AIM clinical guidelines: translating medical evidence and real-life application into best practices

Julie Thiel, MD
Senior Vice President
Clinical Programs

Chris Buckle, MD, MBA, FRCPC
National Medical Director,
Radiology and Guideline Development

Amy Odgers, MD
Associate Medical Director
Medical Management

With medical advancements moving faster than ever, it can be difficult for even the most diligent practicing physicians to stay current. However, variation from established best practices compromises efficiency, effectiveness, quality, and safety in care. This reality underscores the importance of evidence-based clinical guidelines that help physicians—and our health plan clients— know what’s out there, what’s supported, and what’s not.

AIM can help ensure clinically appropriate care is adopted throughout health plan networks and member groups, and across today’s most complex, costly, and specialized clinical areas. Our evidence-based clinical guidelines are the foundation of our clinical appropriateness review process. When a provider contacts AIM to request a test or treatment, the request is reviewed in real time against our guidelines, health plan medical policy, or both, helping to ensure care that’s appropriate, safe, and affordable.

Drs. Julie Thiel, Chris Buckle, and Amy Odgers recently discussed the AIM clinical guideline development process and how it provides a balanced, unbiased perspective that bridges any gaps between medical research and real-world practices. The trio explained how the guidelines translate recent and relevant research into clear, concise medical best practices that can be meaningfully applied in real-life health care.

“At AIM, we are very focused on being in the vanguard of clinical appropriateness and delivering the best possible product from a provider’s standpoint,” notes Buckle

What’s important about AIM evidence-based clinical guidelines?
How are they used?

Dr. Odgers: The guidelines form the basis for everything we do at AIM. They’re the criteria we use when evaluating provider requests for tests and treatments on behalf of our health plan clients. Our clients and the members they serve rely on us for decisions based on clinically sound and appropriate principles—not only evidence-based, but also reflecting current standards of care. The mission for our business is to promote appropriate, safe, and affordable care, and the guidelines move us toward that goal.

Medical societies, physicians, and many other groups seem to have their own guidelines for clinical best practices. How are AIM evidence-based clinical guidelines different?

Dr. Thiel: Many guideline developers begin and end with evidence-based research. That’s our foundation, too, and we have a great team of specialized clinicians, medical librarians, and evidence reviewers who research and review the literature. We also take into account guidelines from other sources such as professional medical specialty associations and the Centers for Medicare and Medicaid Services (CMS).

With the best evidence collected and reviewed, what’s missing?

Dr. Odgers: The clinical practitioner’s perspective! We pull together the clinical practice of medicine and the literature that supports it.

Dr. Thiel: We build on a strong evidence-based foundation, but also take into account actual clinical scenarios—where real physicians make real decisions about real patients. When we identify the point where researchers and physicians are in agreement, we’ve identified a medical best practice that can promote a higher quality of health care.

Tell me about the guideline development process, how you keep current, and how you pair research with input from external physicians.

“Our clients and the members they serve rely on us for decisions based on clinically sound and appropriate principles—not only evidence-based, but also reflecting current standards of care,” says Odgers.

Dr. Odgers: Our solution medical directors are constantly receiving input that informs guideline development and keeps us current.

We have a team of medical librarians who do targeted surveillance in the areas of medicine that we manage. They are experts at keeping abreast of current literature and their input forms the basis for guideline updates.

AIM medical directors are also out in the community, interacting with providers, medical specialty societies, and health plan medical directors. If something is changing in the practice realm, they’re hearing about it.

Dr. Buckle: We have a very active, engaged clinical leadership team at AIM, representing many specialty areas. Many of us still maintain a practice. The things we’re hearing in the field are discussed among our colleagues here at AIM. This facilitates interdisciplinary content development. Then, all the internal discussion and external input goes into our draft guidelines, which are then validated by external physician panels.

How do you select members of your external panels?

Dr. Thiel: We look for physicians who come from diverse clinical practice settings, spanning community practices to academic medical centers and teaching hospitals. We also look for diversity in specialty and subspecialty. For example, our radiology panel includes general radiologists as well as specialists in body imaging and neuroradiology. We strive for geographic diversity as well.

And, we look for any conflict of interest. A nationally recognized specialist may be involved in their own research or associated with a pharmaceutical company, so it’s important that we are aware of any conflicts and manage them. If a conflict is deemed to be significant, that person can’t be on our panel.

So we have evidence and a diverse, unbiased panel of external experts. Are we ready to publish?

Dr. Odgers: Not quite. We also need to evaluate how any change to our guidelines will play out in clinical practice—and that requires feedback from the provider community.

Can you describe how external provider input led to a change in AIM evidence-based guidelines?

“We have a very active, engaged clinical leadership team at AIM, representing many specialty areas. Many of us still maintain a practice. The things we’re hearing in the field are discussed among our colleagues here at AIM. This facilitates interdisciplinary content development,” per Buckle.

Dr. Buckle: A recent example began when we identified an uptick in MRI requests for prostate cancer. Provider feedback prompted us to examine new literature and evidence, and that led us to enhance our guidelines, which now facilitates MRI approvals for certain cases. We are very focused on being in the vanguard of clinical appropriateness and delivering the best possible product from a provider’s standpoint.

Is it fair to say that the AIM evidence-based clinical guidelines have flexibility?

Dr. Odgers: These are not laws; they’re guidelines—a set of principles by which providers can gauge appropriateness of tests and procedures. Physicians will always use their clinical judgment for individual patient circumstances and our process supports that.

How so? What do you do when a provider request doesn’t appear to align with AIM guidelines, but the provider feels a patient’s clinical condition warrants further consideration?

Dr. Thiel: Our peer-to-peer consultation addresses this need. We now have 150+ physician reviewers across more than 20 medical and surgical specialties—neurosurgery, pediatrics, obstetrics and gynecology, oncology, and more. For us, it’s about getting the right service for the patient and minimizing disruption to the provider.

AIM recently took an important step forward by restructuring radiology guidelines. What’s behind this change?

Dr. Buckle: Radiology has long been an independent core solution for AIM. With the addition of new clinical solutions like oncology and musculoskeletal (MSK) added in the last few years, we saw that imaging was part of establishing a diagnosis or potentially helping to guide therapies in other AIM solutions. We felt it was time to restructure the radiology guidelines in a way that aligns with our other solutions and capabilities.

That’s why we’re moving to have specialty panels from different clinical specialties review radiology content. For example, we’re already working with the musculoskeletal specialty panel. We feel strongly that this will help ensure the best and most appropriate care for a particular disease state. I’m not sure anyone else is doing this.

Another important dimension of the restructured radiology guidelines is greater transparency between the guideline and the medical evidence we used to develop those guidelines. The rationale section in many of our newly restructured guidelines discusses key pieces of evidence that support a guideline’s position.

“We build on a strong evidence-based foundation, but also take into account actual clinical scenarios—where real physicians make real decisions about real patients,” states Thiel. “When we identify the point where researchers and physicians are in agreement, we’ve identified a medical best practice that can promote a higher quality of health care.”

It sounds like AIM is constantly evolving its evidence-based guidelines and processes—so what lies ahead?

Dr. Thiel: We’re always looking for ways to improve. How can we better tap into research that other organizations are doing and quickly validate this research? How can we more efficiently search medical literature—especially in areas where evidence is weak, shows bias, or doesn’t even exist? In areas where the literature rapidly changes—for example in oncology—we need to have better tools to efficiently capture and review pertinent articles.

Chris brought up overlapping medical specialties, and I think that’s an area where we will just keep getting stronger. We’re really looking at how we can leverage our internal experts, our subject matter experts, and our panelists—especially where one specialty touches other specialties within a larger clinical domain such as oncology or musculoskeletal.

We’ve already put these questions on the table, and we’re well on our way to discovering the answers.

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