does formally recommend a PACU check, so we're in line with that. Okay. And I think even some of the, the

Brazilian society, the Australian Society, I think they recommend some similar PACU things, so I know those aren't our people

per se, but it's nice to always have other people aligned.

[00:49] Nirav Shah, MPOG: Yeah, it is, yeah, for sure. Marvella, did you have… Was that your question, or did you have

another one.

[00:49] Marbelia Gonzalez, Dartmouth Health - Hitchcock: No, I was just going to say, why it's so important for, at least in

my practice, why it's so important that I continue my provider's checking in the OR, before even reaching PACU, because I

find that the most… sometimes the most difficult part when to treat hyperglycemia of some of my inpatients is PACU,

because then PACU is the land of too many people, where where order sets have not been released yet, because those are

inpatients that are going to go to the floor, where the anesthesia team forgets to put PACU orders for insulin treatment,

because it's not part of what they feel comfortable, because then they leave, and then no one checks. And because PACU

nursing teams sometimes Checks, but forgets. to call someone. So, so, even, we created a PACU order, PACU anesthesia, all

my insulin set, because exactly that's part of the problem. So, if you don't come out of the OR, and then all of a sudden your

blood sugar is 200 in PACU, but no one really knew about it.

[00:51] Paige Georgiadis, UVM (via chat): We also ask for an intraop re-check for any diabetic patients with case length

longer than 2 hours.

[00:51] Marbelia Gonzalez, Dartmouth Health - Hitchcock: Those are the patients that sometimes we miss, and that's the

phase of care that we sometimes have more trouble with. So I think it's an ideal situation.

[00:51] Nirav Shah, MPOG: Okay.

[00:51] Marbelia Gonzalez, Dartmouth Health - Hitchcock: when… when you recheck in the OR, and now you're coming

with a much more clear idea of where's your patient's going to land in PACU, Sometimes.

[00:51] Nirav Shah, MPOG: Okay. Blake?

[00:51] Blake Wilson, MyMichigan Health: Yeah, Blake Wilson, sorry, I didn't say this earlier, my Michigan Health, I agree. I

think PACU can potentially be a blind spot. I also think that, some of these patients who are borderline preoperatively may

deserve a second check in PACU. I guess my question would be how to design that within the metric that doesn't affect our

other metrics. So, my specific concern is, does this, First of all, are we only talking about Phase 1 pack, or are we talking

about Phase 2?

[00:52] Branden Yee, WUSTL (via chat): Given the bulk of some clinicians’ volume may occur in high-throughput ASC (i.e.,

cataracts), are there case durations where we may not want to force a PACU recheck?

[00:52] Blake Wilson, MyMichigan Health: And are we talking about, surgery duration or, duration from, their pre-procedure

check to PACU? Are we going to exclude, a certain short duration cases, potentially. And then the third is, will this impact, or

increase the potential for dose stacking if, in the event of a short case, if they were treated Perhaps, at some point, and then

you're going to… necessitate a PACU check within the 120 minutes, let's say, that they have been treated, either

intraoperatively or preoperatively, and now how are you going to treat that potential high glucose level, say 190, when they've

already received treatment within that 120-minute window. Just a couple of thoughts.

[00:53] Nirav Shah, MPOG: Yeah, I'll just answer the one question you had about PACU Phase 1 or Phase 2, at least from an

MPOG perspective. It would just be, PACU, say, because I don't think we have great visibility across all of PACU into what the

specific phase of care, even though we may have… at some institutions, we may, but not… not widely across all. So that

would… Anyways, I think… I don't know. If we… if we decided to implement the PACU component, it would be, like. didn't

happen across, the entire PACU stay. Marbela?

[00:53] Marbelia Gonzalez, Dartmouth Health - Hitchcock: our, our, PACU order sets have a specific provision that, if your,

if your glucose is above the 180, but it's below the previous one, so then wait another hour before applying a treatment. So,

that's as consistent with… depending on, of course, depending on what insulin was administered. IV, 60 minutes, sub-Q, 120.

So, in that way, they… we avoid nursing stacking insulin, treatment in PACU, but that, that was, that comes from an order

shed, nothing to do with, the metric, Specific.

[00:54] Blake Wilson, MyMichigan Health: Yeah, our, our order set, you know. I've designed them to hopefully avoid that as

well. I just worry about, other, MPOG quality metrics and how that would affect, performance. If… if we were going to require a

recheck and PACU across the board.

[00:54] Kate Buehler, MPOG: Hey, Kate Buehler, Clinical Program Manager for MPOG. The only thing I want to caveat here is

that if a patient doesn't go to PACU, or a PACU, end time is not documented, we will default to just using anesthesia end, and

so I just, you… then I think would have to decide, is it okay if it defaults to intraop? It seems, clinically, that would be fine, but

are you okay for patients that don't go to PACU basically getting, an intraop? Assessment instead.

[00:55] Blake Wilson, MyMichigan Health: Or maybe they get excluded if they don't have those values.

[00:55] Kyle Kirkham, UHN: That'd be another option.

[00:55] Kate Buehler, MPOG: action.

[00:55] Kyle Kirkham, UHN: I would exclude them, personally. It starts to confabulate too many different things.

[00:55] Kate Buehler, MPOG: Totally.

[00:55] Blake Wilson, MyMichigan Health: Gotcha.

[00:55] Nirav Shah, MPOG: Yeah. I think the other thing is if, intraop… if an intraop case is particularly short, if you had a

diabetic patient, saying that you get one in pre-op, saying that you want to pack you, and then you have to have, a 60-minute

case. in… intraop, then, do we also… Want them to, that seems a lot to, and so… there is that consideration as well. I would

meet…

[00:56] Beth Duggan, University of Alabama at Birmingham: I was going to say, it seems we all gravitate a little bit towards

that 2-hour mark, and I think that's because that data, there is… Some small data that says that's when the surgical stress

response starts to… kick in and lead to hyperglycemia. So I… I don't… can you do an either-or metric? I am so sorry, I'm not

very familiar, but…

[00:56] Nirav Shah, MPOG: So, yeah, that's exactly… so this is, we don't always do it, but for this measure, we're let us try

this, this relatively complicated algorithm, yeah.

[00:56] Beth Duggan, University of Alabama at Birmingham: you, you have a check in the PACU for, cases I guess, around

that 2-hour mark. I don't know how to phrase this, and then… and or an intraoperative check for cases greater than 2 hours.

I'm reading the chats and listening, and it feels that might… capture practice not grossly different than what we're doing.

There is a little data for that 2-hour mark. And maybe that offsets… I think to many people's points that blood glucose check,

blood glucose check, and then also, there is a risk of stacking if there's not great communication. Between that intraoperative

and PACU team, and then we're… a little sad. Totally. Because it created a problem.

[00:57] Nirav Shah, MPOG: Yeah, yeah. Honestly, what we found here, because we were pretty bad at the perioperative

glucose measures, and tried to focus on here in Michigan Medicine, is we found that that's where we broke down, those in

transitions of care, and that's… that's… the thing that the teams have been working on is, how do we improve communication

between pre-op nursing, intraoperative team, and PACU nursing, which is a interesting journey for us. Okay, in the interest of

time, this has been awesome. Thanks, thanks. By the way, for folks who looked at the chat, because I missed… I missed

those comments in the chat, so thanks for, thanks for taking a look at that. Okay, if it's okay, I'm going to move on to a couple

more topics in the last 15 minutes or so that we have. I think this one should be, I think, relatively straightforward, and this is

essentially updating our, hyperglycemia treatment measure, and so this is if your blood sugar is greater than 180 milligrams

per deciliter, or 10 millimoles per liter. Do we have anyone from Canada? Thank you, Kelly. Yes, so, are we, treating those with

insulin within 60 minutes? So that went from 90 to 60 minutes, based on a review from Dr. Henson previously, and this is the

one, That we are removing that legacy exclusion, for outpatient cases, less than 4 hours. again. in the measure summary

screens on the reporting tool, I showed, gave you a preview for before, we would indicate, phase of care, for those, that were

interested in, further delving into, where the… where the flags were happening. I know we talked a little bit about this before.

Any… any additional questions, comments, thoughts on this? Excluding the OB population, I believe, caesarean delivery is

labor, I think there's going to be separate discussions on those within the OB subcommittee. Awesome. Just to go back for a

minute to the, visualization that Megan and team, came up with. our thought, not, this happens to be one example, but, for

other measure summary screens as well, we want to provide more information than we do currently. Right now, it's, it's the

trend line, there's the result reasons, which shows, the reasons why a measure may have been flagged, or excluded, or

passed.

[01:00] Bethany Pennington, WUSTL (via chat): This is great! So helpful.

[01:00] Nirav Shah, MPOG: And then there's the benchmarking across all the institutions. And we have a couple of examples

across other measures of additional visualizations on the measure summary screen, but this is what we want to go for, which

is really to provide, the detail that you would need as a quality champion or leader in your In your department, that you could

then share, with the, the boots on the ground and, and other leaders as well about, some of the nuances related to, to, to

quality improvement. So… so this is you know. this is what we came up with. If there… this is also an opportunity for folks, as

you think about this, not just at this meeting, but maybe afterward. if there are additional ways that you would want to see, if

you were designing a glycemic management dashboard, how would you want to see this information? We would love to hear

from you. About ideas. We'll share this slide deck as well with everyone after the meeting, so if you want to stare at this for a

little bit longer, you can, but this is how we were thinking about it. Both show the distribution of flagged events, show, do, a

phase of care analysis. Time to treatment distribution, so we know, we have this, like. threshold of 60 minutes, but, it may be

interesting to see, where a given practice or location lies. Is it different in your cardiovascular center versus your main OR

versus your pediatric or otherwise? And so we wanted to share some of that information with you.

[01:01] Blake Wilson, MyMichigan Health: Nirav, this is, amazing, by the way. I… I love this visualization. And if we can

implement this, this would be fantastic, and it would save so many hours, because a lot of what our ACQRs and myself do is

go back and review failed cases and find out where exactly we failed, and it takes

[01:02] Mara Bollini, WUSTL (via chat): I agree — this is so helpful to have this at your fingertips.

[01:02] Blake Wilson, MyMichigan Health: a lot of time, to figure that out, because that's how we can actually go and direct,

our improvement, projects and that thing, and focus our time. So this, this would be very helpful, and if we can adopt this,

within other metrics, I think this would be great.

[01:02] Nirav Shah, MPOG: Yeah. Yeah, that's our dream. And, I mean, we've spent a lot of time the past couple years, we've

completely rebuilt our QI, the reporting tool, we've, On the processing side, we've made a lot of improvements, we still have

more to go, and it's all… it's we've wanted to do this for a long time. We feel we're at this phase where we can actually at least

for some measures, build it in. And so, yeah, we hope to see, we hope to see more of this. Okay, thank you. Okay, This is the

SAMBA, so it's GLU-17, the hyperglycemia treatment for outpatient cases. I do have… I'll bet the good, you're still on. There's

one specific question I have for you as one of the co-authors for the SAMBA recommendation, and that… and that is, this

notion of Are we going for ambulatory surgical center cases, or are we going for outpatient cases that may occur in our case,

in our cardiovascular center, and in the same location that we do, complex lung surgery. The way that it's built now, it's

outpatient class, which may occur anywhere, but the way… from what I had thought. there was a part of me which I thought

this was only meant… at least more meant for ambulatory surgical centers, and I was hoping to get a little bit of clarification

on that.

[01:04] Beth Duggan, University of Alabama at Birmingham: Okay, I think it's a great question. As a group, we did not clarify

specifically. We had a lot of internal debate around this. Many of the co-authors are spearhead centers that are ambulatory,

freestanding, you don't do inpatient-type procedures there. so, this is just stalts, this is nowhere written, and I just think.

[01:04] Nirav Shah, MPOG: Totally.

[01:04] Beth Duggan, University of Alabama at Birmingham: to behind-the-scenes discussions. Okay. I think this better fits

freestanding ambulatory surgery centers than it does the cases being done in an inpatient center Where the patient is going

home.

[01:04] Nirav Shah, MPOG: Yes.

[01:04] Beth Duggan, University of Alabama at Birmingham: But maybe had, right, a 9-hour EP case. Totally. Different

ballgame. It just all… that is not…

[01:04] Nirav Shah, MPOG: Yeah. I totally agree with that, and I would to propose to this group that we… and it's not a huge

modification on our end, but to modify this from outpatient class, which would mean, yes, that 9-hour EP case is included in

here, to just focusing on cases in ambulatory surgical centers.

[01:05] Beth Duggan, University of Alabama at Birmingham: I think that's totally appropriate, yeah.

[01:05] Nirav Shah, MPOG: Okay. Great. Does anyone have…

[01:05] Blake Wilson, MyMichigan Health: So then, just for clarification, then, is… then Glucose 16, the new proposed GLU-

16, would be a catch-all for all patients… Done at a non-ambulatory surgery center, correct?

[01:05] Nirav Shah, MPOG: So, as it's written right now, glucose, 16 would include essentially every… so they're not… they're

overlapping.

[01:05] Blake Wilson, MyMichigan Health: Yeah.

[01:05] Nirav Shah, MPOG: So, yes, yes. And so that, we would have to see if that ends up causing a problem. The fact that

they're… that they're overlapping. And the reason we did that is because there was some discussion about, well, we… we

apply the same standards to everyone. No matter where they are, and… but there was also this SAMBA measure that we

wanted to make sure that we aligned with as closely as possible. So they are… they are overlapping, so… If that, that… May

cause a problem, yeah.

[01:06] Blake Wilson, MyMichigan Health: So if you're an outpatient procedure in a non-ASC, If we went with the proposed

change here for, GLU-17. We would have two different thresholds. There'd be a 180 if you're done in the hospital, but you're

an outpatient. Whereas if you get done in ASC, then your threshold is 250. Correct. It seems… Seems a little strange to have

the same exact procedure, have two different thresholds for passing.

[01:06] Nirav Shah, MPOG: Yeah, I mean, and to be fair…

[01:06] Blake Wilson, MyMichigan Health: Different standards, I guess.

[01:06] Nirav Shah, MPOG: That's exactly… that is exactly how our protocol at Michigan Medicine is written. If you get. a case

at East Ann Arbor, then it's $250. Same… same… same procedure, same surgeon, same anesthesia provider, different

location, but if you're at or CVC, it's 180. Which I think, I agree, it seems strange from a patient perspective, but, that's how it

is. Kyle and then Beth, I know. animal.

[01:07] Kyle Kirkham, UHN: I know we're getting to the end of time. I have a little concern about the location part of that

conversation, and it's just… our own practice, I suppose, because… Toronto Western and Toronto General, which are part of

the UHN group, neither of those are considered an ambulatory surgical center. Toronto Western does complex spine, neuro,

all of that stuff. It's a full inpatient hospital, but we probably… 50% of our surgical population, maybe 60% is ambulatory in

that center, and that's really where we do all of our ambulatory surgery. We don't have a standalone ambulatory surgical

center. So, if we were to make that distinction, then we would essentially not use GLU17, all of our patient population will be

captured under the other, which I think Isn't really the spirit of what I'm looking at this metric as… I would maybe be okay with

that if the display that we just looked at for phase of care also distinguished between whether a patient was ambulatory or

inpatient in the other metric, so that I could tease out some of that and interpret them differently. I'm not too fussed about the

thresholds. I think we're okay. I mean, we do tend to use the same threshold for all of our patient population, so… this 14

millimoles per liter is… I would be interested in that, but I'm not too worried about it because I prefer the tighter threshold.

But, but I am a little bit worried about them all just being lumped into one catch-all.

[01:09] Nirav Shah, MPOG: Okay, that's good feedback, yep. Pat?

[01:09] Beth Duggan, University of Alabama at Birmingham: I think… just further knowledge on it. A lot of the pushback

from the ambulatory community was cases cataracts, endoscopy, colonoscopy, those 30, 40-minute cases where you're

trying to get a blood… somebody comes in with a blood sugar of 360, and you're trying to get them 180, and you're in this fast

turnover center, and you just get these patients stuck in your PACU. trying to treat them. So I agree with you entirely. I was the

lone pushback voice, I will tell you right now on 250. I still don't love it. I was just do 180 for everyone. But I say this just

because I think the ambulatory community, where they're struggling is not the cases you're mentioning. It's not the big spines,

it's not the colons, it's… it's really these… people that come in for 15- or 20-minute procedures that they really could only

check a blood sugar once, right? And treat once, and then they were really struggling to get a metric that provided some sense

of control. So, no rights or wrongs, but just background, that I agree. I don't think it should be time. It almost feels more, case-

related. what are you having done? Then, where are you having it? Yeah. Kind of thing.

[01:10] Nirav Shah, MPOG: Yeah. And as we look, we do our usual case validation as we go through it, as we see signals of.

flags that shouldn't be happening, at scale, then, as always, we can, we can tweak the inclusion and exclusion criteria.

[01:10] Beth Duggan, University of Alabama at Birmingham: And I actually think this is a fantastic publication, frankly,

right? If you can compare colons here and colons here, and these are at 250 and these are 180, I think you're going to

demonstrate that you have a difference, and I think that really speaks volumes as to how we think as.

[01:10] Nirav Shah, MPOG: Yeah.

[01:10] Beth Duggan, University of Alabama at Birmingham: Outpatient, inpatient.

[01:10] Nirav Shah, MPOG: Yeah, for sure. Okay, So just to show you the variation, which is just stunning, this is, this is at

250. This is, variation in performance at, a blood glucose greater than 250 milligrams per deciliter treatment, with insulin

across MPOG in the last year. It's like… I mean, if this is not right for another study, or eventually a pragmatic clinical trial,

then, I don't know what is. Allison, would you agree with that? Or no? As our pragmatic clinical trial.

[01:11] Allison Janda, MPOG: I mean, this is striking variation. This is, exactly what you used to demonstrate that there's

equipoise here, but I… I don't know if we think there's actually clinical equipoise here. We should be treating it.

[01:11] Nirav Shah, MPOG: But…

[01:11] Allison Janda, MPOG: I.

[01:11] Nirav Shah, MPOG: The majority of the community, yeah.

[01:11] Allison Janda, MPOG: Yeah. I'm sorry.

[01:11] Nirav Shah, MPOG: Yeah, I listened to your lecture this morning.

[01:11] Allison Janda, MPOG: No, thanks.

[01:11] Nirav Shah, MPOG: Okay, so, lastly, I know we're, I know we're very close to time, and, and this is the hypoglycemia

treatment measure that, Beth, you reviewed. So… you know. the plan, obviously, is to implement what you and the Quality

Committee… what you proposed and the Quality Committee reviewed in May, and the main thing that I wanted to share is

that you had talked about this other component of, rechecking, how do we… how should we recheck blood glucose when we

see hypoglycemia? And I just wanted to mention that we haven't… lost sight of that component, but the plan was to focus on

the treatment first over time, see how folks respond to that, and then go back and look at, what should the appropriate

recheck algorithm be? That's still on the slate. Any questions or comments on this? Okay, great. Okay, so I think we've got our

time. From Next Steps perspective, as I mentioned before, I want to reiterate this, the Michigan sites will maintain GLU-11 as

is. We will, based on the discussions we will have had here, we'll refine, the specifications, send them out to folks. Talked a

little bit about, the ambulatory surgical center cases. Kyle, with your feedback about being able to slice and dice location, so,

take that into account. I do… we do need to share some of this back with the broader quality committee and let them know

what we've discussed. And then we'll also come back with the… as we internalize as well and discuss at the Coordinating

Center, come back with the… a plan for, building and validation and release, and I hope that we don't need to schedule

another meeting for this group, but if we do, we definitely will, but we'll… in the meantime, if there's ad hoc information that

we need to share. Across this group, we'll make sure we send it via email. Any final comments or thoughts on anyone before

we sign off? Okay, guys, thank you guys very much for joining. Appreciate it. Take care, everyone.

[01:14] Mara Bollini, WUSTL: Thank you.

[01:14] Kyle Kirkham, UHN: Take care.