MPOG Cardiac Subcommittee Minutes 10.05.2026

Cardiac Anesthesia Subcommittee Minutes

October 05, 2026

3:00pm – 4:00pm EST

Zoom

Attendance:

Atwood, Tammy (Henry Ford Health)

Kertai, Miklos (Vanderbilt Health)

Bardia, Amit (Mass General Brigham)

Malenfant, Tiffany (MPOG)

Billings, Josh (Vanderbilt Health)

Mathis, Mike (University of Michigan Health - Michigan Medicine)

Buehler, Kate (MPOG)

McCaughan, Michael (University of Michigan Health-Sparrow Lansing)

Calabio, Mei (MPOG)

McKinney, Emily (Trinity)

Cassidy, Ruth (MPOG)

Negele, Judy (Trinity Health)

Charette, Megan (MPOG)

Notorianni, Andrew (Yale New Haven Health)

Claybaugh, Deborah (MyMichigan Medical Center Midland)

O'Dell, Diana (MPOG)

Coleman, Rob (MPOG)

Pantis, Rebecca (MPOG)

Delhey, Leanna (MPOG)

Pennington, Bethany (BJC Healthcare)

Deporre, Alex (Henry Ford Health)

Riggar, Ronnie (MPOG)

Foster, Julie (MyMichigan Health)

Rolfzen, Megan (University of Michigan Health)

Geube, Mariya (Cleveland Clinic Health System)

Sarwar, Aqsa (MPOG)

Goatley, Jackie (University of Michigan Health)

Schonberger, Rob (Yale New Haven Health)

Grewal, Ashanpreet (Ashan) (University of Maryland)

Shah, Nirav (University of Michigan Health)

Heiter, Jerri (Trinity Health)

Szymanski-Bogart, Brooke (MPOG)

Janda, Allison (University of Michigan Health)

Zittleman, Andrew (MPOG)

Meeting Start: 1503

1. Agenda

a. Welcome & Announcements

b. GLU-06-C Measure Review

c. GLU-08-C Measure Review

d. GLU-07-C Measure Review

e. GLU-14-C Updates and Preliminary Performance

2. Announcements

• New members are welcome to join the Cardiac Anesthesia Subcommittee. Interested colleagues

may contact Allison Janda or Megan Charette to be added to Basecamp announcements and the

meeting invitation listserv.

• Volunteers are needed to review ABX-02, ABX-03, ABX-04, and the ABX-05 composite measure for

the next meeting, anticipated in March 2027. The reviews will likely be divided among two or three

reviewers.

• The MPOG Retreat will be held Friday, October 16, in conjunction with the ASA meeting in San Diego,

with in-person and virtual attendance options. The Cardiac Anesthesia Subcommittee will provide

an update on work completed since the previous retreat.

• Amit Bardia and Mike Mathis introduced the proposed VANISH AKI comparative-effectiveness trial of

norepinephrine versus vasopressin infusion, with acute kidney injury as the primary endpoint. The

PCORI letter of intent was accepted, and the team is developing the protocol and site survey.

o The proposed trial is expected to include 16 to 18 sites and approximately 3,700

participants, with a recruitment goal of approximately 60 participants per site per year. The

team will seek sites for study design, trial participation, advisory roles, and patient-partner

engagement.

o A one- to two-page protocol summary will be shared after preliminary advisory-board

feedback and sent to potential sites for further discussions and interest in participation in

the trial should it be funded. The proposal has a soft deadline of December 21 and a hard

deadline of January 11, so the VANISH-AKI study team will be reaching out soon to potential

sites with more information.

3. GLU-06-C Discussion

Reviewer: Joshua Billings, MD, MSc (Vanderbilt University)

Review Document: MPOG Measure Review Template - GLU-06 - Google Docs

Background

GLU-06-C evaluates the percentage of adult patients undergoing an open cardiac procedure whose

intraoperative blood glucose values do not exceed 180 mg/dL. Cases pass when glucose remains below the

threshold and are flagged when a value exceeds 180 mg/dL or when no glucose value is documented. The

assessment period extends from anesthesia start through 30 minutes after anesthesia end. The measure is

intended to support perioperative euglycemia because both significant hyperglycemia and hypoglycemia are

associated with poor outcomes and to encourage anticipatory glucose management rather than a reactive

response after hyperglycemia occurs.

Discussion

The reviewer initially proposed extending the recheck window from 30 to 60 minutes because glucose

monitoring and insulin-infusion adjustments are commonly performed hourly. The group clarified that the 30-

minute recheck is not intended to assess whether insulin treatment lowered the glucose. It is a confirmatory

check used to determine whether an elevated result was erroneous, such as a specimen affected by

dextrose administration or line contamination. A true glucose value above 180 mg/dL remains a flagged

result. The group agreed that the current wording could be misinterpreted as expecting treatment to reduce

glucose below 180 mg/dL within 30 minutes, which could encourage overly aggressive insulin dosing.

Reviewer Recommendations

Retain the 30-minute recheck window, but revise the measure language to identify the repeat value as a

confirmatory recheck used to verify whether the initial elevated glucose was accurate or erroneous. The

revised text should make clear that the measure does not expect a true hyperglycemic value to fall below 180

mg/dL within 30 minutes as a treatment response. The reviewer agreed to review the revised wording.

Vote:

The modification vote was 82% Modify, 18% Continue as is, and 0% Retire.

4. GLU-08-C Discussion

Reviewer: Joshua Billings, MD, MSc (Vanderbilt University)

Review Document: MPOG Measure Review Template - GLU-08 - Google Docs

Background

GLU-08-C evaluates whether hyperglycemia was addressed during an open cardiac procedure. When a

blood glucose value is greater than 180 mg/dL, the case meets the measure when insulin is administered,

regardless of dose or route, or when a repeat glucose within 30 minutes is less than 180 mg/dL and confirms

that the initial elevated value was inaccurate. The measure assesses whether treatment occurred, not

whether insulin successfully reduced the glucose below 180 mg/dL.

Discussion

The reviewer supported retaining the measure and its broad treatment definition across different practices,

including subcutaneous insulin, intravenous insulin, an infusion, or a bolus. The discussion focused on the

purpose of the 30-minute recheck. Participants agreed that the recheck is intended to identify a spurious

elevated value, not to evaluate whether insulin treatment returned the glucose to the target range within 30

minutes. They also identified comparison-sign errors in the attribution language and agreed that values at the

threshold should be represented with greater-than-or-equal-to signs.

Reviewer Recommendations

Clarify the measure language so the 30-minute repeat glucose is described as a confirmatory recheck for a

potentially inaccurate initial value and does not imply a change to usual insulin-titration or glucose-

monitoring intervals. Correct the comparison signs in the attribution language to greater than or equal to, and

make the corresponding measure-specification and coding changes.

Vote:

The modification vote was 90% Modify, 10% Continue as is, and 0% Retire.

5. GLU-07-C Discussion

Reviewer: Robert Schonberger, MD, MHCDS (Yale University)

Review Document: MPOG Measure Review Template - GLU-07 - Google Docs

Background

GLU-07-C evaluates hypoglycemia management for adult patients undergoing an open cardiac procedure. A

case meets the measure when the lowest intraoperative blood glucose remains at or above 70 mg/dL, or

when a glucose value below 70 mg/dL is rechecked within 15 minutes and the repeat value is at or above 70

mg/dL, indicating that the initial low result was inaccurate. The assessment period extends from anesthesia

start through 15 minutes after anesthesia end. Cases with no documented blood glucose value are also

flagged. The reviewer found the measure rationale, inclusions, exclusions, and definitions appropriate and

identified a 2025 American Diabetes Association standard of care to add to the references.

Discussion

The discussion focused on whether the 15-minute recheck could be interpreted as an interval for evaluating

treatment or as a confirmatory check for a potentially erroneous low value. The group clarified that the

measure is intended to identify true hypoglycemia by promptly verifying whether the initial value was

accurate. A longer interval could allow a treatment effect to influence the repeat value and make the intent

less clear. Participants also raised the practical concern that a laboratory blood gas and glucose result may

take more than 15 minutes. The group agreed that the wording should distinguish a confirmatory or verified

glucose recheck from a treatment-response recheck. A separate concern about refining the cardiac and

cardiothoracic case phenotype was noted, but the reviewer stated that this issue was not directly part of the

measure itself.

Reviewer Recommendations

Retain the 15-minute recheck window and revise the measure language to state clearly that the repeat

glucose is a confirmatory or verified recheck used to determine whether the initial low value was accurate.

Add the 2025 American Diabetes Association standard of care to the references. The reviewer changed the

recommendation from Continue as is to Modify so the wording would be consistent with the other glucose

measures.

Vote:

The modification vote was 100% Modify, 0% Continue as is, and 0% Retire.

Additional Discussion: The group briefly considered creating a cardiac measure to assess whether

hypoglycemia was treated, similar to a non-cardiac measure. Participants noted that hypoglycemia case

counts are low and questioned whether a separate measure would add enough value to justify the

programming and review burden. No decision was made to develop an additional measure.

6. New Measure: GLU-14-C Performance

GLU-14-C evaluates successful treatment of hyperglycemia by the end of an open cardiac procedure. The

measure identifies the percentage of adult patients whose last intraoperative blood glucose value before

anesthesia end is less than 180 mg/dL. Unlike the 30- or 60-minute intervals discussed for other glucose

measures, GLU-14-C does not require treatment success within a specified interval; it assesses whether the

final intraoperative glucose is below 180 mg/dL. The group noted that hyperglycemia most often occurs when

a patient presents with an elevated glucose or develops hyperglycemia during bypass. A late first elevated

value could limit the time available for treatment, although this was described as unlikely based on prior

case reviews. Overall performance showed that most patients had a final glucose below 180 mg/dL. The

measure was proposed by Ashan Grewal earlier in the spring and released in June.

• Sites were asked to review their individual data and report anything that appears incorrect or

unusual. Updates may be made as needed rather than waiting for the routine three-year review.

7. Measure Review Process

Measures are reviewed at least every three years to determine whether they should continue as written, be

modified, or be retired. The group noted the value of detailed reviewer and subcommittee discussion,

particularly because the current review identified unclear language about whether glucose recheck windows

were intended to confirm an erroneous value or assess treatment response. Sites may report typographical

errors, unexpected data, or other concerns when identified; updates can be made between scheduled

reviews when needed.

8. Upcoming Cardiac-Focused Measure Reviews

The next Cardiac Anesthesia Subcommittee meeting is planned for March 2027. The group will review ABX-

02, ABX-03, ABX-04, and the ABX-05 composite measure. The reviews are expected to be divided among two

or three volunteers. The anticipated 2027 meeting schedule includes meetings in March, July, and November.

9. Cardiac Anesthesia Subcommittee Membership

New members are welcome to join the Cardiac Anesthesia Subcommittee. Members were encouraged to

invite interested colleagues from their own or other institutions. Allison Janda or Megan Charette can add

interested participants to Basecamp announcements and the meeting invitation listserv.

10. Summary and Next Steps

• The group agreed to revise GLU-06-C, GLU-07-C, and GLU-08-C to clarify that the specified repeat

glucose checks are confirmatory checks used to determine whether an initial value was accurate or

erroneous, rather than intervals for assessing treatment response.

• GLU-08-C will also be corrected so the attribution language and corresponding specifications use

greater-than-or-equal-to signs. Revised wording will be shared with the measure reviewers for

review.

• The next meeting is planned for March 2027 and will focus on the antibiotic measures. Volunteers

interested in reviewing ABX-02, ABX-03, ABX-04, or the ABX-05 composite were asked to contact the

subcommittee leadership.

Meeting adjourned: 1606

MPOG Cardiac Anesthesia Subcommittee

Cleaned Transcript

October 5, 2026

Welcome & Announcements

Allison Janda [University of Michigan Health]: I’d like to kick off the October 5 MPOG Cardiac

Anesthesia Subcommittee meeting. I apologize for being a few minutes late, and thank you for your

patience. Today, we’re going to discuss a few announcements and then review three measures. We are

reviewing glucose 06, 08, and then 07 because the reviewer for glucose 06 and 08 is the same person.

Thank you, Dr. Billings. Glucose 07 was reviewed by Dr. Schonberger. The numbers are out of order so

that we can address each presenter’s measures together. We’ll then review updates and preliminary

performance reports for glucose 14, the measure Dr. Grewal proposed a few months ago, followed by a

summary and next steps. By way of introduction, I’m the chair of the Cardiac Anesthesia

Subcommittee, and Ashan Grewal is the vice chair, a role he began earlier this year. Megan Charette is

the QI specialist who has been leading this work from the MPOG Coordinating Center and quality

perspective. She helped generate these slides, so thank you. Thanks to everyone joining from the

participating sites. We have many people who attend these calls periodically, so if this is your first call,

welcome. We’re glad you could join us. We have a few announcements. At the end of this slide, I’ll hand

it over to Dr. Bardia, who will share updates about a new proposed study. First, if you have colleagues at

your institution or elsewhere who would like to join the subcommittee, please let Megan and me know.

We’re happy to add them to the Basecamp announcements and our meeting invitation listserv. We are

also seeking volunteers for our next group of measure reviews. We review measures every three years

as part of the overall quality assessment to determine whether they should be revised, modified,

retired, or continued as is. The next group will be reviewed at our next meeting, likely in March, and will

include ABX-02, ABX-03, ABX-04, and the composite measure ABX-05. We will likely divide these

reviews among two or three people. Please reach out if you are interested. We acknowledge measure

reviewers on our website and thank everyone who has reviewed measures so far. We will discuss these

measures at the next meeting and will involve the reviewers earlier than we did last time. Sorry, Rob and

Josh. We’ll make sure to find a date that works well for everyone. Another announcement is that the

MPOG Retreat is coming up on Friday, October 16, in conjunction with the ASA meeting in San Diego.

You can use the link embedded in these slides to register for in-person or virtual attendance. I will

provide a brief update on the Cardiac Subcommittee’s work since the last MPOG Retreat, and the other

committees will also give updates during that session. The additional programming looks exciting. Our

final announcement is an overview and introduction to the VANISH AKI study proposed by Amit Bardia

and Mike Mathis. I’ll hand it over to Amit to provide an overview of the grant and keep the group informed

and engaged as needed.

Amit Bardia [Mass General Brigham]: I’m Amit from Mass General Brigham, and I’m excited that we

are proposing the VANISH AKI trial. It is currently at the PCORI grant application stage. The letter of

intent has been accepted. Through this trial mechanism, we are trying to address an everyday question

in the operating room: When blood pressure decreases, should we start a norepinephrine infusion or a

vasopressin infusion? This is a comparative-effectiveness trial, and our primary endpoint is AKI. The

inspiration for the trial is the VANCS trial, which was published in the mid-2010s. It was a single-center

trial that showed a remarkable reduction in AKI among patients who received vasopressin compared

with norepinephrine.

[Via Chat] Michael Mathis [University of Michigan Health - Michigan Medicine]:

https://pubmed.ncbi.nlm.nih.gov/27841822/.

Amit Bardia [Mass General Brigham]: To determine whether those results can be replicated on a much

larger scale, we want to conduct this trial. As I mentioned, the letter of intent has been accepted. We

are now drafting the basic protocol outline and reaching out to patient partners who are helping us

define the outcomes that matter to them as part of the PCORI trial mechanism. Soon, we will contact

sites that may be interested in joining us and helping address this question. We will send a flyer with

basic information about the trial. We are aiming for 16 to 18 sites. Based on our power analysis, this will

be a very large trial—one of the largest in cardiac surgery—with about 3,700 participants. Our

recruitment goal will be approximately 60 participants per site per year. We are finalizing surveys to

determine site fit and understand each site’s practices. There are many understated political factors

unique to each site. Some clinicians may strongly prefer norepinephrine and may not want vasopressin

used at their site, while other sites may use phenylephrine as their primary vasopressor. Those factors

are unique to each site, and we would like to understand them. The survey will be distributed soon. If

you are interested, please feel free to email me, Mike, or Allison. I’ll put my email in the chat. We would

love for you to stay engaged in this trial. Mike, do you have anything to add?

Michael Mathis [University of Michigan Health - Michigan Medicine]: More details will be

forthcoming. It’s an ambitious trial, but we’ve done ambitious things within MPOG before with THRIVE,

VEGA-2, and other PCORI- and NIH-funded studies. I should also mention InteropOx, with Josh on the

call. We’ve learned a lot about how MPOG infrastructure can be used for different types of trials,

including cluster-randomized and individually randomized trials, as well as studies involving different

funding agencies. We’ve also learned how to overcome logistical, regulatory, and political hurdles to do

great work. PCORI has accepted the letter of intent. One benefit of MPOG is access to historical data.

Through an honest-broker process, we can already determine, to some extent, which sites primarily use

which vasopressors. We will contact sites that may be interested in participating in the research or

helping design the study, sites that may perform the trial, and people who may serve on the study

advisory board or help identify patient partners. We are excited, and Amit, hats off to you for the work

you’ve already done to move the full proposal forward.

Amit Bardia [Mass General Brigham]: It's totally a team effort. I'm excited that our team continues to

grow, and I'm really excited that I'm sure that a lot of sites would be interested in addressing this

question.

Allison Janda [University of Michigan Health]: It is very exciting work and we wanted to just make an

announcement about it at this meeting since it pertains to the interests of a lot of people on this call in

the cardiac cohort. Dr. Billings.

Josh Billings [Vanderbilt Health]: Would you have a skeleton of the protocol, or at least how these two

different infusions are used during surgery that we could look at as we consider interest?

Michael Mathis [University of Michigan Health - Michigan Medicine]: We are putting that together

now. We want preliminary feedback from an advisory board of surgeons, nephrologists, and cardiac

anesthesiologists. We want at least a rough idea of what is most likely to succeed across the greatest

number of MPOG sites. We’ll send a one- to two-page summary of a flexible protocol that will remain a

moving target as we develop the full proposal. We should be sending that out shortly, and the team is

working on it now.

Amit Bardia [Mass General Brigham]: The focus is generalizability and it being pragmatic, so that if we

get any result, it can be deployed rapidly across centers.

Allison Janda [University of Michigan Health]: This is very exciting work. We are excited to be involved

and hopeful for a favorable PCORI review. We will keep the group informed as we reach out to gauge

interest in participating in the study. Amit, can you share the grant deadline so the group understands

the overall timeline for letters of support or conversations with colleagues?

Amit Bardia [Mass General Brigham]: Absolutely. Our soft deadline is December 21. We hope to

complete the proposal before the holidays, but the hard deadline is January 11.

Allison Janda [University of Michigan Health]: Outstanding. Are there any other questions before we

proceed with the glucose-related cardiac measure reviews?

GLU-06-C Measure Review

Allison Janda [University of Michigan Health]: I’m going to hand it over to Dr. Billings at Vanderbilt

University. He was kind enough to complete the glucose 06 and glucose 08 measure reviews. For each

measure, we have an overview of the measure itself. I’d like Dr. Billings to review his findings, and then

we’ll examine the overall performance, discuss his recommendation, and move on to glucose 08.

Josh Billings [Vanderbilt Health]: Thanks, Allison. I was happy to review these two measures. I

considered the background, rationale, measurement details, management recommendations, and

criteria for passing, failing, or being flagged. In brief, evidence shows that both significant hyperglycemia

and hypoglycemia are associated with poor outcomes, supporting efforts to maintain relative

euglycemia during surgery. The rationale is strong in both the literature and the community, and I had no

objections to having a mechanism that promotes euglycemia. The description is the percentage of adult

patients undergoing an open-heart procedure for whom no intraoperative blood glucose value exceeds

180 milligrams per deciliter. I also liked that success requires the anesthesia team to anticipate and act

preemptively. It is not simply a reactive response after hyperglycemia occurs. A case is already flagged

if that happens, so the measure requires the team to remain observant, understand the patient’s

trajectory, and anticipate hyperglycemia before it occurs. You pass if the blood glucose remains below

180, or 10 millimoles per liter. You are flagged if the blood glucose is greater than 180 or if no blood

glucose values are measured. The measure is assessed from anesthesia start through 30 minutes after

anesthesia end, extending into the first set of measurements upon arrival in the ICU, PACU, or other

recovery unit. I think that is appropriate.

Allison Janda [University of Michigan Health]: Here is the overall measure performance from

September 2025 through August 2026. We can see some high-performing and some low-performing

sites. Some low performance may reflect cases that were inappropriately classified as cardiac. Overall,

there is considerable opportunity to align performance with the STS threshold of 180 or less throughout

the case. Josh, I’ll pull up your overall recommendation.

Josh Billings [Vanderbilt Health]: My main—and in fact only—recommendation for this measure is to

consider changing the window for both rechecking and determining a subsequent pass or fail from 30

minutes to 60 minutes. I do not have specific literature or recommendations to support that change,

and I’m interested in hearing whether other sites take a different approach. Insulin infusions are

typically adjusted hourly, and glucose is generally rechecked hourly. A value obtained one hour after an

intervention may better reflect whether glucose has successfully returned toward the target range. I’m

suggesting changing the interval from 30 to 60 minutes because hourly measurement appears to be the

interval most commonly used clinically in both operating room and intensive care settings.

[Via Chat] Ashan Grewal [University of Maryland]: How will the window change effect a

flagged case? since any value above 180 is flagged.

Josh Billings [Vanderbilt Health]: For determining whether an insulin adjustment effectively changed

the glucose value, if our clinical settings already use an hourly assessment window, I think the MPOG

measure should work within that framework. We should not ask clinicians both to improve glucose

control and to change their measurement frequency. That is the main change I would consider for

glucose 06 and glucose 08.

Allison Janda [University of Michigan Health]: Ashan asked in the chat how changing the window

would affect a flagged case, since any value above 180 is flagged. This gets to the intended purpose of

the recheck. The measure was designed to allow a recheck that could rule out an erroneous value. For

example, if a glucose measurement is 300 because the sample was contaminated after D50 was given,

and a repeat measurement within 30 minutes is below 180, the original value would be considered

erroneous and the case would not be flagged inappropriately.

[Via Chat] Amit Bardia [Mass General Brigham]: My email- abardia@mgb.org, please feel

free to reach out regarding VANISH AKI.

Allison Janda [University of Michigan Health]: The recheck is intended to occur soon after the initial

glucose measurement to rule out an erroneous value. That is the specific purpose of the recheck

window in this measure. Josh, however, you raise an important point about how the purpose of that

recheck is described.

Allison Janda [University of Michigan Health]: If the purpose of rechecking glucose were to determine

whether it had fallen below 180 after treatment, that would be a different intention for the measure. If

we were trying to assess the effect of insulin, we would not necessarily recheck within 30 minutes; we

would use hourly checks, which I agree with. For this measure, the 30-minute window is intended to

rule out an erroneously high glucose result, such as a sample drawn from a line after D50 was

administered to help correct a patient’s potassium. If a repeat value is below 180, the original result

would be considered erroneous and the case would not be flagged. When we developed this measure,

the intent was to flag any value above 180 unless an immediate recheck showed that the result was

erroneous.

Ashan Grewal [University of Maryland]: The distinction between a 30- and 60-minute window makes

sense if the purpose is to recheck a value that may not accurately reflect the patient’s current glucose.

Before requiring treatment or flagging the case, it is reasonable to allow time for a repeat measurement.

I have nothing further to add.

Josh Billings [Vanderbilt Health]: The text could be reframed to say that a case is flagged unless a

repeat measurement within 30 minutes confirms that the original result was spurious. When I first read

the measure, I interpreted it as Ashan did: If the case had already failed, changing the window would not

affect the result. I also interpreted the wording as an attempt to change normal glucose-monitoring and

treatment intervals, which I now understand was not the intent.

Allison Janda [University of Michigan Health]: That is an excellent suggestion, Josh. The wording

should make clear that the repeat measurement confirms whether the original value was erroneous.

The 30-minute window allows time to verify a potentially erroneous hyperglycemia result. As written, the

intended purpose of the recheck is confusing. Adding the word “confirmatory” and explicitly stating that

glucose is not expected to fall below 180 within that window after insulin treatment would help. As you

noted, the full effect of insulin may not be seen for 60 minutes, and rapidly lowering glucose from 300 to

170 may not be safe for a patient with brittle diabetes. It is important that we clarify this distinction.

[Via Chat] Rob Schonberger [Yale New Haven Health]: That makes sense to me. I was

reviewing a flagged case this AM for Glu-07 with a glucose of 20 (ie clearly erroneous).

Allison Janda [University of Michigan Health]: Rob also noted in the chat that he reviewed a glucose

07 case that morning with a glucose value of 20, which was clearly erroneous. The sample may have

been diluted with saline. The proposed modification would clarify that the recheck is intended to

identify an erroneous value. We do not want the measure to encourage overly aggressive insulin

treatment simply to bring glucose below the threshold within 30 minutes. The current wording is

confusing because I initially assumed that your proposed modification was intended to give clinicians

more time to recheck a potentially erroneous value. If the purpose is to rule out an erroneous result, do

you think the window should remain at 30 minutes, be shortened, or be lengthened?

Josh Billings [Vanderbilt Health]: I think 30 minutes is a good timeframe for that purpose. Will your

team, Allison, make the text modifications, or is that something you also want proposed at the meeting?

How do you proceed there?

Allison Janda [University of Michigan Health]: I agree that we need to be more explicit about the

purpose of that recheck.

Allison Janda [University of Michigan Health]: I’m happy to make the modifications and send the

revised wording to you to confirm that it addresses your concern. Are there any other discussion points

before we vote on this measure? Each site has one vote. The options are to continue the measure as is,

modify it, or retire it. The proposed modification is to clarify the text, context, and description of the 30-

minute recheck window. The language should explain that, in normal clinical care, an actual elevated

glucose value would not necessarily fall below 180 within 30 minutes; rather, the recheck is intended to

confirm whether the original result was erroneous. More than 50% of votes would be required to retire

the measure, and neither retirement nor continuation without changes appears to be recommended.

Eighty-two percent voted to modify the measure as proposed. We will revise the wording to clarify the

purpose of the 30-minute recheck and avoid encouraging overly aggressive insulin dosing.

GLU-08-C Measure Review

Allison Janda [University of Michigan Health]: Moving on to glucose 08, which was also reviewed by

Dr. Billings. This measure assesses whether treatment occurred, not whether glucose was ultimately

brought below 180. A glucose value above 180 meets the measure if insulin was administered or if a

repeat value within 30 minutes was below 180, indicating that the original result was erroneous.

Glucose 06 flags any glucose value above 180 unless a repeat measurement confirms that the original

value was inaccurate. Glucose 08 evaluates whether insulin was given in any amount or whether a

repeat measurement showed that the original result was inaccurate.

Josh Billings [Vanderbilt Health]: I had similar thoughts, and it may have been my own confusion in

reading through it, but as you mentioned, Dr. Janda, was any treatment administered, regardless of

whether that treatment was effective? I recommend clarifying the text, or writing it differently, to explain

that the recheck within 30 minutes was intended to determine whether the value over 180 was spurious,

rather than whether the administered insulin effectively brought the blood sugar back into the

euglycemic range. As far as the rationale, I think it supports trying to keep patients euglycemic during

cardiac surgery. That is reasonable and appropriate. I also think it is reasonable for a measure applied

across a wide, diverse group of practices and practitioners not to be more specific about the treatment

modality, dosing, or type of insulin. It is fine to include subcutaneous, IV, infusion, or bolus treatment.

My only recommendation is to look closely at the text around the 30-minute recheck and clarify the

purpose of that interval, rather than suggesting changes in the overall titration of an insulin infusion for

glucose management.

Allison Janda [University of Michigan Health]: Thank you. This is the current glucose 08 performance.

Although glucose values above 180 still occur, they are more often treated than left untreated, which is

encouraging. Performance for glucose 08 is higher than for glucose 06, but there is still room for

intervention. This remains a useful measure to monitor, with a somewhat arbitrary adherence goal of

90% shown in red.

Josh Billings [Vanderbilt Health]: The other issue is highlighted in yellow. I think these were equal

signs, but they should be greater-than-or-equal-to signs. I recommend correcting them.

Allison Janda [University of Michigan Health]: Thank you for catching that; we agree. Those should all

be greater-than-or-equal-to signs. The issue appears in the attribution section, where we had not

included values equal to 180. We will correct the measure specification and code to make them

consistent. We will also modify the wording around the 30-minute window to clarify its purpose and

avoid encouraging overly aggressive insulin treatment.

Rob Schonberger [Yale New Haven Health]: I'm sorry, are the typo things should be a modify? Or.

Allison Janda [University of Michigan Health]: Yes, those typographical corrections count as a

modification. Thank you, Rob, for confirming. The options are to continue the measure as is, modify it by

correcting the greater-than-or-equal-to signs and clarifying the language around the 30-minute recheck,

or retire it. A clear majority voted to modify the measure. I’m going to close the poll. We will correct the

signs and clarify the intended purpose of the rechecks.

GLU-07-C Measure Review

Allison Janda [University of Michigan Health]: I’m going to hand it over to Dr. Schonberger at Yale,

who reviewed the glucose 07 measure. As with Dr. Billings’ reviews, we’ll review the measure, examine

the preliminary performance, and then discuss Dr. Schonberger’s recommendations.

Rob Schonberger [Yale New Haven Health]: Thank you for allowing me to participate. At a glance,

glucose 07 applies to adult patients undergoing open cardiac surgery. It assesses whether any

intraoperative blood glucose value is below 70 without a repeat value within 15 minutes confirming that

the original result was erroneous. Fifteen minutes seems like an appropriate timeframe given the

urgency of hypoglycemia. If you obtain a low value, you should recheck it immediately to confirm

whether it is accurate. The assessment period is from anesthesia start through 15 minutes after

anesthesia end. A case is also flagged if no blood glucose values are available, because hypoglycemia

could have gone undetected and glucose monitoring is standard care in open cardiac surgery. I agree

with the rationale: Early recognition and treatment of hypoglycemia help prevent serious complications

and support evidence-based perioperative glucose management. I reviewed literature published since

the measure was last reviewed in 2023, and the measure was well referenced. A new 2025 American

Diabetes Association Standard of Care is available, so I suggested adding it; the PMID is included on the

review sheet. It recommends promptly treating glucose below 70 and targeting 100 to 180, consistent

with lessons from the NICE-SUGAR study regarding mortality with tight glucose control and the use of

180 as a safe upper limit. I found the inclusions, exclusions, and definitions appropriate. Unless adding

a reference constitutes a formal change, I would recommend continuing the measure as is while

updating the reference. Allison and I also discussed revisiting the cardiac and cardiothoracic case

phenotype to make it more specific because a few locally flagged cases were not open cardiac cases.

That issue is not directly related to the measure itself, which I believe is evidence based and

appropriate. My question is whether updating the references counts as continuing the measure as is or

as a modification.

Allison Janda [University of Michigan Health]: We will update the reference regardless of the vote,

especially because it is a newer reference.

Allison Janda [University of Michigan Health]: Your proposal is to update the reference, which is a

small change. The other question is whether we should modify the language around the 15-minute

recheck. A window as short as 15 minutes suggests that the purpose is adjudication or confirmation

because hypoglycemia would not necessarily resolve within that timeframe. We could revise the

wording to make clear that the repeat measurement is confirmatory, consistent with the other measure

reviews today. If the group agrees, that clarification could be the proposed modification.

Rob Schonberger [Yale New Haven Health]: If you obtain a critically low glucose value—and it is not

clear that 69 is critical, but there is a point at which it becomes critical and D50 is given—I would expect

a repeat measurement within 15 minutes in my practice. The 15-minute window may therefore serve

two purposes: confirming the value and ensuring that action was taken. I am comfortable with the

current language, but others may disagree, and I do not want my opinion to outweigh the group’s.

Josh Billings [Vanderbilt Health]: I think we are still unclear about the reason for the time interval. We

are discussing it as though it is a window for taking action, but the purpose may be only to determine

whether the original result was spurious. It is unclear whether these intervals define a time to treat or

simply a time to redraw the sample. Even the language for glucose 08 that was on the previous slide

remained confusing. I do not have the measure specifications in front of me, but for glucose 07 the

interval is 15 minutes.

[Via Chat] Ashan Grewal [University of Maryland]: The lowest blood glucose was maintained

at >/=70 mg/dL, or Glucose <70mg/dL that was rechecked within 15 minutes and found to be

>/=70mg/dL.

Josh Billings [Vanderbilt Health]: Is the interval intended for action, or only to confirm whether the

original result was inaccurate? That is not clear.

Allison Janda [University of Michigan Health]: The intent of the shorter recheck window is not to

assess treatment with D50. This measure flags any glucose value below 70 unless a repeat

measurement shows that the original value was erroneous.

[Via Chat] Ashan Grewal [University of Maryland]: Those are the success criteria for this

measure.

Allison Janda [University of Michigan Health]: The question is whether 15 minutes is too short a

window for confirming that the original value was erroneous.

[Via Chat] Amit Bardia [Mass General Brigham]: Thoughts on labs taking more than 15

minutes to run an ABG and hence glucose?

Allison Janda [University of Michigan Health]: This relates to the question Rob posed to the group: Is

hypoglycemia critical enough that it should be verified within 15 minutes? We should not disregard a

value simply because it is rechecked 27 minutes later and the repeat value is somewhat higher; by then,

the treatment effect may already be visible. If the goal is to identify true hypoglycemia, we should

probably limit the confirmatory window to 15 minutes so that treatment does not affect interpretation.

Treatment is often given quickly after confirming that the original value was not erroneous. That is the

intent of the recheck.

[Via Chat] Rob Schonberger [Yale New Haven Health]: I suppose I see your points. I would

change to verified glucose not to confuse and to be consistent with our prior changes.

Ashan Grewal [University of Maryland]: The measure description lists the two success criteria I put in

the chat: either the lowest blood glucose never fell below 70, or a value below 70 was immediately

rechecked and found to be above 70. My interpretation is that the repeat value confirms that the initial

low result was inaccurate, possibly because the specimen was diluted with saline or was otherwise not

an accurate blood sample.

Allison Janda [University of Michigan Health]: I agree that is the intention of how it is written, but I

hear the group saying that we could add words such as, “rechecked within 15 minutes and found to be

greater than or equal to 70,” which does not confirm hypoglycemia. We could strengthen the text

around that by describing it as a confirmatory recheck rather than a treatment recheck. I am hearing two

reasons people would recheck: Did my treatment work, or was the actual value accurate? Here, we are

trying to determine whether the actual value is accurate. I can see why people could assume either

purpose, especially when the threshold is 30 minutes, because treatment effects may begin by then or

people may think they should achieve tighter glucose control within that window, which we do not want

to perpetuate. At 15 minutes, the window appears more confirmatory, and you would not expect to see

a treatment effect by then. We can refine the language to say that a glucose less than 70 was rechecked

within 15 minutes as a confirmatory test and found to be greater than 70 milligrams per deciliter,

indicating that hypoglycemia did not occur. Josh, I would refine that and send it to you for approval. Rob,

I can do that for you as well, and see whether it addresses the concerns if people vote to modify. It

would also be consistent with the other glucose measures. Overall, people are doing quite well and are

not overtreating glucose values. I am going to launch the poll, and then we have some brief updates.

Rob Schonberger [Yale New Haven Health]: So, I'll change my recommendation to modify.

Ashan Grewal [University of Maryland]: Allison, I have a question outside the scope of this review. For

non-cardiac surgery, we have a measure that also evaluates treatment of hypoglycemia, but we do not

have one for cardiac surgery. Was there a reason it was not replicated?

Allison Janda [University of Michigan Health]: No. Initially, we were only trying to create a

countermeasure for glucose 06. We could develop a treatment measure if clinicians would find it

helpful to confirm that hypoglycemia was treated. The vote to modify this measure was unanimous.

Does the group see value in a counterpart to glucose 08C—potentially glucose 15C—that would assess

whether hypoglycemia occurred and whether it was treated, rather than only whether hypoglycemia

occurred? The counts for cardiac surgery are very low.

Ashan Grewal [University of Maryland]: To your point, I just reviewed our performance. Over the last

12 months, we had 47 cases with hypoglycemia, or about four cases per month.

Rob Schonberger [Yale New Haven Health]: Then the highest non-perfect score you could get would

be 5%.

Ashan Grewal [University of Maryland]: Yes, you're right.

Rob Schonberger [Yale New Haven Health]: That is the low-count issue. I would be inclined not to

pursue an additional measure because of the low counts and the amount of work it could create for the

Coordinating Center, which already has many potential measures to program.

Allison Janda [University of Michigan Health]: I am not sure there is much additional utility from my

perspective at Michigan. If I am looking at all my flagged hypoglycemia cases, I am going to check the

record to see whether they were treated promptly. Identifying hypoglycemia likely prompts that review. I

do not think there would be additional utility in flagging cases that were not treated, because I would be

very surprised if there were any.

GLU-14-C

Allison Janda [University of Michigan Health]: In the remaining minutes, let’s talk about glucose 14C.

If anybody has additional thoughts about the hypoglycemia treatment measure, please feel free to add

them in the chat. Glucose 14 measures successful treatment of hyperglycemia by the end of the case. It

is the percentage of adult patients undergoing open cardiac surgery whose last intraoperative blood

glucose before anesthesia end is less than 180. The most likely occurrence of hyperglycemia is that

patients either arrive with hyperglycemia or become hyperglycemic on bypass. This measure marks

cases as successful when the blood glucose is less than 180 by the end of the case. There is no

timeframe of 30 or 60 minutes; the question is whether the patient was transferred with a blood glucose

less than 180. There could be a scenario in which the first high blood glucose occurs immediately

before transfer or an hour before transfer and is profoundly high, but that is very unlikely based on

previous reviews of other measures and unblinded reviews. Most hyperglycemia is present on arrival or

occurs on bypass. People are doing quite well on this measure. It was proposed by Ashan earlier this

spring and released in June. Please review your individual data and let us know if anything seems

different. We are always happy to correct typographical issues as needed. You do not need to wait for

the three-year review if you notice something. We make rolling updates when needed, but at minimum,

we review these measures every three years.

Allison Janda [University of Michigan Health]: Are there any other thoughts or questions about

glucose 14? The measure is live, and your institution has a couple of months of data available. Please

review those cases and adjudicate them clinically.

Summary and Next Steps

Allison Janda [University of Michigan Health]: Thank you for participating in the measure review

process. I know it requires considerable effort from the reviewers, so thank you to Dr. Schonberger and

Dr. Billings for your thoughtful reviews. These measures have been discussed and considered by this

group for years, yet we had not identified the confusion created by the wording of the recheck windows.

These detailed discussions and reviews are valuable. We will revise all three measures to improve the

language and clarify that the rechecks are intended to determine whether a value was accurate or

erroneous. We will also correct the greater-than-or-equal-to signs in glucose 08. Thank you, Josh, for

identifying that. Our next meeting will be in March 2027. We moved this meeting back to ensure that

everyone presenting could attend. Since we have nothing pressing to discuss before then, we will make

these changes in the meantime. We will review the antibiotic measures in March, so please let me know

if you are interested in reviewing that group of measures. Next year’s meetings are scheduled for March,

July, and November. Thank you for your active participation. Thank you again, Dr. Schonberger and Dr.

Billings, for your thoughtful reviews and the time you invested in today’s discussion.