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Armstrong Institute for Patient Safety and Quality

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Appropriate Use Criteria (AUC) Program

Johns Hopkins Medicine unites physicians and scientists of the Johns Hopkins University School of Medicine with the organizations, health professionals and facilities of The Johns Hopkins Hospital and the Johns Hopkins Health System. Johns Hopkins Medicine, which offers an array of health care services, has six academic and community hospitals, four suburban health care and surgery centers, over 40 patient care locations, a home care group and an international division.

As a leader in health care delivery, research and education, Johns Hopkins Medicine is committed to providing the highest quality patient care, based on evidence and standardized across the health system. Our high value care clinical leaders design systemwide diagnostic algorithms that can be embedded into our electronic health record system (EPIC). These algorithms include appropriate use criteria for imaging developed in accordance with the Centers for Medicare & Medicaid Services (CMS) regulations for eight clinical priority areas:

  • Coronary artery disease and chest pain
  • Pulmonary embolism
  • Neck pain
  • Low back pain
  • Shoulder pain
  • Hip pain
  • Headache
  • Lung cancer

In December 2018, the Johns Hopkins University School of Medicine applied to be recognized as a CMS qualified provider-led entity. The school of medicine satisfies the CMS criteria in the following ways:

  1. We use an evidentiary review process to develop and modify appropriate use criteria.
  2. A multidisciplinary team of physicians develops the criteria.
  3. We manage conflicts of interest and post disclosures online.
  4. We publish appropriate use criteria on our website.

We use an evidentiary review process to develop and modify appropriate use criteria.

The Johns Hopkins University School of Medicine collaborates with the Harvard Medical School Library of Evidence database when developing and modifying appropriate use criteria. The school of medicine reviews the library’s literature review and evidence grades assigned for each logic point and assesses whether the review and grading are acceptable, as required under CMS appropriate use criteria regulations.

Additionally, the Johns Hopkins University School of Medicine performs its own literature searches and creates evidence tables. We have a dedicated informationist from the Johns Hopkins University School of Medicine’s Welch Medical Library, and we have defined procedures and policies for evidence collection and review. This process includes:

  1. The Johns Hopkins University School of Medicine performs literature review to identify high quality evidence, with searches developed by an informationist in cooperation with subject specialists.
  2. The informationist helps translate clinical questions into functional search strategies, identifying the relevant databases (including but not limited to MEDLINE/PubMed), running the search, 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.
  3. The informationist provides all relevant documentation from the search process, including databases searched, search dates, and number of references and duplicate references.
  4. The search strategy results are uploaded to Covidence and reviewed in duplicate. Titles are excluded from the review when two independent reviewers determine to do so. Included titles are reviewed at the abstract and full article levels, with the same methodology applied. Data from included articles are abstracted in duplicate. The evidence is graded using University of Oxford Centre for Evidence-Based Medicine levels of evidence.

A multidisciplinary team of physicians develops the criteria.

Our multidisciplinary team includes more than seven practicing physician members, with at least one having expertise in the clinical topic related to the appropriate use criteria being developed or modified. Many of these physicians have been engaged in development of the diagnostic algorithms that are already operational. Each of the physicians who make up the multidisciplinary team is employed by the Johns Hopkins University School of Medicine, and each nonphysician is employed by The Johns Hopkins Hospital or the Johns Hopkins Health System.

Diagnostic radiologists with subspecialty expertise in the eight clinical priority areas:

  • Pamela Johnson, M.D., body imaging and oncology
  • Ari Blitz, M.D., neuroradiology
  • Shadpour Demehri, M.D., musculoskeletal radiology
  • Shivani Ahlawat, M.D., musculoskeletal radiology
  • Laura Fayed, M.D., M.S., musculoskeletal radiology

Primary care physicians:

  • Leonard Feldman, M.D., internal medicine and pediatrics
  • Amit Pahwa, M.D., internal medicine and pediatrics
  • Carrie Herzke, M.D., internal medicine
  • Stephen Blash, M.D., family medicine

In addition to radiology and primary care, the following specialties and subspecialties will participate in development of relevant AUC.

  • Headache: neurology, neurosurgery, emergency medicine
  • Neck pain: neurology, neurosurgery, emergency medicine, orthopaedic surgery
  • Shoulder pain: emergency medicine, orthopaedic surgery
  • Hip pain: emergency medicine, orthopaedic surgery
  • Back pain: emergency medicine, orthopaedic surgery
  • Pulmonary embolism: pulmonology, hematology, emergency medicine
  • Chest pain: cardiology, emergency medicine

Expert in statistical analysis and clinical trial design: Brandyn Lau, M.P.H.

Informationist for systematic literature search: Katie Lobner, M.L.S., Johns Hopkins University School of Medicine Welch Medical Library

We manage conflicts of interest and post disclosures online.

We use a transparent process to publicly identify potential conflicts of interest, and to resolve conflicts of interest of members of the multidisciplinary teams and any other party participating in appropriate use criteria development or modification. Resolution may include recusal or exclusion.

The Johns Hopkins University School of Medicine requires all practicing physicians and staff members participating in the development of criteria to disclose information in accordance with the university’s conflict of interest policies.

In addition, the Johns Hopkins University School of Medicine requires all practicing physicians participating in the development of criteria to disclose the following information, which is made publicly available in a timely fashion upon request for at least five years after the most recent published update of the relevant appropriate use criteria.

  1. Direct or indirect financial relationships among individuals, or their spouses or minor children, who substantively participated in the development or modification of criteria, and companies or organizations participating in the criteria development or modification that may benefit financially from the criteria. These financial relationships may include compensation arrangements such as salary, grants, speaking or consulting fees, contracts or collaboration agreements.
  2. Ownership or investment interests among individuals, or their spouses or minor children, who substantively participated in the development or modification of criteria or may benefit financially from the criteria.
  3. The Harvard Medical School Library of Evidence will confirm that all individuals who participate in the work of the library complete the electronic conflicts of interest disclosure process required by Harvard Medical School and/or Partners HealthCare. Individuals outside of these systems who participate in the work of the library will be asked to complete paper versions of this disclosure. Upon public request, the library will make this conflict of interest information available in a timely fashion for at least five years after the most recent published update of the information.

We publish appropriate use criteria on our website.

The Johns Hopkins University School of Medicine transparently shares on its website the criteria, updates to the criteria, and how the institution meets requirements. Shared information includes:

  • The title, authors and key references for evidence
  • Relevant priority clinical area
  • Whether the criteria is evidence- or consensus-based
  • Any external parties involved in the criteria development