Appropriate use criteria

Background

Founded by a radiologist, HVPAA  includes radiologists from >25 academic radiology departments, many of whom have experience with existing clinical decision support tools to guide ordering of advanced imaging tests. The radiology collaborative has organized a multispecialty team to research and design evidence based-appropriate use criteria for both diagnosis and treatment across a range of common clinical indications, beginning with the 8 CMS clinical priority areas:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

In addition to providing evidence-based guidance to order imaging tests (CT, MR and nuclear medicine), our algorithms include appropriate use criteria (AUC) for lab tests, medications, invasive procedures (e.g. cardiac catheterization, bronchoscopy, etc), consults and the most appropriate patient care setting (e.g. outpatient vs inpatient treatment for pulmonary embolism). As such, we have submitted an application to be recognized as a CMS Provider Led Entity (PLE).

Policies and Procedures

The High Value Practice Academic Alliance (HVPAA) adheres to the evidence-based processes required when developing or modifying AUC. Detailed below are the HVPAA policies and procedures required by CMS for approval as a PLE.

The HVPAA has a dedicated informationist from the Johns Hopkins School of Medicine Welch Library and defined procedures and policies for evidence collection and review

  1. Systematic literature review of the clinical topic and relevant imaging studies: The HVPAA performs systematic review based on comprehensive searches developed by an informationist in cooperation with subject specialists. The informationist assists in translating the clinical question into a functional search strategy, identifying the relevant databases (including, but not limited to MEDLINE/PubMed and Embase), running the search in each database, performing an initial deduplication of the results, and exporting the references for the team to screen. The informationist also updates the searches, as needed. Clinical guidelines and consensus statements by professional medical societies are included in the evidence assessment.
  2. The informationist provides all relevant documentation from the search process including databases searched, date(s) of search, number of references, and number of duplicate references.
  3. Results from the search strategy are uploaded to Covidence and reviewed in duplicate. Titles are excluded from the review when two independent reviewers determine to exclude the title. Included titles are reviewed at the abstract and full article levels with the same methodology applied. Data from included articles are abstracted in duplicate.
  4. The evidence is critiqued using GRADE Working Group criteria, a formal, published and widely recognized methodology for grading evidence and scores provided in an evidence table. 

Faculty roster

HVPAA has compiled a multidisciplinary team of practicing physicians with autonomous governance, decision-making and accountability to develop and modify AUC. At a minimum, 10 practicing faculty with clinical expertise in the clinical areas relevant to CMS priority clinical areas are included on the team:

  • Cardiology: Jeff Trost, MD, Johns Hopkins Hospital
  • Surgery: Rodrigo Alban, MD, Cedars Sinai Medical Center
  • Otolaryngology: Lisa Ishii, MD, MHS Johns Hopkins Hospital
  • Urology: Matt Nielsen, MD, MS UNC Chapel Hill
  • Anesthesiology: Carol Peden, MD, MPH USC, Steve Frank, MD, Johns Hopkins Hospital and Amy Lu, MD, Stanford Medical Center
  • Gastroenterology: Deepak Agrawal, MD, UTSW
  • Pediatrics: Marlene Miller, MD, Johns Hopkins Children’s Center
  • Emergency Medicine: Susan Peterson, MD, Johns Hopkins Hospital
  • Pathology and Laboratory: Mike Borowitz, MD, PhD, Johns Hopkins Hospital
  • Neurology: Hans Puttgen, MD, Johns Hopkins Hospital
  • Oncology: Josephine Feliciano, MD, Johns Hopkins Hospital

Practicing diagnostic radiologists from multiple subspecialties with expertise in the imaging studies related to the AUC include:

  • Pamela Johnson, MD, Body Imaging, Johns Hopkins Hospital
  • Bruno Soares, MD, Pediatric Radiology, Johns Hopkins Hospital
  • Danny Kim, MD, MBA, Body Imaging, NYU Langone Health
  • Shadpour Demehri, MD, Musculoskeletal Radiology, Johns Hopkins Hospital
  • Leon Ryback, MD, Musculoskeletal Radiology, NYU Langone Health
  • Edward Herskovits, MD, PhD, Neuroradiology, University of Maryland
  • Ryan Lee, MD, MBA, Neuroradiology, Einstein Health Network

Practicing primary care, internal medicine physicians:

  • Lenny Feldman, MD, Internal Medicine and Pediatrics, Johns Hopkins Hospital,
  • Amit Pahwa, MD, Internal Medicine and Pediatrics, Johns Hopkins Hospital
  • Nicole Adler, MD, Internal Medicine, NYU Langone Health
  • Frank Volpicelli, MD, Internal Medicine, NYU Langone Health

Expert in statistical analysis and clinical trial design:

  • Brandyn Lau, MPH, Johns Hopkins Hospital

Informationist for systematic literature search:

  • Katie Lobner, MLIS, Welch Medical Library, Johns Hopkins Medicine

Conflict of Interest Disclosures

Identifying, resolving and publically reporting conflicts of interest

The HVPAA utilizes a transparent process for publicly identifying potential conflicts of interest and for resolving conflicts of interest of members on the multidisciplinary team, the PLE, and any other party participating in AUC development or modification. Resolution may include recusal or exclusion of individuals, as appropriate.

The HVPAA documents the following information and make it publically available in timely fashion upon request, for a period of not less than 5 years after the most recent published update of the relevant AUC:

  1. Direct or indirect financial relationships that exist between individuals, or their spouse or minor children, who have substantively participated in the development or modification of AUC and companies or organizations including the PLE and any other party participating in AUC development or modification that may financially benefit from the AUC. These financial relationships may include compensation arrangements such as salary, grant, speaking or consulting fees, contracts, or collaboration agreements.
  2. Ownership or investment interests between individuals, or their spouse or minor children, who have substantively participated in the development or modification of AUC and companies or organizations including the PLE or any other party participating in AUC development or modification that may financially benefit from the AUC.
  3. All participating collaborators are required to provide this information using the ICMJE Conflict of Interest Form.

Website distribution and updating of AUC

  1. Each individual criterion is published on the HVPAA website (hvpaa.org/appropriate-use-criteria), to include an identifying title, all members of the multidisciplinary AUC development team who contributed to authorship of the AUC, and key references used to establish the evidence.
  2. Each of our first 8 AUC are relevant to a priority clinical area. The AUC are designed to enable a comprehensive diagnostic approach to patient care and reasonably address the entire clinical scope of the corresponding priority clinical area.
  3. The HVPAA identifies key points in an individual AUC as evidence-based or consensus-based, and grades such key points in terms of strength of evidence using a formal, published and widely recognized methodology (GRADE Workgroup).
  4. The HVPAA uses a transparent process for the timely and continual updating of each AUC. Each AUC will be reviewed annually and update as deemed necessary.
  5. The HVPAA has publicly posted the process for developing or modifying the AUC on our website.
  6. The HVPAA will disclose parties external to the PLE when such parties have involvement in the AUC development process.