American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,

American College of Physicians

Department of Clinical Policy Disclosure of Interests: Supplement

Name: Elie Akl, MD, MPH, PhD

Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.

Thank You.

If in doubt, err on the side of full disclosure

For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)

YES NO

Point of Care Ultrasound ☐ ☒

High flow nasal oxygen ☐ ☒

Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?

☐ ☒

For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)

YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION

I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.

Signature Date December 30, 2019

Dec30,201905:47:07ESTAmer icanCol legeofPhysiciansElieAkl

SummaryofFinancialInterests

CompanyorOrganizat ion

Ent it y T ype Int erest HeldBy Value

Alliancef orHealt hPolicyandSyst emsResearch Grant/Contract Self $180 ,119.00

AmericanCollegeof Rheumatology Grant/Contract Self $96,276.00

Deut scheGesellschaf t f ürInt ernat ionaleZusammenarbeit (GIZ )GmbH Grant/Contract Self $1,275.00

eilNat ionalDeRecherchesScient if iques(CNRS) Grant/Contract Self $25,082.00

Facult yof MedicineMedicalPract icePlan(MPP),AmericanUniversit yof Beirut Grant/Contract Self $36,000 .00

Facult yof MedicineMedicalPract icePlan(MPP),AmericanUniversit yof Beirut Grant/Contract Self $18,000 .00

GlobalEvidenceSynt hesisInit iat ive Grant/Contract Self $255,550 .00

DisclosurePurpose:AnnualGovernanceDisclosure2019

RecipientName:Centerforsystematicreviewsofhealthpolicyandsystemsresearch(SPARK),AmericanUniversityof

RecipientType:InstitutionGrant/ContractDescription:EstablishingarapidresponseservicetoaddressrequestsfrompolicymakersforHPSRinLMICsinthe

Grant/ContractPurpose:Research Grant/ContractAmount:$180 ,119.00Grant/ContractValuationDate:04/05/2019 ContractStartDate:09/01/2016 ContractEndDate:12/18/2018AdditionalInformation:

RecipientName:AUBGRADEcenter RecipientType:InstitutionGrant/ContractDescription:Conductingsystematicreviewsforthe2020udpateoftheAmericanCollegeofRheumathology(ACR)gui

Grant/ContractPurpose:ResearchGrant/ContractAmount:$96,276.00

Grant/ContractValuationDate:04/05/2019 ContractStartDate:08/01/2018 ContractEndDate:12/01/2020AdditionalInformation:

RecipientName:AUBGRADECenter,AmericanUniversityofBeirut(AUB) RecipientType:IndividualGrant/ContractDescription:SupportINASantéinTunisiaindevelopingthecapacitytoadaptclinicalpracticeguidelines



RecipientName:CenterforSystematicReviewsinHealthPolicyandSystemsResearch(SPARK)

RecipientType:InstitutionGrant/ContractDescription:Applyinganimpact-orientedapproachtosupport,protectandaddresstheneedsofHealthCareWorker

Grant/ContractPurpose:Research Grant/ContractAmount:$25,082.00Grant/ContractValuationDate:04/05/2019 ContractStartDate:01/01/2018 ContractEndDate:12/30 /2019AdditionalInformation:

RecipientName:ElieAkl RecipientType:IndividualGrant/ContractDescription:Developingamethodologyforverifyingtheaccuracyandcompletenessofconflictofinterestdisclos

Grant/ContractPurpose:ResearchGrant/ContractAmount:$36,000 .00


RecipientName:ClinicalResearchInstitute,AmericanUniversityofBeirut RecipientType:InstitutionGrant/ContractDescription:Intellectualconflictwhenconsideringtreatmentoptions(INCONFLICT)



Int ernat ionalLeagueAgainst Rheumat ism(ILAR) Grant/Contract Self $25,000 .00

Nat ionalInst it ut ef orHealt hResearch Grant/Contract Self $13,083.00

WorldHealt hOrganizat ion Grant/Contract Self $5,400 .00

AdditionalInformation:

RecipientName:Centerforsystematicreviewsofhealthpolicyandsystemsresearch(SPARK),AmericanUniversityof

RecipientType:InstitutionGrant/ContractDescription:HostingSecretariatfortheGlobalEvidenceSynthesisInitiative(GESI)

Grant/ContractPurpose:Research Grant/ContractAmount:$255,550 .00Grant/ContractValuationDate:04/05/2019 ContractStartDate:06/01/2016 ContractEndDate:06/01/2019AdditionalInformation:

RecipientName:AUBGRADEcenter RecipientType:InstitutionGrant/ContractDescription:Adaptationofthe2015AmericanCollegeofRheumatology(ACR)RheumatoidArthritisguidelinesforth



RecipientName:ClinicalResearchInstitute(AUB) RecipientType:InstitutionGrant/ContractDescription:UpdatingCochranesystematicreviewsonanticoagulationinpatientswithcancer


Grant/ContractValuationDate: ContractStartDate:01/01/2018 ContractEndDate:12/31/2018AdditionalInformation:

RecipientName:ElieAkl RecipientType:IndividualGrant/ContractDescription:serveasaguidelinemethodologistfortheWHOguidelinesonAfricanTrypanosomiasis


Grant/ContractValuationDate:04/05/2019 ContractStartDate:02/22/2019 ContractEndDate:03/30 /2019AdditionalInformation:

1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.

None

2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.

a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?

Yes.

i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.

Yes

ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."

Yes

iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsof

Certification

Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:

Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations

Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence

part icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.

Yes

iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.

Yes

Jan02,202011:44:34ESTAmer icanCol legeofPhysiciansLauraBaldwin


Idonothaveanyfinancialintereststodiscloseatthistime.


Certification


Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizations

DisclosurePurpose:AnnualStaffDisclosure2019


2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.

a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Ot her(meet ingguest s,cont ract ors,aut hors,et c.)

Yes.


Yes

ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."

Yes

iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.

Yes


Yes

Participationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations


Jan02,202010:06:29ESTAmer icanCol legeofPhysiciansKateCarroll




AmericanCollegeof Physicians Employment Self -

T heBeasleyFirm,LLC Employment Spouse/Partner -


DisclosurePurpose:CGC/PMC/SMPC,Entry

Title:Manager,ClinicalPolicy PositionDescription:StartDate:08/26/2014 EndDate: AdditionalInformation:

Title:TechnologySpecialist PositionDescription:StartDate:09/01/2009 EndDate: AdditionalInformation:




Yes.


Yes


Yes


Yes


Yes

Certification




American College of Physicians Department of Clinical Policy

Disclosure of Interests: Supplement

Name: Robert M. Centor, MD, MACP

Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure


YES NO




☐ ☒


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Robert M. Centor, MD, MACP Date 1/9/20

Jan23,202010:04:46ESTAmer icanCol legeofPhysiciansRobertCentor




Dynamed Consultant Self $1,000 .00

MDCalc Consultant Self -

Medscape Consultant Self -

NKF Consultant Self -

T heCurbsiders Consultant Self -

U.S.Department of Vet eransAf f airs Employment Self -



Category:Consultant ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:

Year Amount T ype

2019 $1,000 .00 Estimated

AdditionalInformation:ReviewchaptersforDynamed-receive$500 perchapterreview

Category:Consultant ConsultantDescription:StartDate:01/01/2018 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Ontheadvisoryboard

Category:Consultant ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:AdditionalInformation:OccasionallyIwriteapieceandtheypaymeupto$1000

Category:Consultant ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:MemberofanNKFperformancemeasuredevelopmentcommittee

Category:Consultant ConsultantDescription:StartDate:01/01/2018 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Appearasaguestdiscussantontheirpodcast

Title:Physician PositionDescription:Inpatientwardattending3.5monthseachyearStartDate:07/01/1993 EndDate: AdditionalInformation:

Certification





Iexcludedactivitiesgreaterthan3yearsold


a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)

Yes.


Yes


Yes


Yes


Yes

Jun24,201917:41:49EDTAmer icanCol legeofPhysiciansDouglasDeLong




Certification

Icertifythattomyknowledgeandbeliefthattheforegoingdisclosureoffinancialandintellectualinterestsiscompleteandtruthful,andIwillpromptlydiscloseanychanges.

DisclosurePurpose:ANNUALGOVERNANCEDISCLOSURE2019




Yes.


Yes


Yes


Yes


Yes

Jan14,202011:39:30ESTAmer icanCol legeofPhysiciansSarahDinwiddie





smartworkingmom.com OtherBusinessOwnership Self -

T ownSport sInt ernat ional Employment Spouse/Partner -



Title:Associate,PerformanceMeasurement PositionDescription:Assisttheclinicalpolicydepartmentintheexecutionofallperformancemeasurement-relatedactivities

StartDate:11/14/2014 EndDate: AdditionalInformation:

FormofBusinessDescription:Educationalresourceofferingprovenstrategiesonhowtobuildanonlinebusinessandmonetizeitforpassiveincome

OwnershipCategory:FounderPartnershipCategory:InvestmentAmount:$1,000 .00

InvestmentAmountValuationDate:01/14/2020 AnnualCompensation:AdditionalInformation:

Title:FitnessManager PositionDescription:ManagethepersonaltrainingprogramsforPhiladelphiaSportsClubeswithinthePAregion





Yes.


Yes


Yes

Certification





Yes


Yes



Name: Mary Ann Forciea MD MACP



YES NO




☐ ☒


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Mary Ann Forciea MD MACP Date 1/9/2020

Dec24,201915:35:15ESTAmer icanCol legeofPhysiciansMaryForciea




Cent erf orMedicareServices Grant/Contract Self -

Nat ionalBoardof MedicalExaminers Consultant Self -

PerelmanSchoolof Medicine,Universit yof Pennsylvania Employment Spouse/Partner -

PerelmanSchoolof Medicine,Universit yof Pennsylvania Employment Self -

T heRalst onCent er FiduciaryOfficer Self -

T IAA-CREFInst it ut e Stock Self -



RecipientName:UniversityofPennsylvania RecipientType:InstitutionGrant/ContractDescription:DemonstrationProject-IndependenceatHome

Grant/ContractPurpose:Other-HealthServicesResearchGrant/ContractAmount:

Grant/ContractValuationDate:05/03/2019 ContractStartDate: ContractEndDate:06/30 /2020AdditionalInformation:

Category:Consultant ConsultantDescription:StartDate:08/01/2005 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:AdditionalInformation:

Title:ProfessorofPediatrics PositionDescription:FacultyStartDate:07/01/1980 EndDate: AdditionalInformation:

Title:ClinicalProfessorofMedicine PositionDescription:ClinicalFacultyStartDate:07/01/2000 EndDate:06/28/2019 AdditionalInformation:

OfficialTitle:Member,BoardofManagers PositionDescription:BoardMemberCompensationType:Unpaid OtherCompensation:StartDate:05/01/2006 EndDate:AnnualCompensation:AdditionalInformation:

PercentageOwnership: EstimatedValue:ValuationDate: DivestmentDate:AdditionalInformation:Retirementaccount



Certification





Yes.


Yes


Yes


Yes


Yes



Name: Raymond A Haeme



YES NO




☐ ☒


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Date: Jan 3. 2020

Jan03,202015:39:11ESTAmer icanCol legeofPhysiciansRayHaeme




Certification







Yes.


Yes


Yes


Yes


Yes


YES

Point of Care Ultrasound! □

High flow nasal oxygen! □

Any other intellectual interests that you feel are relevant! D but have not been captured in Convey or above?

NO

�

M

For the Scientific Medical Polic Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)

Hematuria

Antibiotics

Any other intellectual interests that you feel are relevant! but have not been captured in Convey or above 7;

YES NO

□ �

□

□

DECLARATION ,----;

I certify that to my knowledge and bel· any changes.

Signature

/'/ ,/ ,...

e disclosed my financial and non-financial interests �6�ve �nd I will promptly disclose

/ ✓t'

Date (1t�tm\i/ 2021) ·

Jan09,202017:51:07ESTAmer icanCol legeofPhysiciansPeterHamilton




Certification


Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)



nil



Yes.


Yes


Yes


Yes


Yes

Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations




Name: Russell Harris



YES NO

Point of Care Ultrasound ☐ ☐

High flow nasal oxygen ☐ ☐


☐ ☐


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Russell Harris Date December 24, 2019

Mar 18,201913:36:59EDTAmer icanCol legeofPhysiciansRussellHarris




Certification

Icertifythattomyknowledgeandbeliefthattheforegoingdisclosureoffinancialandintellectualinterestsiscompleteandtruthful,andIwillpromptlydiscloseanychanges.



2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.


Yes.


Yes


Yes


Yes


Yes

Dec28,201921:27:54ESTAmer icanCol legeofPhysiciansGregoryHood




Certification







Yes.


Yes


Yes


Yes


Yes



Department of Clinical Policy


Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests

that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines

Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.

Thank You.


Name: UA.d!w-

Jan13,202017:04:33ESTAmer icanCol legeofPhysicianslindahumphrey




Upt oDat e Consultant Self $3,000 .00



Category:Consultant ConsultantDescription:StartDate:01/01/2010 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:

Year Amount T ype

2019 $3,000 .00 Estimated

AdditionalInformation:Iwriteachapteronlungcancerscreeningandreceiveroyaltiesthattypicallyarearound3kperyear


asabove.



Yes.


Yes


Yes


Yes

iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeof

Certification




Physician’sAnt i-Harassment Policy.

Yes



Name: Janet Jokela



YES NO




☐ ☒


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Janet Jokela Date 01/09/2020

Jan22,202012:46:33ESTAmer icanCol legeofPhysiciansJanetJokela



Ent it y T ype Int erest HeldBy

Value

AAMC,Ent rust ableProf essionalAct ivit iesCoreWorkingGroup,UnivILCollegeof Medt eam(member)

Other Self -

AmericanBoardof MedicalSpecialt ies,Commit t eeonCert if icat ion(COCERT )member Other Self -

AmericanCollegeof Physicians Other Self $15,000 .00

ChampaignCount yAudubonBoardmember Other Self -

MississippiValleyRegionalBloodCent er FiduciaryOfficer

Self -

Universit yof Illinoisat Urbana-Champaign Employment Spouse/Partner -

Universit yof IllinoisCollegeof Medicineat Urbana-Champaign Employment Self -

DisclosurePurpose:January2020 GovernanceDisclosure

Category:Other ConsultantDescription:StartDate:07/01/2014 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:


Category:Other ConsultantDescription:StartDate:01/22/2020 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:

Year Amount T ype

2020 $15,000 .00 Estimated

AdditionalInformation:MKSAPDeputyEditor


OfficialTitle:Boardmember PositionDescription:serveasamemberoftheMVRBCBoardasafiduciaryofficer

CompensationType:Unpaid OtherCompensation:StartDate:02/01/2018 EndDate:AnnualCompensation:AdditionalInformation:

Title:Professor PositionDescription:FoundersProfessor,CollegeofEngineering,DepartmentofComputerScience


VAIllianaHealt hcareCent er Employment Self -

IntellectualProperty

T ype IsLicensed Int erest HeldBy Value

OtherInt ellect ualPropert y-Nat ionalAcademyof Medicine,st andingcommit t ee... - Spouse/Partner -

OtherInt ellect ualPropert y-NSF,pediat ricvaccineresearch,endedAugust 20 - Spouse/Partner -

OtherInt ellect ualPropert y-NSF,BroaderImpact Init iat ive;AirForceOf f ice... - Spouse/Partner -


Title:ActingRegionalDean PositionDescription:ChiefAcademicandFiduciaryOfficerfortheregionalcampusoftheUniversityofIllinoisCollegeofMedicineinUrbana

StartDate:02/16/2017 EndDate: AdditionalInformation:myprimaryemployment

Title:InfectiousDiseaseconsultant PositionDescription:StartDate:02/01/2000 EndDate: AdditionalInformation:

Description:NationalAcademyofMedicine,standingcommitteeCDCStrategicNationalStockpile(member)

IncomeSource:

YearlyIncome: AdditionalInformation:

Description:NSF,pediatricvaccineresearch,endedAugust2017 IncomeSource:YearlyIncome: AdditionalInformation:

Description:NSF,BroaderImpactInitiative;AirForceOfficeofScientificResearch,ended02/2018

IncomeSource:NSF

YearlyIncome: AdditionalInformation:


noadditionalrelevantinfo



Yes.


Yes


Yes


Certification




Yes


Yes



Name: Devan Kansagara


Thank You.



YES NO




☐ ☒


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Date

1/9/20

Jan13,202013:44:06ESTAmer icanCol legeofPhysiciansDevanKansagara




Certification



DisclosurePurpose:committeemembership




Yes.


Yes


Yes


Yes


Yes


Jan13,202019:27:50ESTAmer icanCol legeofPhysiciansRachaelLee


IntellectualProperty

T ype IsLicensed Int erest HeldBy Value

OtherInt ellect ualPropert y-Honoraria - Self $5,000 .00



Description:Honoraria IncomeSource:YearlyIncome:Amount T ype Year Payment Receipt

$5,000 .00 Actual 2019 DirectPayment

AdditionalInformation:Honorariaforwebinarandlivemeetingoninfluenza


IdidonewebinarandonelivemeetingoninfluenzaforPrimeEducationLLCthatisnotrelatedtoworkforACP



Yes.


Yes


Yes


Yes


Yes

Certification




AmericanCollegeofPhysiciansDepartmentofClinicalPolicy

DisclosureofInterests:Supplement

Name:MauraMarcucci

Purpose:Thisisasupplementaldisclosureofinterests(DOI)worksheettoreportanyintellectualinterests

thatarerelevanttoclinicaltopicsontheagendafortheupcomingClinicalGuidelines

Committee/PerformanceMeasurementCommittee/ScientificMedicalPolicyCommitteemeeting.

ThankYou.

Ifindoubt,erronthesideoffulldisclosure

FortheClinicalGuidelinesCommittee:Inthelast3years,haveyouoranyhouseholdmemberspublishedonanyofthefollowingtopicareas?Pleaseincludebothpeer-reviewedandnon-peer-reviewedsources(e.g.newspaperop-ed;blog)

YES NO

PointofCareUltrasound � �

Highflownasaloxygen � �Anyotherintellectualintereststhatyoufeelarerelevant

buthavenotbeencapturedinConveyorabove?� �

FortheScientificMedicalPolicyCommittee:Inthelast3years,haveyouoranyhouseholdmemberspublishedonanyofthefollowingtopicareas?Pleaseincludebothpeer-reviewedandnon-peer-reviewedsources(e.g.newspaperop-ed;blog)

YES NO

Hematuria� �

Antibiotics� X

Anyotherintellectualintereststhatyoufeelarerelevant

buthavenotbeencapturedinConveyorabove?

� �

DECLARATION

IcertifythattomyknowledgeandbeliefthatIhavedisclosedmyfinancialandnon-financialinterestsaboveandIwillpromptlydiscloseanychanges.

Signature DateJanuary5th,2020

Jan25,202012:50:04ESTAmer icanCol legeofPhysiciansMauraMarcucci




CanadianInst it ut esof Healt hResearch Grant/Contract Self $380 ,000 .00

EuropeanCommission Grant/Contract Self -

McMast erUniversit y Employment Self -

Networkof CanadianEmergencyResearchers Other Spouse/Partner -

PSIFoundat ion Grant/Contract Self $230 ,000 .00


DisclosurePurpose:AnnualGovernanceDisclosure2019,AnnualGovernanceDisclosure2020

RecipientName:MauraMarcucci RecipientType:IndividualGrant/ContractDescription:Granttosupportatrialoninterventionstoreducepostoperativedeliriumandcognitiveoutcome

Grant/ContractPurpose:ResearchGrant/ContractAmount:$380 ,000 .00

Grant/ContractValuationDate: ContractStartDate:10 /01/2019 ContractEndDate:AdditionalInformation:

RecipientName:Fondaz ioneIRCCSCa'Granda,Milan,Italy RecipientType:InstitutionGrant/ContractDescription: Grant/ContractPurpose:Grant/ContractAmount: Grant/ContractValuationDate:01/25/2020ContractStartDate:05/01/2015 ContractEndDate:04/30 /2018 AdditionalInformation:

Title:AssistantProfessor PositionDescription:StartDate:07/01/2017 EndDate: AdditionalInformation:


RecipientName:MauraMarcucci RecipientType:IndividualGrant/ContractDescription:CareerAward Grant/ContractPurpose:ResearchGrant/ContractAmount:$230 ,000 .00 Grant/ContractValuationDate:01/05/2020ContractStartDate:03/01/2020 ContractEndDate:02/28/2023 AdditionalInformation:


none


a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?

Certification




Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)

Yes.


Yes


Yes


Yes


Yes

Jun26,201906:47:37EDTAmer icanCol legeofPhysiciansRobertMcLean



Nort heast MedicalGroup Employment Self -


Certification

Icertifythattomyknowledgeandbeliefthattheforegoingdisclosureoffinancialandintellectualinterestsiscompleteandtruthful,andIwillpromptly

DisclosurePurpose:annualdisclosure

Title:EmployedPhysician PositionDescription:Physician&MedicalDirectorofClinicalQualityStartDate:11/01/2012 EndDate: AdditionalInformation:


AmericanCollegeofRheumatologyQualityofCareCommitteetermwasNov2015-Nov2018ABIMRheumatologySub-specialtyBoardtermwasApril2014-June2018



Yes.


Yes


Yes


Yes


Yes

discloseanychanges.

Dec26,201917:52:40ESTAmer icanCol legeofPhysiciansAdamObley




Advent ist Healt hPort land Other Self $2,500 .00

Cent erf orEvidence-basedPolicy Employment Self -

MedicalSociet yof Met ropolit anPort land FiduciaryOfficer Self -

MilbankMemorialFund Travel Self $10 ,000 .00

Nat ionalConf erenceof St at eLegislat ures Travel Self $1,000 .00

Port landVAMedicalCent er Employment Self -

Schoolof Medicine,OregonHealt handScienceUniversit y Employment Self -



Category:Other ConsultantDescription:StartDate:09/26/2018 EndDate:09/26/2018 CompensationType:CashOtherCompensation: AnnualCompensation:

Year Amount T ype

2018 $2,500 .00 Actual

AdditionalInformation:Speakinghonorarium

Title:ClinicalEpidemiologist PositionDescription:CEbPsupports0 .5FTEStartDate:08/01/2014 EndDate: AdditionalInformation:

OfficialTitle:Trustee PositionDescription:TrusteeCompensationType:Unpaid OtherCompensation:StartDate:08/01/2015 EndDate:AnnualCompensation:AdditionalInformation:

Location(s):Variousmeetingsandstateworkshops(asfaculty) TravelStartDate:01/01/2015 TravelEndDate:06/01/2019EstimatedValue:$10 ,000 .00 ValuationDate:12/26/2019Purpose:FacultyforEvidence-informedHealthPolicyWorkshops AdditionalInformation:

Location(s):Nashville,TN TravelStartDate:05/05/2018 TravelEndDate:05/07/2018EstimatedValue:$1,000 .00 ValuationDate:12/26/2019Purpose:FacultyforEvidence-informedHealthPolicyWorkshop AdditionalInformation:

Title:StaffPhysician PositionDescription:DivisionofGeneralMedicine,DepartmentofHospitalandSpecialtyMedicine


Title:AssociateProfessorofMedicine PositionDescription:Facultyappointment,notcompensatedStartDate:07/01/2013 EndDate: AdditionalInformation:

Certification







Yes.


Yes


Yes


Yes


Yes



Name: Adam Obley


Thank You.



YES NO

Point of Care Ultrasound ☐ ☐

High flow nasal oxygen ☐ ☐


☐ ☐


YES NO

Hematuria ☐ ☒

Antibiotics ☐ ☒


☐ ☒

DECLARATION


Signature Date

Dec03,201915:33:28ESTAmer icanCol legeofPhysiciansAmirQaseem





Cent ersf orDiseaseCont rolandPrevent ion Other Self -

Cochrane Other Self -

Dynamed Other Self -

Dynamed Other Self -

GRADEWorkingGroup Other Self -

MeasuresApplicat ionPart nership Other Self -

MedBiquit ous Other Self -

DisclosurePurpose:ClinicalPolicy,test

Title:VicePresident PositionDescription:ClinicalPolicyStartDate:12/07/2003 EndDate: AdditionalInformation:

Category:Other ConsultantDescription:StartDate:01/01/2016 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactdates


Category:Other ConsultantDescription:StartDate:07/01/2014 EndDate: CompensationType:OtherOtherCompensation:honorarium AnnualCompensation:AdditionalInformation:

Category:Other ConsultantDescription:StartDate:01/01/2013 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonotknowtheexactstartdate.

Category:Other ConsultantDescription:StartDate:01/01/2003 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonothavetheexactstartdate

Category:Other ConsultantDescription:StartDate:01/01/2014 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonotremembertheexactstartdate.

Nat ionalAcademiesof Sciences,Engineering,andMedicine Other Self -

Nat ionalQualit yForum Other Self -



PCPI Other Self -

PCPI Other Self -

RIGHT WorkingGroup Other Self -

T homasJef f ersonUniversit y Other Self -

Women'sPrevent iveServicesInit iat ive Other Self -

Category:Other ConsultantDescription:StartDate:01/01/2013 EndDate:01/01/2019 CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:Donothaveexactstartorenddates




Category:Other ConsultantDescription:StartDate:01/01/2015 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Don'thavetheexactstartdate

Category:Other ConsultantDescription:StartDate:01/01/2017 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactstartdate

Category:Other ConsultantDescription:StartDate:01/01/2015 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Donothaveexactstartdate

Category:Other ConsultantDescription:StartDate:01/01/2014 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonothavetheexactstartdate



Certification








No.

Jan13,202016:54:01ESTAmer icanCol legeofPhysiciansJeffShafiroff






Certification

DisclosurePurpose:ClinicalPolicyCommitteesACPStaff

Title:SeniorAnalyst PositionDescription:StartDate:11/07/2016 EndDate: AdditionalInformation:


Noinformationtoreport



Yes.


Yes


Yes


Yes


Yes




Jan13,202016:38:32ESTAmer icanCol legeofPhysiciansPatriciaSiemion




Certification


Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizations

DisclosurePurpose:AnnualStaffDisclosure2019,AnnualStaffDisclosure2020




Yes.


Yes


Yes


Yes


Yes

Participationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations


Jan10,202009:33:04ESTAmer icanCol legeofPhysiciansFarahSultan





SigmaHeat hConsult ingLLC Other Self -



Title:ResearchAssociate PositionDescription:Provideclinicalinputonevidencereviews,guidelines,performancemeasures,andhighvaluecaretopics.LeadScientificMedicalPolicyCommittee(SMPC),andsupporttheworkoftheSMPC,andother


Category:Other ConsultantDescription:StartDate:05/16/2019 EndDate:12/16/2019 CompensationType:CashOtherCompensation: AnnualCompensation:AdditionalInformation:Part-timecontractposition(inactive)


None



Yes.


Yes


Yes


Certification




Yes


Yes

Jan18,202020:07:12ESTAmer icanCol legeofPhysiciansJenniferYost




CanadianInst it ut esof Healt hResearch Grant/Contract Self $9,310 ,000 .00

CanadianInst it ut esof Healt hResearch Grant/Contract Self $22,600 .00



EvidenceBasedResearchNetwork FiduciaryOfficer Self -

EvidenceSynt hesisInt ernat ional FiduciaryOfficer Self -

McMast erUniversit y Employment Self -

SigmaT het aT auInt ernat ional FiduciaryOfficer Self -


RecipientName:Dr.MichaelMcGillion RecipientType:IndividualGrant/ContractDescription:TheSMArTVIEW,CoVeRed Grant/ContractPurpose:ResearchGrant/ContractAmount:$9,310 ,000 .00 Grant/ContractValuationDate:10 /15/2015ContractStartDate:10 /15/2015 ContractEndDate:09/30 /2019 AdditionalInformation:

RecipientName:Dr.SandraCarroll RecipientType:IndividualGrant/ContractDescription:FollowingtheC-SPINRoadmap:Realiz ingMeaningfulPatientEngagement



RecipientName:Dr.MichaelMcGillion RecipientType:IndividualGrant/ContractDescription:THESMArTVIEW,CoVeRed Grant/ContractPurpose:ResearchGrant/ContractAmount:$226,000 .00 Grant/ContractValuationDate:03/01/2016ContractStartDate:03/01/2016 ContractEndDate:02/28/2018 AdditionalInformation:

RecipientName:Dr.SandraCarroll RecipientType:IndividualGrant/ContractDescription:PrEPARE:PreparingforMeaningfulPatientEngagementatthePopulAtionHealthREsearch



OfficialTitle:SteeringCommitteeMember PositionDescription:CompensationType: OtherCompensation:StartDate:10 /01/2016 EndDate:AnnualCompensation:AdditionalInformation:

OfficialTitle:Secretariat PositionDescription:OrganizeandsupportactivitiesoftheorganisationCompensationType: OtherCompensation:StartDate:03/01/2018 EndDate:AnnualCompensation:AdditionalInformation:

Title:AssistantProfessor PositionDescription:StartDate:06/01/2010 EndDate:06/30 /2017 AdditionalInformation:

Universit yof Bologna Other Self $5,213.19

VillanovaUniversit y Employment Self -


OfficialTitle:President-AlphaNuChapter PositionDescription:President-AlphaNuChapterCompensationType: OtherCompensation:StartDate:09/01/2019 EndDate:08/31/2021AnnualCompensation:AdditionalInformation:

Category:Other ConsultantDescription:StartDate:11/16/2019 EndDate:11/22/2019 CompensationType:CashOtherCompensation: AnnualCompensation:

Year Amount T ype

2019 $5,213.19 Actual

AdditionalInformation:GuestLecturer

Title:AssociateProfessor PositionDescription:StartDate:08/22/2017 EndDate: AdditionalInformation:


N/A



Yes.


Yes


Yes


Yes


Yes

Certification




Documents

American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,