outcomes 2008 - cleveland clinicthis complimentary online tool offers secure access to your...
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9500 Euclid Avenue, Cleveland, OH, 44195
© The Cleveland Clinic Foundation 2009
Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.
Please visit us on the Web at clevelandclinic.org.
Neurological Institute
2008Outcomes
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137Neurological Institute
Resources for Physicians
Cleveland Clinic Secure Online Services
Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.
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DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].
MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.
Critical Care Transport: Anywhere in the world
Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call 877.279.CODE (2633). For all other transfers, call 216.444.8302 or 800.553.5056.
CME Opportunities: Live and Online
Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.
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Neurological Institute 1
Surgical OverviewTo promote quality improvement, Cleveland Clinic has created a series of Outcomes books similar to this one for many of its institutes. Designed for a physician audience, the Outcomes books contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a review of new technologies and innovations.
Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase
unavailable, we often report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques.
In addition to our internal efforts to measure clinical quality, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives:
(www.qualitycheck.org)
(www.hospitalcompare.hhs.gov)
Our commitment to providing accurate, timely information about patient care will also help patients and referring physicians make informed healthcare decisions.
quality/outcomes.
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Outcomes 20082
Dear Colleague,
On behalf of Cleveland Clinic, I am pleased to present our 2008 Outcomes books. The primary purpose of our annual Outcomes book initiative is to promote quality improvement at Cleveland Clinic, thereby optimizing the care we provide to our
accountability, transparency and results.
requiring hospitals to report more and more quality and patient safety data. We view our Outcomes books as voluntary supplements to the required public reporting and an opportunity to share selected innovations with colleagues across the country.
Designed for the physician reader, each book in the annual series focuses on care provided by one of our patient-centered
content informative.
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Neurological Institute 3
Institute Overview 06
Quality and Outcomes Measures
Brain Tumors 12
Cerebrovascular Diseases 28
Epilepsy 36
Neuroimaging 82
Neurosurgical Anesthesia 88
Innovations 100
Contact Information 132
Cleveland Clinic Overview 136
what’s inside
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Outcomes 2008
Chairman’s Letter
Dear Colleagues,
Clinic’s Neurological Institute. We strive continuously to enhance our monitoring of quality measures and outcomes because we view this initiative as an integral part of our clinical practice. In sharing
specialized care.
which we can monitor longitudinally to encourage continuous improvement. This is the core of ©, through which we are capturing outcomes and quality measures in each
patient’s electronic medical record.
Our work is incomplete, however, if we focus solely on traditional medical parameters and neglect
we are working toward incorporating measurement of this critical component of the healthcare
treatment. We will manage your discomfort and pain. We will respond when you need us. These simple precepts serve to remind us that the practice of even the most sophisticated medicine is a human endeavor.
We believe our statistics support the assertion that, in terms of both outcomes and patient
of a new, laser-based system for minimally invasive treatment of brain tumors, development of
4
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Neurological Institute
patients taking Natalizumab, development of an improved monitoring system for deep brain stimulators
implementation of new paradigms to improve the
nation’s few dedicated biofeedback programs for chronic insomnia patients.
satisfaction is an essential piece in our never-ending drive to strengthen our clinical programs and our ability to conduct research with the potential to improve patients’ lives. We look forward to the opportunity to partner with you in delivering the highest level of neurological care.
Chairman, Neurological Institute
5
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Institute Overview
The multidisciplinary Cleveland Clinic Neurological Institute
specialists dedicated to the treatment of adult and pediatric patients with neurological and psychiatric disorders. The
to care. Our unique, fully integrated model strengthens our current standard of care, allows us to measure quality and outcomes on a continual basis and enhances our ability to conduct research.
U.S.News & World Report’ssurvey has consistently ranked our neurology and neurosurgery programs among the top 10 in the nation. In 2008, our pediatric neurology and neurosurgery programs
neurosurgery, pediatric neurology/neurosurgery and psychiatry programs are also ranked best in Ohio.
6 — Cleveland Clinic’s national ranking for neurology and neurosurgery in U.S.News & World Report’s 2008 “America’s Best Hospitals” survey.
4 — U.S.News & World Report’s national pediatric specialty ranking for our pediatric neurology and neurosurgery programs.
6 Outcomes 2008
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The institute model allows our patients to better access the care they need through specialized,
neurosurgeons, orthopaedic surgeons, psychiatrists, psychologists, physiatrists, neuroradiologists and others into the comprehensive care of neurological and psychiatric disease:
We provide care across the spectrum of neurological disorders, including primary and metastatic tumors of the brain, spine and nerves; pediatric and adult epilepsy; headache, facial pain
tremor and dystonia; neurocognitive disorders; cerebral palsy and spasticity; hydrocephalus; metabolic and mitochondrial disease; fetal and neonatal neurological problems; multiple sclerosis; stroke; cerebral aneurysms; brain and spinal vascular malformations; carotid stenosis; intracranial atherosclerosis; nerve and muscle diseases, including amyotrophic lateral sclerosis, peripheral neuropathy, myasthenia gravis and myopathies; sleep disorders; and mental/behavioral health disorders and chemical dependencies.
Neurological Institute 7
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Outcomes 2008
Institute Overview
Expert, Specialized Diagnosis
angiography, interventional neuroradiology and carotid and transcranial Doppler ultrasound. Our
disease, ensuring accurate, in-depth interpretations.
neuropsychological testing facilities, electromyography laboratory, autonomic laboratory and cutaneous nerve laboratory.
The Latest Treatment Modalities
advance such innovations as deep brain stimulation (brain pacemakers), epilepsy surgery, stereotactic spine radiosurgery, endovascular treatment of cerebral aneurysms and vascular malformations, and neuroendoscopy. Distinctive services such as our three-week outpatient program for sufferers of
process of bringing novel therapeutic agents from the laboratory to the patient, while maintaining the
providing the most advanced and highest quality of care to our patients.
Relevant Research
programs in translational research, clinical trials of drug and device interventions, neuroimaging research, epidemiology and health outcomes, behavioral and psychiatric research, and research into better diagnostic methods. Typically, more than 100 clinical research trials are under way at
research grants and contracts.
8
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Neurological Institute 9
Convenient Care in the Community
We are committed to making access to world-class care convenient for all patients. Our Neurological Institute regional centers
community.
multiple specialists and provides a convenient suburban location where they may undergo procedures and use additional services required for their diagnosis and care. In addition, Cleveland Clinic neurologists oversee inpatient care at a number of Cleveland Clinic hospitals.
locations throughout the community for patients’ convenience and comfort.
Integrated Nursing Services
Nursing in the institute integrates inpatient and ambulatory nursing, enhancing the continuum of patient care. This unique structure also lends itself to greater information sharing and process improvement opportunities. Through continuing education programs, we are able to broaden nursing educational opportunities from basic nursing instruction to subspecialization in neurological nursing, enabling nurses, like our physician colleagues, to provide specialized care.
Pioneering the Collection of Data and Outcomes
©
Division, is designed to harness routinely collected electronic clinical and administrative data to allow us to optimize patient care and outcomes. Data from multiple electronic sources, including imaging results and clinical information collected during
that can be accessed and queried by healthcare personnel. An integral part of this initiative is the standardization of clinical
guides clinical care, quality improvement and research.
and to advancing medical education and research in all areas of neurology, neurosurgery and psychiatry.
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Outcomes 200810
Institute Overview
2008 Statistical Highlights
Inpatient Facilities (Main Campus)
Initial Outpatient Visits 9,711
Total Outpatient Visits 138,713
Admissions 7,132 Brain Tumor Neuro-Oncology 813
Cerebrovascular 1,113
Epilepsy 1,283
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Neurological Institute
Inpatient Days 37,658
Neurocognitive 2,083
Surgical/Interventional Procedures 5,596 Brain Tumor Neuro-Oncology 822
Neuroimaging Studies*
32,023
* studies performed on main campus, Cleveland Clinic satellites, and
family health centers
11
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Outcomes 2008
Brain Tumor Diagnosis Distribution (N = 1,915)
2008
Brain Tumor Procedures (N = 822)
2008
Among patients diagnosed in 2008, gliomas were the most common type of brain tumor.
169, 9% Pituitary169, 9% Pituitary147, 8% Schwannoma147, 8% Schwannoma
336, 18% Meningioma336, 18% Meningioma
419, 22% Metastasis419, 22% Metastasis
844, 44% Glioma844, 44% Glioma
100%100%
82, 10% Novalis® Radiosurgery82, 10% Novalis® Radiosurgery57, 7% Infratentorial Craniotomy57, 7% Infratentorial Craniotomy51, 6% Brain Biopsy51, 6% Brain Biopsy
99, 12% Pituitary Surgery99, 12% Pituitary Surgery
215, 26% Supratentorial Craniotomy215, 26% Supratentorial Craniotomy
318, 39% Gamma Knife® Radiosurgery318, 39% Gamma Knife® Radiosurgery
100%100%
Brain Tumors
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Neurological Institute
Brain Tumor Surgical Site Infection Rates
Enrollment of Patients with Brain Tumors in Clinical Trials
encountered and, in the case of brain tumor surgery, neither the respiratory nor the alimentary tracts are entered. N = number of clean cases per year.
Clinical research trials remained an important therapeutic option for many of our brain tumor patients.
10
5
002005
(N = 593)2006
(N = 604)2007
(N = 502)2008
(N = 451)
Rate per 100 Clean Cases (Percent)
500
400
300
200
100
02004 2005 2006 2007 2008
Number of Patients Enrolled
Therapeutic TrialsGenetic Trials
13
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Outcomes 2008
Supratentorial Craniotomy: Survival
only those patients with available data are included in the calculation.
100
80
60
40
20
0
100
80
60
40
20
0
Number of Surgeries
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
100
75
50
25
0
400
300
200
100
0
Percent Survival Number of Surgeries30-Day 180-Day
2004 2005 2006 2007 2008
Brain Biopsy: Survival
Brain Biopsy
Supratentorial Craniotomy
Brain Tumors
14
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Neurological Institute
Supratentorial Craniotomy: Inpatient Mortality
Supratentorial Craniotomy: Length of Stay (LOS)
severity of patient illness.
10
8
6
4
2
0
Percent Mortality
ActualExpected
2004(N = 263)
2005(N = 284)
2006(N = 299)
2007(N = 273)
2008(N = 215)
8
6
4
2
02004
(N = 263)2005
(N = 284)2006
(N = 299)2007
(N = 273)2008
(N = 215)
Days
Actual Mean LOSExpected Mean LOS
15
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Outcomes 2008
Supratentorial Craniotomy: Karnofsky Performance Scale (KPS) N = 176
2008
Supratentorial Craniotomy: Survival by tumor type
Glioma: Survival
100
80
60
40
20
0Declined Improved No Change
Percent of Patients
100
80
60
40
20
0
150
120
90
60
30
0
Percent Survival Number of Surgeries30-Day 180-Day
2004 2005 2006 2007 2008
Brain Tumors
16
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Neurological Institute
Meningioma: Survival
Metastasis: Survival
Thirty and 180-day survivals were high in 2008 for supratentorial craniotomies independent of tumor type.
100
80
60
40
20
0
80
60
40
20
0
Percent Survival Number of Surgeries30-Day 180-Day
2004 2005 2006 2007 2008
100
80
60
40
20
0
50
40
30
20
10
0
Percent Survival Number of Surgeries30-Day 180-Day
2004 2005 2006 2007 2008
17
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Outcomes 2008
Infratentorial Craniotomy: Survival
Infratentorial Craniotomy
Infratentorial Craniotomy: Inpatient Mortality
100
80
60
40
20
0
100
80
60
40
20
0
Percent Survival Number of Surgeries30-Day 180-Day
2004 2005 2006 2007 2008
10
8
6
4
2
02004
(N = 74)2005
(N = 98)2006
(N = 66)2007
(N = 53)2008
(N = 57)
Percent Mortality
ActualExpected
0 0 0 0
Brain Tumors
18
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Neurological Institute
Infratentorial Craniotomy: Length of Stay (LOS)
Infratentorial Craniotomy: KPS Status (N = 27)
8
6
4
2
02004
(N = 74)2005
(N = 98)2006
(N = 66)2007
(N = 53)2008
(N = 57)
Days
Actual Mean LOSExpected Mean LOS
100
80
60
40
20
0Declined Improved No Change
Percent of Patients
2008
19
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Outcomes 2008
Glioma: Survival
Infratentorial Craniotomy: Survival by Tumor Type
Meningioma: Survival
100
75
50
25
0
25
20
15
10
5
0
Number of Surgeries
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
100
75
50
25
0
25
20
15
10
5
0
Number of Surgeries
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
Brain Tumors
20
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Neurological Institute
Metastasis: Survival
Schwannoma: Survival
Thirty-day survival for infratentorial craniotomy remained at 100 percent independent of
100
75
50
25
0
20
15
10
5
0
Number of Surgeries
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
100
75
50
25
0
10
8
6
4
2
0
Number of Surgeries
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
21
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Outcomes 2008
Pituitary Surgery: Survival
Pituitary Surgery
Pituitary Surgery: Inpatient Mortality
Inpatient mortality following pituitary surgery remained at zero percent. Expected mortality is based on national normative data and APR-DRGs, a method of adjusting for severity of patient illness.*
Among patients who underwent pituitary surgery, 30- and 180-day survival rates remained stable at more than 95 percent. For 180-day survival rates in 2008, data were available only for the first six months; only those patients with available data are included in the calculation.
100
75
50
25
0
100
75
50
25
0
Number of Procedures
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
1.2
1.0
0.8
0.6
0.4
0.2
0.02004
(N = 67)2005
(N = 60)2006
(N = 99)2007
(N = 81)2008
(N = 99)
Percent Mortality
0 0 0 0 0
ActualExpected
Brain Tumors
22
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Neurological Institute
Pituitary Surgery: Length of Stay
Pituitary Surgery: KPS Status (N = 11)
4
3
2
1
02004
(N = 67)2005
(N = 60)2006
(N = 99)2007
(N = 81)2008
(N = 99)
Days
Actual Mean (LOS)Expected Mean (LOS)
100
80
60
40
20
0Declined Improved No Change
Percent of Patients
2008
23
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Outcomes 2008
Stereotactic Radiosurgery: Gamma Knife®
Gamma Knife® Radiosurgery: Overall Survival
Gamma Knife® Radiosurgery: Meningioma Survival
patients with available data are included in the calculation.
100
75
50
25
0
400
300
200
100
02004 2005 2006 2007 2008
Number of Gamma Knife® ProceduresPercent Survival 30-Day 180-Day
100
80
60
40
20
0
50
40
30
20
10
0
Number of Gamma Knife® Procedures
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
Brain Tumors
24
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Neurological Institute
Gamma Knife® Radiosurgery: Metastasis Survival
Gamma Knife® Radiosurgery: Pituitary Tumor Survival
100
75
50
25
0
200
180
160
140
120
Number of Gamma Knife® Procedures
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
100
75
50
25
0
20
15
10
5
0
Number of Gamma Knife® Procedures
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
25
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Outcomes 2008
Stereotactic Radiosurgery: Novalis®
Gamma Knife® Radiosurgery: Schwannoma Survival
Novalis® Stereotactic Radiosurgery: Survival
and 180-day survival for this type of treatment, used to treat malignant and metastatic tumors
available data are included in the calculation.
100
80
60
40
20
0
50
40
30
20
10
0
Number of Gamma Knife® Procedures
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
100
75
50
25
0
100
75
50
25
0
Number of Novalis® Procedures
2004 2005 2006 2007 2008
Percent Survival 30-Day 180-Day
Brain Tumors
26
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Neurological Institute
Novalis® Stereotactic Radiosurgery: Treatment of Painful Spinal Metastases (N = 103)
2007 - 2008
Brief Pain Inventory (BPI) scores following spine radiosurgery in patients presenting with painful spinal metastases. Individual and mean patient scores + 1 s.e on the BPI, a 10-item self-rating pain scale, are plotted for baseline and various time periods — weeks 1-3 (W1-W3) and months 1, 3, 6 and 9 (M1, M3, M6, M9) — after spine radiosurgery. Higher scores indicate greater pain. Spine radiosurgery is a palliative treatment for pain, typically used in end-stage cancer patients. In 2007 and 2008, 103 patients with painful spinal metastases were treated with single fraction Novalis® spine radiosurgery. As early as week 1 after treatment, there was a statistically significant improvement in patient pain scores (P ≤ 0.001 for all time points except M9; P = 0.01 for M9). These results remained stable over time.
10
9
8
7
6
5
4
3
2
1
0
Baseline(N = 103)
W1(N = 69)
W2(N = 44)
W3(N = 50)
M1(N = 75)
M3(N = 54)
M6(N = 26)
M9(N = 19)
Brief Pain Inventory (BPI) Score
27
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Outcomes 200828
“Get With The Guidelines” Stroke Performance and Quality Measures
Measure Description
Acute ischemic stroke patients who arrive at the ED within 120 minutes of onset of stroke symptoms and who receive IV tPA within 180 minutes of onset of stroke symptoms
Patients with ischemic stroke or TIA who receive antithrombotic therapy by the end of hospital day 2
Patients with ischemic stroke or TIA prescribed antithrombotic therapy at discharge (e.g., warfarin, aspirin, other antiplatelet drug)
Patients with ischemic stroke or TIA with atrial fibrillation who are discharged on anticoagulation therapy
Patients with ischemic stroke, TIA or hemorrhagic stroke who are nonambulatory and receive DVT prophylaxis by the end of hospital day 2
Ischemic stroke or TIA patients with LDL >100, or LDL not measured or on cholesterol reducer prior to admission who are discharged on cholesterol-reducing drugs
Patients with ischemic, TIA or hemorrhagic stroke with a history of smoking cigarettes who are, or whose caregivers are, given smoking cessation counseling during the hospital stay
2008
88.9%
94.4%
99.7%
98.4%
97.0%
94.7%
91.5%
2007
60.0%
96.1%
98.6%
94.6%
93.6%
90.9%
100.0%
2006
85.0%
96.7%
96.2%
97.0%
91.3%
85.2%
85.0%
GWTG Stroke Performance Measure Goal
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
National Cleveland Clinic
Average*
72.8%
97.0%
98.9%
98.4%
89.5%
88.3%
93.6%
Clinical Measure
IV tPA use (eligible < 2 hour arrival)
Early antithrombotics (< 48 hour arrival)
Antithrombotics at discharge
Anticoagulation for atrial fibrillation
Deep venous thrombosis (DVT) prophylaxis
Lipids measure (statin at discharge)
Smoking cessation counseling
Get With The GuidelinesSM (GWTG) is a hospital-based performance and quality improvement program for the American
hospital’s commitment to superior patient care using current, evidence-based guidelines. Cleveland Clinic was a 2008
improvement.
with acute stroke or transient ischemic attack. Circulation
Cerebrovascular Disease
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Neurological Institute 29
Distribution of Major Cerebrovascular Procedures by Case Type
Ruptured Cerebral Aneurysm: Inpatient Mortality
The number of procedures for ruptured cerebral aneurysms increased 11 percent from
180
120
60
0
Number of Procedures
Ruptured Cerebral AneurysmNonruptured Cerebral AneurysmArteriovenous Malformation
2005 2006 2007 2008
30
20
10
0
Percent Mortality
ActualExpected
2005 2006 2007 2008
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Outcomes 200830
Ruptured Cerebral Aneurysm: Length of Stay (LOS)
Nonruptured Cerebral Aneurysm: Inpatient Mortality
mortality seen in our patient population (patients may be spending more time in the hospital
20
15
10
5
0
Days
Actual Mean LOSExpected Mean LOS
2005 2006 2007 2008
3
2
1
0
Percent Mortality
2005 2006 2007 2008
Actual Expected
Cerebrovascular Disease
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Nonruptured Cerebral Aneurysm: Length of Stay
6
4
2
0
Days
2005 2006 2007 2008
Actual Mean LOSExpected Mean LOS
31Neurological Institute
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Outcomes 2008
Conditions Treated with Endovascular Therapy (N = 366)
2008
Aneurysm 36%
Other 3%
Cerebrovascular Disease
32
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Neurological Institute 33
Endovascular Procedures: Inpatient Mortality
Endovascular Procedures: Length of Stay
20
15
10
5
0
Percent Mortality
2005(N = 51)
2006(N = 72)
2007(N = 87)
2008(N = 86)
Actual Expected
20
15
10
5
0
Days
2005(N = 51)
2006(N = 72)
2007(N = 87)
2008(N = 86)
Actual Mean LOSExpected Mean LOS
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Outcomes 200834
Microsurgery: Inpatient Mortality
Microsurgery: Length of Stay
10
8
6
4
2
0
Percent Mortality
2005(N = 81)
2006(N = 79)
2007(N = 59)
2008(N = 45)
Actual Expected
10
8
6
4
2
0
Days
2005(N = 81)
2006(N = 79)
2007(N = 59)
2008(N = 45)
Actual Mean LOSExpected Mean LOS
Cerebrovascular Disease
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Neurological Institute 35
Aneurysm and Ischemic Stroke: Discharge Status
2008
Stroke: Inpatient Mortality
Stroke
30
20
10
0
Percent Mortality
2005 2006 2007 2008
Actual Expected
Ruptured Aneurysm Nonruptured Aneurysm Ischemic Stroke
A
Other 10% 2% 6%
65315_CCFBCH_Text_ACG 35 7/7/09 3:39:26 PM
Long-Term Seizure Freedom following Frontal Lobe Surgery for Epilepsy (N = 132)
1.0
0.8
0.6
0.4
0.2
0.0
Probability of Seizure Freedom
10 2 3 4 5 6
Years from Surgery
7 8 9 10 11 12
Time from Surgery 6 months 1 year 2 years 5 years
Epilepsy
Outcomes 200836
65315_CCFBCH_Text_ACG 36 7/7/09 3:39:28 PM
1.0
0.8
0.6
0.4
0.2
0.0
Probability of Seizure Freedom
Years from Surgery
10 2 3 4 5 6 7 8 9
Long-Term Seizure Freedom following Parieto-Occipital Lobe Surgery for Epilepsy (N = 61)
Time from Surgery 6 months 1 year 2 years 5 years
Epilepsy surgery in the parieto-occipital lobe is relatively infrequent, compared to frontal and temporal lobe
37Neurological Institute
65315_CCFBCH_Text_ACG 37 7/7/09 3:39:30 PM
Outcomes 200838
1.0
0.8
0.6
0.4
0.2
0.0
Probability of Seizure Freedom
Years from Surgery
10 2 3 4 5 6 7 8 9 10
Long-Term Seizure Freedom following Temporal Lobe Surgery for Epilepsy (N = 550)
Time from Surgery 1 year 2 years 5 years 10 years
in seizure frequency). National seizure-free rates represent a weighted average of recent studies conducted in the .
Mil Med.
study. Neurology. Neurology.
Neurology.
Neurology.
Epilepsia.
JAMA.
Epilepsy
65315_CCFBCH_Text_ACG 38 7/7/09 3:39:32 PM
Neurological Institute 39
45
35
25
15
5
Quality of Life in Epilepsy (QOLIE-10) Score
After SurgeryBefore Surgery
Improvement in Quality of Life following Epilepsy Surgery (N = 22)
Quality of Life before and after Epilepsy Surgery
implemented practice of assessing a comprehensive set of health status measures allows us to evaluate our patients’ global state of health following surgery.
effects and mental effects of medication), mental health (energy, depression, overall quality of life) and role
65315_CCFBCH_Text_ACG 39 7/7/09 3:39:34 PM
Outcomes 200840
100
80
60
40
20
0
Percent of Patients
Before After
0
None Moderate
Problems Performing Typical Daily Activities
Severe
80
60
40
20
0
Percent of Patients
None Moderate
Mood Symptoms (Depression/Anxiety)
Severe
Before After
0
Functional Status before and after Epilepsy Surgery (N = 24)
Mood Symptoms before and after Epilepsy Surgery (N = 24)
through November 2008 and who had functional status data collected both before and after surgery.
through November 2008 and who had mood symptom data collected both before and after surgery.
Epilepsy
65315_CCFBCH_Text_ACG 40 7/7/09 3:39:36 PM
Neurological Institute
20
10
0Before
Surgery
After
Percent of Patients Driving
0
Driving before and after Epilepsy Surgery (N = 22)
Surgical Dates: January 2007 – November 2008
Regaining driving privileges is a major goal for most epilepsy patients. Following epilepsy surgery, 14 percent of patients were able to return to driving. Mean follow-up was 5.7 months after surgery. Information is based on 22 adult patients who had epilepsy surgery from January 2007 through November 2008 and who provided driving status both before and after surgery (P = 0.04, chi-square test).
41
65315_CCFBCH_Text_ACG 41 7/10/09 10:13:50 AM
90
70
50
30
10
-10
LSSS
After SurgeryBefore Surgery
Improvement in Seizure Severity following Epilepsy Surgery (N = 19)
In addition to seizure severity, the average seizure frequency was reduced from 12.3 seizures per month before surgery to 2.2
Epilepsy
Outcomes 200842
65315_CCFBCH_Text_ACG 42 7/7/09 3:39:49 PM
40
20
0Preoperative Postoperative
Stimulator OffPostoperativeStimulator On
Average Unified Parkinson’s Disease Rating Scale (UPDRS) Score
Parkinson’s Disease: Improvement in Motor Scores with Deep Brain Stimulation (DBS) (N = 27)
2008
Movement Disorders
43Neurological Institute
65315_CCFBCH_Text_ACG 43 7/7/09 3:39:51 PM
Outcomes 2008
1200
800
400
0Before DBS After DBS
Mean Levodopa Equivalent Dose (Milligrams)
Parkinson’s Disease: Reduction in Medication Dose with DBS (N = 27)
2008
Movement Disorders
44
65315_CCFBCH_Text_ACG 44 7/7/09 3:39:53 PM
Neurological Institute 45
Intrathecal Baclofen Therapy
after the surgery. The hardware was removed, and the patient opted to have the pump reimplanted a few months later. No patients chose to discontinue the therapy.
Diagnosis/Indication for ITB Number of Patients
Cerebral Arteritis 1
Multiple Sclerosis
65315_CCFBCH_Text_ACG 45 7/7/09 3:39:53 PM
4
3
2
1
0Before After
Treatment
Spasticity Score
2008
increase in tone) at baseline and after ITB therapy
10 , paired t-test) reduction in spasticity after
was 160 days.
Multiple Sclerosis
46 Outcomes 2008
65315_CCFBCH_Text_ACG 46 7/7/09 3:39:56 PM
Neurological Institute 47
4
3
2
1
0Before After
Treatment
Spasm Frequency Score
10
8
6
4
2
0Before After
Treatment
Mean Pain Score
Spasm Frequency before and after ITB (N=17)
2008
Pain Scores before and after ITB (N = 17)
2008
, paired
65315_CCFBCH_Text_ACG 47 7/7/09 3:39:59 PM
Outcomes 2008
bothersome spasticity, which may interfere with activities of daily living, sleep and quality
patients after ITB.
25
20
15
10
5
0Before After
Treatment
Mean Gait Speed (Seconds)
Gait Speed before and after ITB Timed 25-Foot Walk (N = 7)
2008
test, following ITB for the patients who remained ambulatory.
Multiple Sclerosis
48
65315_CCFBCH_Text_ACG 48 7/7/09 3:40:00 PM
Neurological Institute 49
Natalizumab (Tysabri®) Therapy
administer Natalizumab.
1.0
0.8
0.6
0.4
0.2
0.00 252015105
Months from Treatment Initiation
Probability of Remaining on Natalizumab
Time to Tysabri® Treatment Discontinuation (N = 195)
65315_CCFBCH_Text_ACG 49 7/7/09 3:40:02 PM
Outcomes 200850
Reasons for Discontinuing Natalizumab (N = 51)
Number of Reason for Discontinuation Patients Details
Allergy 6
Antibodies 2 Two patients developed neutralizing antibodies against Natalizumab.
Infections 2 Two patients developed infections that were neither severe nor due to opportunistic organisms.
related to Natalizumab.
Other 6 One patient became pregnant, one patient moved and was not able to continue Natalizumab for logistical reasons and four patients had a change in insurance resulting in lack of coverage for Natalizumab therapy.
Deceased 1 One patient died; the cause was not related to Natalizumab.
Multiple Sclerosis
65315_CCFBCH_Text_ACG 50 7/7/09 3:40:03 PM
Neurological Institute 51
Multiple Sclerosis (MS) Literacy Assessment and Patient Education
100
75
50
25
0Before After
Percent Correct
Health Literacy Test Results before and after Patient Education (N = 47)
Average percentage correct on 11 multiple choice questions assessing health literacy improved following the
participant attending a single educational session.
65315_CCFBCH_Text_ACG 51 7/7/09 3:40:04 PM
52
6
4
2
0Initial Follow-up
Visit
Mean MG-ADL* Score
Myasthenia Gravis Functional Status (N = 12)
2008
Myasthenia Gravis
Neuromuscular Disease
Outcomes 2008
65315_CCFBCH_Text_ACG 52 7/7/09 3:40:07 PM
53
headache and chronic daily headache may receive intravenous infusion
patients treated in 2008.
40
30
20
10
00-24 25-49 50-74
Percent Pain Reduction
75-100
Percent of Patients
Infusion Therapy for Headache
Pain Reduction Immediately following Infusion Therapy (N = 196)
2008
Pain/Headache
Neurological Institute
65315_CCFBCH_Text_ACG 53 7/7/09 3:40:09 PM
Outcomes 200854
Interdisciplinary Method for the Assessment and Treatment of Chronic Headache (IMATCH)
a more comprehensive assessment of their pain, patients are asked to rate their current pain as well as pain over the preceding week. Current pain is the level of pain at that moment; average, least and worst levels of pain are reported for the preceding week. Information is
in 2008.
subscale scores are plotted with their standard deviations.
10
8
6
4
2
0
Pain Score(0 = No Pain; 10 = Worst Possible Pain)
Current Average
Pain
Least Worst
AdmissionDischarge
30
20
10
0
Depression Anxiety Stress Scale (DASS) Score
AdmissionDischarge
Stress(0-42)
Anxiety(0-42)
Depression(0-42)
Pain Ratings before and after IMATCH (N = 64)
2008
Stress, Anxiety and Depression before and after IMATCH (N = 64)
2008
Pain/Headache
65315_CCFBCH_Text_ACG 54 7/7/09 3:40:12 PM
Neurological Institute 55
80
60
40
20
0
Disability Score
AdmissionDischarge
Pain Disability Index(0-70)
Headache Impact Test(36-78)
5
4
3
2
1
0Whole Program Medical
TreatmentPsychological
Treatment
Program Components
Physical TherapyTreatment
Average Satisfaction Score
Functional Status before and after IMATCH (N = 64)
2008
Patient Satisfaction with IMATCH (N = 64)
2008
65315_CCFBCH_Text_ACG 55 7/7/09 3:40:14 PM
56
Cleveland Clinic Chronic Pain Rehabilitation Program
to the treatment of patients with chronic pain. These patients typically have pain that is
distress as well.
were disabled.
300
200
100
02004 2005 2006 2007 2008
Number of Patients
Chronic Pain Rehabilitation Program Admissions
Pain/Headache
Outcomes 2008
65315_CCFBCH_Text_ACG 56 7/7/09 3:40:16 PM
57
100
75
50
25
02004 2005 2006 2007 2008
Percent of Patients Completing Program
10
8
6
4
2
0
Mean Pain Score(0=No Pain; 10=Worst Possible Pain)
AdmissionDischarge6-month Follow-up
2004 2005 2006 20082007
Chronic Pain Rehabilitation Program Completion Rate
Pain Intensity before and after CPRP
Neurological Institute
65315_CCFBCH_Text_ACG 57 7/7/09 3:40:18 PM
Outcomes 200858
Depression scores, as measured with the DASS depression subscale, show improvement following treatment. Higher scores indicate more severe depression.
Anxiety scores, as measured with the DASS anxiety subscale, show improvement following treatment. Higher scores indicate more severe anxiety.
30
20
10
0
Mean Depression Anxiety Stress Scale Score
2006 20082007
AdmissionDischarge6-month Follow-up
20
10
0
Mean Depression Anxiety Stress Scale Score
2006 20082007
AdmissionDischarge6-month Follow-up
Depression before and after CPRP
Anxiety before and after CPRP
Pain/Headache
65315_CCFBCH_Text_ACG 58 7/9/09 12:38:43 PM
Neurological Institute 59
scores indicate greater disability.
improvement, as it suggests that their lives are less affected by their pain.
60
40
20
0
Mean Pain Disability Index (PDI)
2004 2007 200820062005
AdmissionDischarge6-month Follow-up
25
20
15
10
5
0
Mean Hours of Rest
Admission6-Month Follow-up
2006 2007 2008
Functional Status before and after CPRP
Activity Level before and after CPRP
65315_CCFBCH_Text_ACG 59 7/7/09 3:40:23 PM
60
as the number of headache days in the previous three months. Comparing group means for headache frequency between visit 1 and visit 2, there was an improvement
assessment on at least two occasions in 2008.
40
30
20
10
0
Mean
Visit 1Visit 2
PedsMIDAS Headache Frequency Rescue Doses
Pediatric Headache
Headache Disability (N = 46)
2008
Pediatric Neurology
Outcomes 2008
65315_CCFBCH_Text_ACG 60 7/7/09 3:40:26 PM
61
number of complete and partial school days missed in the preceding three months
12
8
4
0Visit 1 Visit 2
School Days Missed
School Days Missed (N = 17)
2008
Neurological Institute
65315_CCFBCH_Text_ACG 61 7/7/09 3:40:28 PM
Outcomes 200862
*mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard
200
150
100
50
0New Patient Consults Diagnosis Established via Muscle,
Genetic or CSF* Testing
Number of Patients
Pediatric Neurometabolic Clinic
The term idiopathic developmental delay
remained largely without a diagnosis. With advances in technology and improving diagnostic skills, the ability to reach conclusive diagnoses in this population has steadily improved. While there is no national standard for diagnostic yield in this patient population, tertiary care centers such as ours have the potential
Neurometabolic Clinic Diagnostic Yield
Pediatric Neurology
65315_CCFBCH_Text_ACG 62 7/7/09 3:40:38 PM
63
Cleveland Clinic is one of very few medical centers in the country that provide high-quality
Pediatric Electromyography (EMG)
Pediatric EMG
70
60
50
40
30
20
10
0
Number of Studies
Total EMGsEMGs with OR/Sedation
2004 2005 2006 20082007
Neurological Institute
65315_CCFBCH_Text_ACG 63 7/7/09 3:40:56 PM
Outcomes 200864
patient illness.*
Pediatric Congenital Malformation: Length of Stay (LOS)
Chiari Malformation: Length of Stay
8
6
4
2
0
40
30
20
10
0
Days (Mean LOS) Number of ProceduresActual Expected
2005 2006 2007 2008
80
60
40
20
0
8
6
4
2
0
Days (Mean LOS) Number of ProceduresActual Expected
2005 2006 2007 2008
Pediatric Neurosurgery
65315_CCFBCH_Text_ACG 64 7/7/09 3:40:59 PM
Neurological Institute 65
such as laminectomy with section of the spinal accessory nerve and implantation of a drug infusion device.
Chiari Malformation: Inpatient Mortality
Spasticity: Length of Stay
5
4
3
2
1
0
Percent Mortality
2005
0 0 0
2006 2007 2008
Actual MortalityExpected Mortality
100
75
50
25
0
8
6
4
2
0
Days (Mean LOS) Number of ProceduresActual Expected
2005 2006 2007 2008
65315_CCFBCH_Text_ACG 65 7/7/09 3:41:02 PM
Outcomes 200866
Pediatric Hydrocephalus: Length of Stay
50
40
30
20
10
0
10
8
6
4
2
0
Days (Mean LOS) Number of ProceduresActual Expected
2005 2006 2007 2008
Pediatric Neurosurgery
65315_CCFBCH_Text_ACG 66 7/7/09 3:41:23 PM
Neurological Institute 67
scores, a measure of depression severity, were compared from baseline to one year after the
Change in Depressive Symptoms with Group Medication Management (N = 29)
10
5
0Baseline 1 Year
Mean PHQ-9** Score
Women’s Mental Health Management Group for Depression
Psychiatric Disorders
65315_CCFBCH_Text_ACG 67 7/7/09 3:41:24 PM
Outcomes 200868
on this measure.
100
75
50
25
0
Percent of Patients
Baseline1 Year
Not at all Somewhat Very Extremely
0% 0%
Psychiatric Disorders
65315_CCFBCH_Text_ACG 68 7/7/09 3:41:36 PM
Neurological Institute
Depressive Symptoms before and after Treatment (N = 202)
2008
Inpatient Treatment for Depression
40
30
20
10
0
Mean Scale Score
AdmissionDischarge
Hamilton DepressionScale
Montgomery-AsbergDepression Rating Scale
69
65315_CCFBCH_Text_ACG 69 7/7/09 3:41:38 PM
Outcomes 200870
scores of less than eight are considered normal.
Binge Eating
Binge Eating Disorder (BED). BED has been associated with poorer surgery outcomes, including weight regain, and is thus an important factor to assess and treat for bariatric surgery patients.*,
satisfaction questionnaire.
Illness Severity and Manic Symptoms before and after Treatment (N = 202)
2008
7
6
5
4
3
2
1
0
Mean Scale Score
Clinical Global ImpressionSeverity Scale
Young Mania Rating Scale
AdmissionDischarge
Psychiatric Disorders
65315_CCFBCH_Text_ACG 70 7/7/09 3:41:39 PM
Neurological Institute 71
whom information is available.
Binge Eating before and after Therapy (N = 168)
2008
30
20
10
0
Number
Before TreatmentAfter Treatment
Average BES Average Number ofBinge Eating Episodes
Eat
Weight Disord.
a review. Psychosom Med.
Addict Behav.
65315_CCFBCH_Text_ACG 71 7/7/09 3:41:40 PM
Outcomes 200872
Patients with 2 or More Binge Eating Episodes per Week before and after Therapy (N = 168)
2008
160
120
80
40
0Before After
Treatment
Number of Patients
binge eating disorder (two or more binges per week). Only 61 patients (36 percent) met the
with 33 percent afterward.
Psychiatric Disorders
65315_CCFBCH_Text_ACG 72 7/7/09 3:41:54 PM
Neurological Institute 73
Adult Sleep Studies
There has been a progressive increase in the number of adult sleep studies over the past four years.
The number of pediatric sleep studies has doubled in the past three years.
Pediatric Sleep Studies
4,000
3,000
2,000
1,000
0
Number of Studies
PSG/EEGCPAP/BiPAPSplitMSLT/MWT
2007 200820062005
400
300
200
100
0
Number of Studies
2006 2007 2008
Sleep Disorders
65315_CCFBCH_Text_ACG 73 7/7/09 3:41:57 PM
Sleep Apnea
15
10
5
0
Epworth Sleepiness Scale Score
Before CPAP/BiPAPAfter CPAP/BiPAP
Average Median
Sleepiness before and after Treatment (N = 217)
2008
Sleep Disorders
Outcomes 200874
65315_CCFBCH_Text_ACG 74 7/7/09 3:42:01 PM
Neurological Institute 75
60
40
20
0
Fatigue Severity Scale Score
Average Median
Before CPAP/BiPAPAfter CPAP/BiPAP
Fatigue before and after Treatment (N = 212)
2008
65315_CCFBCH_Text_ACG 75 7/7/09 3:42:02 PM
76
10
8
6
4
2
0
Patient Health Questionnaire-9 Score
Average Median
Before CPAP/BiPAPAfter CPAP/BiPAP
Depressive Symptoms before and after Treatment (N = 212)
2008
Sleep Disorders
Outcomes 2008
65315_CCFBCH_Text_ACG 76 7/7/09 3:42:16 PM
77
30
20
10
0
Functional Outcomes of Sleep Questionnaire Score
Average Median
Before CPAP/BiPAPAfter CPAP/BiPAP
Functional Status before and after Treatment (N = 216)
2008
Neurological Institute
65315_CCFBCH_Text_ACG 77 7/7/09 3:42:25 PM
Outcomes 200878
4
3
2
1
0
Mean FOSQ Subscale Score
GeneralProductivity
SocialOutcomes
ActivityLevel
Vigilance IntimateRelationships
Before CPAP/BiPAPAfter CPAP/BiPAP
Functional Status Domains before and after Treatment (N = 216)
Sleep Disorders
65315_CCFBCH_Text_ACG 78 7/7/09 3:42:27 PM
Neurological Institute 79
Degenerative spine disease is the most common diagnosis among patients who undergo surgery.
1,000
750
500
250
0Lumbar Cervical Thoracic
Number of Procedures
1,400
1,200
1,000
800
600
400
200
0
Number of Procedures
Degenerative Deformity Fracture/Trauma
OtherTumor
Spine Surgical Cases
2008
Distribution of Spine Surgical Cases by Disease Category
2008
Spinal Diseases
65315_CCFBCH_Text_ACG 79 7/7/09 3:42:30 PM
approach for diagnosis, treatment, patient satisfaction and quality for patients with
tumor cases through a logic-based decision-making process. The annual increase in patients and cases studied is attributed to the unique team approach.
300
200
100
0
Patients/Cases
200620072008
Total Cases StudiedTotal Patients Studied
Patients and Cases Studied in Tumor Board Review
Spinal Diseases
80 Outcomes 2008
65315_CCFBCH_Text_ACG 80 7/7/09 3:42:33 PM
81
Outpatient visits trended upward during the 2005 - 2008 period in the Center for Spine Health, representing an overall increase of 34 percent in patient volume.
32,000
24,000
16,000
8,000
0
Total Visits
2005 2006 2007
Year
2008
Center for Spine Health Total Outpatient Visits
2008
Neurological Institute
65315_CCFBCH_Text_ACG 81 7/9/09 12:39:59 PM
Outcomes 200882
Image-guided procedures include spinal arteriograms, Wada tests, diagnostic and
and placement of subarachnoid drains.
The number of cerebral angiographies performed increased by 33 percent in 2008
700
600
500
400
300
200
100
0
Number of Procedures
DiagnosticTherapeutic
2006 2007 2008
4,000
3,000
2,000
1,000
0
Number of Procedures
2006 2007 2008
Image-Guided Procedures
Cerebral Angiography
Neuroimaging
65315_CCFBCH_Text_ACG 82 7/7/09 3:42:39 PM
* Computed Tomography
50,000
40,000
30,000
20,000
10,000
0
Number of Studies
Head CT*Brain MRI**Neurovascular Ultrasound
2006 2007 2008
Cross-Sectional Imaging Studies
83Neurological Institute
65315_CCFBCH_Text_ACG 83 7/7/09 3:42:41 PM
Outcomes 200884
studies as an overall measure of quality assurance. Neuroradiology staff members reinterpret representative samples of their
report is placed into one of three categories: (1) agree with the initial report, (2) mostly agree with the initial report, with no
Because the review takes place daily, the delay in patient care is minimized.
100
80
60
40
20
0
Percent of Studies Reviewed
Strongly DisagreeMostly AgreeAgree
Ultrasound CT
Type of Imaging Study
MRI
Neuroradiology Interobserver Variability
2008
Neuroimaging
65315_CCFBCH_Text_ACG 84 7/7/09 3:42:43 PM
Neurological Institute 85
Median Turnaround Time (Minutes)
Jan(N = 2,198)
Feb(N = 2,655)
Mar(N = 2,667)
Apr(N = 2,915)
May(N = 2,866)
Jun(N = 2,638)
Jul(N = 2,515)
Aug(N = 2,693)
Sep(N = 2,544)
Oct(N = 2,946)
Nov(N = 2,634)
Dec(N = 2,752)
0 25 50 75 100
Month (Number of Reports)
Neuroradiology Report Turnaround Time: CT
2008
65315_CCFBCH_Text_ACG 85 7/7/09 3:42:44 PM
Outcomes 200886
Median Turnaround Time (Minutes)
Jan(N = 3,339)
Feb(N = 3,625)
Mar(N = 3,963)
Apr(N = 4,035)
May(N = 3,973)
Jun(N = 3,966)
Jul(N = 4,002)
Aug(N = 3,768)
Sep(N = 3,876)
Oct(N = 4,277)
Nov(N = 3,662)
Dec(N = 3,973)
0 25 50 75 100
Month (Number of Reports)
Neuroradiology Report Turnaround Time: MRI
2008
Neuroimaging
65315_CCFBCH_Text_ACG 86 7/7/09 3:42:46 PM
Neurological Institute 87
Median Time to Notification (Minutes)
Month (Number of Reports)
Jan(N = 7)
Feb(N = 16)
Mar(N = 21)
Apr(N = 18)
May(N = 29)
Jun(N = 13)
Jul(N = 14)
Aug(N = 19)
Sep(N = 17)
Oct(N = 29)
Nov(N = 19)
Dec(N = 10)
0 10 20 30
Brain Attack Head CT Reporting
2008
65315_CCFBCH_Text_ACG 87 7/7/09 3:42:47 PM
100
80
60
40
20
0
Percent of Patients
VomitingNausea OnlyNo Nausea or Vomiting
Q1(N = 119)
Q2(N = 149)
Q3(N = 103)
Q4(N = 110)
Nausea and Vomiting within 24 Hours of Craniotomy
2008
in the hospital to evaluate the early postoperative period. One outcome measure, collected from medical record review, is postoperative nausea and vomiting. The department features the management of postoperative nausea and vomiting in its clinical quality improvement program.
Neurosurgical Anesthesia
Outcomes 200888
65315_CCFBCH_Text_ACG 88 7/7/09 3:42:49 PM
100
80
60
40
20
0
Percent of Patients
VomitingNausea OnlyNo Nausea or Vomiting
Q1(N = 215)
Q2(N = 167)
Q3(N = 172)
Q4(N = 161)
Nausea and Vomiting within 24 Hours of Spine Surgery
2008
second postoperative day in the hospital to evaluate the early postoperative period. Information on postoperative nausea and vomiting is collected from medical record review.
89Neurological Institute
65315_CCFBCH_Text_ACG 89 7/7/09 3:42:51 PM
100
75
50
25
0
Percent of Patients Responding with Highest Rating
Q1(N = 35)
Q2(N = 41)
Q3(N = 22)
Q4(N = 21)
Patient Satisfaction with Anesthesia Care for Craniotomy
2008
During rounds on the second postoperative day, patients are asked to respond to the
Neurosurgical Anesthesia
Outcomes 200890
65315_CCFBCH_Text_ACG 90 7/7/09 3:42:53 PM
100
75
50
25
0
Percent of Patients Responding with Highest Rating
Q1(N = 117)
Q2(N = 84)
Q3(N = 80)
Q4(N = 71)
Patient Satisfaction with Anesthesia Care for Major Spine Surgery
2008
rating.
91Neurological Institute
65315_CCFBCH_Text_ACG 91 7/7/09 3:42:54 PM
Outcomes 200892
Surgical Quality Improvement
Hospital Compare: Surgical Care Improvement Project (SCIP)
SCIP - Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision (N = 902)
data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also
0 20
* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008
40 60 80 100
Percent of Patients
NationalAverage*
ClevelandClinic
86
95
65315_CCFBCH_Text_ACG 92 7/7/09 3:42:56 PM
Neurological Institute 93
SCIP - Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time (N = 813)
SCIP - Prophylactic Antibiotic Selection for Surgical Patients (N = 937)
0 20
* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008
40 60 80 100
Percent of Patients
NationalAverage*
ClevelandClinic
84
82
0 20
* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008
40 60 80 100
Percent of Patients
NationalAverage*
ClevelandClinic
92
95
65315_CCFBCH_Text_ACG 93 7/7/09 3:43:00 PM
Outcomes 200894
Surgical Quality Improvement
SCIP - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (N = 677)
SCIP - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery (N = 677)
0 20
* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008
40 60 80 100
Percent of Patients
NationalAverage*
ClevelandClinic
84
96
0 20
* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008
40 60 80 100
Percent of Patients
NationalAverage*
ClevelandClinic
81
95
65315_CCFBCH_Text_ACG 94 7/7/09 3:43:03 PM
Neurological Institute 95
SCIP - Surgery Patients with Appropriate Hair Removal (N = 1,386)
0 20
* Source: www.hospitalcompare.hhs.gov, discharges January - June 2008
40 60 80 100
Percent of Patients
NationalAverage*
ClevelandClinic
95
94
Neurosurgery Morbidity (N = 80)
0
10
20
30Percent
ObservedExpected
National Surgical Quality Improvement Project
65315_CCFBCH_Text_ACG 95 7/7/09 3:43:06 PM
Outcomes 200896
way that elevates Cleveland Clinic’s reputation as one of the world’s best hospitals.
patient- and family-based programs that support this mission.
Outpatient – Neurological Institute
100
80
0
60
40
20
Percent
Excellent Very Good Good Fair Poor
Source: Quality Data Management, a national hospital survey vendor
2008 (N = 6,221)2007 (N = 5,584)
Overall Rating of Outpatient Care and Services
Patient Experience
65315_CCFBCH_Text_ACG 96 7/7/09 3:43:09 PM
Neurological Institute 97
Recommend Outpatient Provider
100
80
0
60
40
20
Percent
Excellent Very Good Good Fair Poor
Source: Quality Data Management, a national hospital survey vendor
2008 (N = 6,221)2007 (N = 5,584)
100
80
0
60
40
20
Percent
ExtremelyLikely
Source: Quality Data Management, a national hospital survey vendor
Very Likely SomewhatLikely
SomewhatUnlikely
VeryUnlikely
2008 (N = 6,221)2007 (N = 5,584)
Rating of Outpatient Provider
65315_CCFBCH_Text_ACG 97 7/7/09 3:43:13 PM
Outcomes 200898
100
80
0
60
68%62%
40
20
Percent
Rate Hospital Would Recommend
% respondentschoosing 9 or 10
% respondents choosing'definitely yes'
Source: Quality Data Management and Press Ganey, national hospital survey vendors
For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.
2008 total survey respondents = 1,1132007 total survey respondents = 732
78% 73%
HCAHPS Overall Assessment
Inpatient – Neurological Institute
reporting are available at www.hospitalcompare.hhs.gov.
Patient Experience
65315_CCFBCH_Text_ACG 98 7/7/09 3:43:15 PM
Neurological Institute 99
100
80
0
60
40
20
Percent
DischargeInformation
Doctor Communication
Nurse Communication
PainManagement
RoomClean
CommunicationNew Medications
Responsivenessto Needs
Quiet atNight
Respondents choosing 'always' or 'yes'
Source: Quality Data Management and Press Ganey, national hospital survey vendors
For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.
2008 total survey respondents = 1,1132007 total survey respondents = 732
HCAHPS Domains of Care
65315_CCFBCH_Text_ACG 99 7/7/09 3:43:21 PM
Outcomes 2008
Innovations
42 — Number of new Neurological Institute clinical research trials in 2008.
1,690 — Number of patients enrolled in Neurological Institute clinical research trials.
Before-and-after treatment views of a magnetic resonance
system.
A Novel, Minimally Invasive Therapy for Brain Tumors Brain Tumor and Neuro-Oncology Center (BTNC)
laser-based system in a human for the minimally invasive (laser interstitial
Inc. (Winnipeg, Canada), is used to coagulate tumors through a special laser probe, precisely directed into the tumor, with the heating process monitored by specialized software and thermal
tumors and spare patients more invasive interventions.
100
round, whitish area, indicated by an arrow) in the deep portion of the left temporal lobe. The image to the right shows the lesion having been essentially eradicated by
(arrow). The markers to the right in each
vertical line indicates an interval of 1 cm.
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Neurological Institute 101
Distribution of patients by type of primary cancer in study of
Cranial Radiosurgery for the Older Old
While cancer can occur at any age, its incidence increases directly with age. By the year 2030, the proportion of the
as 28 percent. With improvements in health and nutrition,
With respect to cancer that spreads to the brain from a site elsewhere (such as lung, breast or kidney cancer), data
age was associated with a poorer prognosis, irrespective of whether the patient received surgery, whole brain radiation
shown to play effective roles in the treatment of brain metastasis.
the sole treatment for these brain metastases, meaning that whole brain radiation was generally not given or was given only with nonresponsiveness, which was rare, or later, when
one or more brain metastases produced results comparable to the results found in younger patients, nearly all of whom
months, with more than a third surviving one year and
brain — remained the principal challenge, although recent innovations in therapies for these cancers appear to be improving overall survival as well.
followed by patients with tumors of the kidney and genitourinary
older patients. Cancer.
9% Melanoma (N = 4)9% Melanoma (N = 4)7% Lung (SLC) (N =3)7% Lung (SLC) (N =3)7% Breast (N = 3)7% Breast (N = 3)7% Unknown (N = 3)7% Unknown (N = 3)
11% GI Tract (N = 5)11% GI Tract (N = 5)
20% GU Tract (N = 9)20% GU Tract (N = 9)
39% Lung (NSCLC) (N = 17)39% Lung (NSCLC) (N = 17)
100%100%
65315_CCFBCH_Text_ACG 101 7/7/09 3:43:25 PM
Outcomes 2008102
Innovations
Stereotactic Radiosurgery of Spinal Tumors
The development of metastases to the spinal column occurs
lead to instability of the spinal column or compression of the spinal cord or nerve roots, and may be associated with disabling pain, neurological dysfunction and paralysis. Early treatment to prevent complications and enhance function is essential.
Traditional treatment options include surgery, conventional radiation therapy, chemotherapy and comprehensive pain management. Now, Cleveland Clinic’s Brain Tumor and
modality that delivers a high dose of radiation to spinal metastases in a conformal fashion, precisely enveloping the
spread beyond the target.
procedure with minimal recovery time. This highly selective, precise radiation therapy results in effective relief of pain —
In our recently reviewed series of more than 100 treated
this observation is not likely to be due to chance alone.])
consistent after therapy, even at 12 months following
perceived to be radioresistant, such as renal cell carcinoma and melanoma.
therapy. (A) The scan shows a painful metastasis to the right side
lumbar vertebral body. The tumor measures nearly 6 cm. (green
taking high doses of morphine but had poor pain control. After a
by one month, he needed only an over-the-counter medication,
ibuprofen, and by three months, he was permanently off all pain
medication. (B)
reduction in the size of the tumor, a reduction that has been
long-standing.
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Neurological Institute 103
Integrating Molecular Genetic Information for Tailored Treatment of Patients with Oligodendroglioma
The discovery of a genetic alteration in oligodendrogliomas that was prognostic of improved response to treatment and
radiation and chemotherapies.
provided by analysis of this alteration, also referred to as
Neuro-Oncology*, the
the use of a chemotherapy-only treatment for patients with
anaplastic gliomas. These studies, which are opening in
patients with grade III gliomas.
1p-deleted grade III oligodendroglioma. The image on the left shows
the patient before the start of chemotherapy with no radiation;
and white arrows). The inset, top, shows the relative loss of one
copy of chromosome 1p in the tumor tissue of a patient with the
deletion (arrow shows the bottom copy missing in the tumor, T,
column), compared with the normal (N) signal in blood cells.
Neuro Oncol. Advance
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104
Innovations
Epilepsy CenterEnhanced Localization Ability with Magnetoencephalography (MEG)
launched in 2008, has enhanced the center’s clinical capabilities
to better identify epileptic sources in patients where the area of
the epileptic focus, b) help guide the placement of intracranial recording electrodes or c) ascertain that the patient is not a surgical candidate.
Our Neurocomputing and Clinical Neurophysiology teams have
advanced. These new developments include the following:
would otherwise obscure the brain activity.
direct correlation of the patient’s physical actions with the
online database to facilitate ongoing quality assessment.
17 — Number of years we have hosted our International Epilepsy Symposium.
Outcomes 2008
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Neurological Institute 105
Mellen Center for Multiple Sclerosis Treatment and ResearchPlasma Exchange as Treatment for Rare Natalizumab Complication
unknown, and treatment options are limited. A drug called
from entering the brain and attacking nerves, but the drug
Natalizumab have suffered an uncommon, but usually fatal
leukoencephalopathy).
Neurology,*
This study showed that monoclonal antibodies can be
needed to effectively remove Natalizumab from the bodies of
with Natalizumab, which would improve the overall safety of this therapy.
and restoring leukocyte function. Neurology
Optical Coherence Tomography (OCT) to Monitor Axonal Injury
OCT is a rapid, noninvasive, painless test that generates
utilization of OCT to measure the thickness of the retinal
form the optic nerve, which connects the eye to the brain) and the volume of the macula (the nerve cell bodies
treatment trials.
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Outcomes 2008106
Innovations
Innovative Study Recruitment Method
(N = 1,611). This novel recruitment method can dramatically accelerate research in chronic disease management.
Center for Neuroimaging
Correcting Motion-Corrupted High-Angular Resolution Diffusion-Weighted Imaging (HARDI) Data
error on the diffusion direction is below 0.2 degrees.
(B) tensor-reference motion correction.
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Neurological Institute 107
Activation Data
most common method of assessing connectivity is to measure the temporal correlation between two functional brain regions. Due to individual variation in functional localization in the human brain, a standard technique for
imposes a serious limitation on the ability to analyze functional connectivity in the human brain in studies in which
on combining anatomic landmarks with a regional measure of temporal coherence. This measure, derived from
The high-resolution anatomic image on the left shows a slice through the anterior mesial temporal lobe. The red region is the
65315_CCFBCH_Text_ACG 107 7/7/09 3:43:43 PM
108
Innovations
Monitoring System for Deep Brain Stimulators during fMRI
important effort in understanding the mechanisms of this important therapy. To date, all
which, when placed over the implant on the patient’s chest, determines the state of the
Development of Post-Processing Labs to Incorporate Qualitative and Quantitative Data for Routine Clinical Use
acquisition devices throughout Cleveland Clinic health system to two post-processing labs. In CT, 2-D and 3-D reconstructions of the original data are produced and forwarded to digital reading stations for interpretation and storage in a central archive so referring
one lab to produce and store qualitative maps (e.g., perfusion) for the neuroradiologists and the referring services. The other lab produces quantitative data (e.g., brain volumes, hippocampal volumes, white matter disease burden) that is incorporated into a standardized report form to aid in interpretation and longitudinal clinical follow-up.
Outcomes 2008
65315_CCFBCH_Text_ACG 108 7/7/09 3:43:44 PM
109
Working with Patients to Improve fMRI Studies
preoperative localization of motor, speech generation and receptive speech areas with an
interviews every patient to individualize the study when indicated, review the nature of the study with the patient, provide instructions for the paradigms, and emphasize the
prescan patient interview in improving scan quality showed that an intensive intervention can
are freely available to any institution.
simpler paradigms are now available incorporating pictures and simpler language. This has
than by a small subset of research scientists.
positive regions.
Attention No Attention
Neurological Institute
65315_CCFBCH_Text_ACG 109 7/7/09 3:43:46 PM
Outcomes 2008
Innovations
110
Initiation of a Lateralization Score for fMRI Studies for Judging Hemispheric Dominance for Speech
and brain tumor patients. The important issue is to identify the essential eloquent (primary) cortical areas governing language and motor activity, so the surgeon can provide adequate margins to minimize post-surgical morbidity. Often, this issue is resolved by determining language lateralization, a process hitherto
10
8
0Right LeftfMRI Lateralization Index
6
2
4
Number
Wada LeftWada BilateralWada Right
65315_CCFBCH_Text_ACG 110 7/7/09 3:43:48 PM
Neurological Institute
Sleep Disorders Center
Multidisciplinary Continuous Positive Airway Pressure (CPAP) Compliance Group Therapy
psychological reasons. The noncompliance rates are estimated to be in the range of
receive tips from professionals while also learning from other patients. They have
the problem, they are given detailed individual treatment plans. The feedback from patients has been very positive.
Biofeedback for Chronic Insomnia
daytime fatigue, increase in workplace and driving accidents, and overall increase in the utilization of healthcare services. Although hypnotic medicines are effective in some patients, they are not always safe for long-term use.
that has a dedicated biofeedback program for chronic insomnia. Biofeedback is a technique in which a patient is trained to improve his or her health by developing a greater awareness and voluntary control over the physiological processes affected by
biofeedback, respiratory biofeedback, thermal biofeedback and neurofeedback.
28 — Number of dedicated beds with state-of-the-art monitoring equipment for overnight sleep studies.
111
65315_CCFBCH_Text_ACG 111 7/7/09 3:43:52 PM
Outcomes 2008
Innovations
Center for Spine Health (CSH)
dramatically decreases the time it takes to perform an intraoperative localizing X-ray for anterior
of a conventional radiograph. Digital imaging provides information equivalent in accuracy to
900
0Conventional Radiograph
N = 10Digital X-Ray
N = 8
600
300
Average Time (Seconds)
Time Savings with Digital Intraoperative X-Rays for Anterior Cervical Fusions
On average, digital intraoperative X-rays for anterior cervical fusions take about one-eighth the time of conventional radiographs.
112
65315_CCFBCH_Text_ACG 112 7/7/09 3:43:54 PM
Neurological Institute
Delaying Recurrences of Myxopapillary Ependymomas
The Utility of Repeated Postoperative Radiographs
regular intervals in asymptomatic patients following single-level anterior cervical decompression fusion and plating do not appear to be warranted and do not alter the
of postoperative radiographs will reduce the amount of
save about $1,000 per patient, reducing the overall cost of healthcare.
obtaining repeated postoperative radiographs following single-level anterior
cervical decompression, fusion, and plate placement. J Neurosurg Spine.
9 — Percent of new Center for Spine Health patients who eventually have spinal surgery.
113
65315_CCFBCH_Text_ACG 113 7/7/09 3:44:00 PM
Outcomes 2008
Selected Publications
The Neurological Institute staff authored more than 470 publications in 2008.For a complete list go to www.clevelandclinic.org/quality/outcomes.
Brain Tumor and Neuro-Oncology Center
institutional phase II study of temozolomide administered twice daily in the treatment of recurrent high-grade gliomas. Cancer.
radiosurgery effectively treats recurrences from whole-brain radiation therapy. Cancer.
with sporadic pituitary adenomas. Clin Endocrinol (Oxf).
Appl Immunohistochem Mol Morphol.
of the treatment of trigeminal neuralgia with gamma knife radiosurgery. Stereotact Funct Neurosurg. 2008;86(3):
and bevacizumab in progressive primary brain tumors, J Neurooncol. 2008
radiosurgical treatment of brain metastases in older patients. Cancer.
glioblastoma survivors: a preliminary feasibility study. Genomics.
114
65315_CCFBCH_Text_ACG 114 7/7/09 3:44:02 PM
Neurological Institute 115
correlation of serum alpha-subunit concentration and magnetic resonance imaging following pituitary surgery in patients with nonfunctional pituitary macroadenomas. Endocr Pract.
in clinoidal meningiomas: rationale for aggressive skull base approach. Acta Neurochir (Wien). 2008
Cerebrovascular Center
Wingspan in-stent restenosis. Neurosurgery. 2008
hemorrhagic risks after intra-arterial revascularization in acute stroke. Neurosurgery.
convenience for rational neurovascular studies. J Cereb Blood Flow Metab.
vasculogenesis and neurogenesis on rat brain development. Neurobiol Dis.
AJNR Am J Neuroradiol.
imaging in the intensive care unit. Radiol Manage. 2008
Neurology.
in cryptogenic TIA or stroke. Neurology. 2008 Nov
wingspan in-stent restenosis. AJNR Am J Neuroradiol. 2008
and monocular blindness after endovascular treatment of large and giant paraophthalmic aneurysms. Neurosurgery.
65315_CCFBCH_Text_ACG 115 7/7/09 3:44:03 PM
Outcomes 2008116
Selected Publications
Epilepsy Center
seizure genes in systemic lupus erythematosus. Epilepsia.
on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord. 2008
patients with medically refractory temporal lobe epilepsy. Epilepsy Res.
with epilepsy: pharmacokinetic interactions, contraceptive options, and management. Int Rev Neurobiol. 2008;83:
Epilepsia.
impact, mechanisms, and prevention. Cleve Clin J Med.
white matter degeneration of the corpus callosum in patients with intractable temporal lobe epilepsy: A diffusion tensor imaging study. Epilepsy Res.
medications after successful epilepsy surgery in children. Pediatr Neurol.
temporal visual language center: cortical stimulation Neurology. 2008 Nov
J Magn Reson. 2008
Mellen Center for Multiple Sclerosis Treatment and Research
is associated with increased levels of ligand in circulation and tissues. Blood.
Neurogenesis in the chronic lesions of multiple sclerosis. Brain.
Mult Scler. 2008
65315_CCFBCH_Text_ACG 116 7/7/09 3:44:04 PM
Neurological Institute 117
atrophy in multiple sclerosis: a longitudinal study. Ann Neurol.
Arch Neurol.
functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp.
Neurology.
orthosis in ambulatory multiple sclerosis patients. Arch Phys Med Rehabil.
Annu Rev Neurosci.
Ann Neurol.
Center for Neuroimaging
information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol.
in association with moya moya disease and bilateral morning glory disc anomaly — broadening the clinical spectrum of midline defects. J Neurol.
functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp.
imaging in the intensive care unit. Radiol Manage. 2008
Neurology. 2008
65315_CCFBCH_Text_ACG 117 7/7/09 3:44:05 PM
Outcomes 2008118
Selected Publications
Center for Neurological Restoration
patients. Brain.
brain stimulation in essential tremor. J Clin Neurophysiol.
Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia.
nucleus deep brain stimulation protocols in a data-driven computational model. J Neurophysiol. 2008
in movement disorders. Neurotherapeutics. 2008
illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet.
J Neurosurg Anesthesiol.
Neurosurgery.
study on suicide outcomes following subthalamic stimulation Brain.
neuronal activity. J Neurosci.
Neuromuscular Center
J Pain Symptom Manage.
microdissection. Mol Vis.
Mil Med. 2008
Intrathecal baclofen for spasticity-related pain in amyotrophic
relief. Muscle Nerve.
Oncology (Williston Park).
65315_CCFBCH_Text_ACG 118 7/7/09 3:44:06 PM
Neurological Institute
dyspnea. Muscle Nerve.
Neurology. 2008 Nov
Epilepsia. 2008
J Neurol Sci. 2008
Neurological Center for Pain
in the acute treatment of menstrually related migraine. Headache.
combination for the treatment of migraine. Expert Rev Neurother.
119
65315_CCFBCH_Text_ACG 119 7/7/09 3:44:09 PM
Outcomes 2008
Selected Publications
serotonin syndrome: a review. Expert Opin Drug Saf. 2008
management using integrated print and video materials: a multisite randomized controlled trial. Pain.
Headache.
screening tool for obstetric and gynecology clinics: the menstrual migraine assessment tool. Headache. 2008
Center for Pediatric Neurology and Neurosurgery
implications of endoscopic third ventriculostomy for the treatment of hydrocephalus. Eur J Obstet Gynecol Reprod Biol.
syndrome in a genotypic male. Ophthalmic Genet. 2008
hydrocephalus in the patient with gait disturbance. Geriatrics.
120
65315_CCFBCH_Text_ACG 120 7/7/09 3:44:13 PM
Neurological Institute 121
Neurology.
of suspected mitochondrial disease. Mol Genet Metab. 2008
Epilepsy surgery in epidermal nevus syndrome variant with hemimegalencephaly and intractable seizures. J Neurol.
in association with moya moya disease and bilateral morning glory disc anomaly — broadening the clinical spectrum of midline defects. J Neurol.
Pediatr Neurol.
in autism spectrum disorder patients: a cohort analysis. PLoS ONE.
Department of Psychiatry and Psychology
on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord. 2008
Curr Opin Organ Transplant. 2008
Br J Psychiatry.
Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia.
sociocultural ideals predicts weight gain. Body Image. 2008
illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet.
heart-brain medicine. Cleve Clin J Med.
and bipolar disorders. Ann Clin Psychiatry. 2008 Dec;20
Cleve Clin J Med. 2008
Psychiatr Clin North Am.
J Clin Anesth.
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122 Outcomes 2008
Selected Publications
Sleep Disorders Center
long-term mortality after prolonged mechanical ventilation. Lung.
Epilepsia.
assessment in bariatric surgery patients. Obes Surg. 2008
pulmonary risk assessment and perioperative management in bariatric surgery patients. Obes Surg.
Sleep Breath.
obstructive sleep apnea in adults with epilepsy: a randomized pilot trial. Neurology.
in patients with pulmonary hypertension. J Heart Lung Transplant.
Epilepsia.
Center for Spine Health
stimulation for cervical fusion. Spine J. 2008
J Am Acad Orthop Surg. 2008
Spinal Disord Tech.
of chronic low back pain with opioid analgesics. Spine J.
fusion in a workers’ compensation population. Neurosurgery.
instrumentation in the management of scoliosis. Neurosurgery.
J Orthop Res. 2008
marrow mesenchymal stem cells and nucleus pulposus cells Spine.
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Neurological Institute
stem cells and nucleus pulposus cells. Spine J. 2008
an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis. Spine J.
Neurosurgical Anesthesiology
spine surgery. Anesthesiology.
lumbar spine surgery. J Neurosurg Anesthesiol. 2008
disruption under general anesthesia: a retrospective review. J Neurosurg Anesthesiol.
J Neurosurg Anesthesiol.
of remifentanil to prevent movement during craniotomy in the absence of neuromuscular blockade. J Neurosurg Anesthesiol.
123
65315_CCFBCH_Text_ACG 123 7/7/09 3:44:21 PM
124124 Outcomes 2008
Staff Listing
Chairman
Vice Chairman, Clinical Areas
Vice Chairman, Research and Development
Department of Neurological Surgery
Chairman, Department of Neurological Surgery
Department of Neurology
Chairman, Department of Neurology
Department of Physical Medicine and Rehabilitation
Chairman, Department of Physical Medicine and Rehabilitation
Kristin Carlin, DO
Department of Psychiatry and Psychology
Chairman, Department of Psychiatry and Psychology
65315_CCFBCH_Text_ACG 124 7/7/09 3:44:22 PM
125125Neurological Institute
Brain Tumor and Neuro-Oncology Center
Director, Brain Tumor and Neuro-Oncology Center
65315_CCFBCH_Text_ACG 125 7/7/09 3:44:23 PM
Outcomes 2008126126
Staff Listing
Lou Ruvo Center for Brain Health Randolph Schiffer, MD Director, Center for Brain Health Cynthia S. Kubu, PhD, ABPP-CN
Richard Lederman, MD, PhD
Richard Naugle, PhD
Michael Parsons, PhD
Alexander Rae-Grant, MD, FRCP (C)
Stephen Rao, PhD
Patrick Sweeney, MD
Janice Zimbelman, PhD
Center for Neuroimaging Thomas Masaryk, MD Director, Center for Neuroimaging Todd Emch, MD
Stephen E. Jones, MD, PhD
Mark Lowe, PhD
Michael T. Modic, MD, FACR
Doksu Moon, MD
Micheal Phillips, MD
Janet Reid, MD
Paul Ruggieri, MD
Alison Smith, MD
Todd Stultz, DDS, MD
Andrew Tievsky, MD
Center for Neurological Restoration Ali Rezai, MD Director, Center for Neurological Restoration Anwar Ahmed, MD
Jay Alberts, PhD
Kenneth Baker, PhD
Scott Cooper, MD, PhD
Milind Deogaonkar, MD
Darlene Floden, PhD
Ilia Itin, MD
Cynthia S. Kubu, PhD, ABPP-CN
Richard Lederman, MD, PhD
Andre Machado, MD, PhD
Donald Malone Jr., MD
Cameron McIntyre, PhD
Samer Narouze, MD
Mayur Pandya, DO
Michael Stanton-Hicks, MD
Patrick Sweeney, MD
Stewart Tepper, MD
Jerrold Vitek, MD, PhD
Weidong Xu, MD
Jianyu Zhang, MD
Center for Pediatric Neurology and Neurosurgery Elaine Wyllie, MD Director, Center for Pediatric Neurology Mark Luciano, MD, PhD Director, Center for Pediatric Neurosurgery Bruce Cohen, MD
Xiao Di, MD, PhD
65315_CCFBCH_Text_ACG 126 7/9/09 12:42:47 PM
Neurological Institute 127127
Stephen Dombrowski, PhD
Gerald Erenberg, MD
Neil Friedman, MBChB
Debabrata Ghosh, MD, DM
Gary Hsich, MD
Irwin Jacobs, MD
Manikum Moodley, MD
Sumit Parikh, MD
A. David Rothner, MD
Center for Regional Neurology Stephen Samples, MD Director, Center for Regional Neurology A. Romeo Craciun, MD
Sheila Rubin, MD
Jennifer Ui, MD
Joseph Zayat, MD
Center for Regional Neurological Surgery
Michael Mervart, MD Director, Center for Regional Neurological Surgery Samuel Borsellino, MD
Samuel Tobias, MD
Center for Spine Health
Edward Benzel, MD Director, Center for Spine Health Gordon Bell, MD Associate Director, Center for Spine Health
Daniel Mazanec, MD Associate Director, Center for Spine Health Lilyana Angelov, MD
Thomas Bauer, MD, PhD
William Bingaman, MD
Edwin Capulong, MD
Alfred Cianflocco, MD
Edward Covington, MD
Russell DeMicco, DO
Frederick Frost, MD
Lars Gilbertson, PhD
Augusto Hsia Jr., MD
Serkan Inceoglu, PhD
Iain Kalfas, MD
Tagreed Khalaf, MD
Ajit Krishnaney, MD
Thomas Kuivila, MD
Eric Mayer, MD
Robert McLain, MD
Thomas Mroz, MD
R. Douglas Orr, MD
Anantha Reddy, MD
Judith Scheman, PhD
Richard Schlenk, MD
Kalyani Shah, MD
Michael Steinmetz, MD
Santhosh Thomas, DO
Deborah Venesy, MD
Fredrick Wilson, DO
Adrian Zachary, DO, MPH
65315_CCFBCH_Text_ACG 127 7/9/09 12:43:56 PM
Referral Contact Information
Outcomes 2008128
Cerebrovascular Center
Director, Cerebrovascular Center
Epilepsy Center Imad Na Director, Epilepsy Center
Staff Listing
128
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Neurological Institute 129129
Mellen Center for Multiple Sclerosis Treatment and Research
Director, Mellen Center for Multiple Sclerosis Treatment and Research Erik B
Neurological Center for Pain Edward Co Director, Neurological Center for Pain
Neuromuscular Center
Director, Neuromuscular Center
65315_CCFBCH_Text_ACG 129 7/7/09 3:44:26 PM
Outcomes 2008130130
Sleep Disorders Center
Director, Sleep Disorders Center
Department of Neurosciences, Lerner Research Institute
Chairman, Department of Neurosciences, Lerner Research Institute
Staff Listing
Biomedical Engineering, Lerner Research Institute
Cell Biology
Anatomic Pathology
Neuroanesthesiology
Section Head, Neurological and Spine Surgery Anesthesiology Section Head, Neuro-Endovascular Anesthesiology
clevelandclinic.org/staff.
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131Neurological Institute
65315_CCFBCH_Text_ACG 131 7/7/09 3:44:32 PM
Outcomes 2008132132
Contact Information
General Patient Referral
Neurological Institute Appointments/Referrals
On the Web at clevelandclinic.org/neuroscience
Additional Contact Information
General Information
Hospital Patient Information
Patient Appointments
Medical Concierge
Complimentary assistance for out-of-state patients and families
Global Patient Services/International Center
Complimentary assistance for international patients and families
clevelandclinic.org/gps
Cleveland Clinic in Florida
For address corrections or changes, please call
65315_CCFBCH_Text_ACG 132 7/7/09 3:44:33 PM
Neurological Institute 133133
Institute Locations
Cleveland Clinic Neurological Institute physicians see
when calling.
Main Campus
Neurological Institute Regional Centers
Euclid Hospital
Fairview Hospital
Hillcrest Hospital
Huron Hospital
Lakewood Hospital
Lutheran Hospital
Marymount Hospital
Cleveland Clinic Children’s Hospital Shaker Campus
65315_CCFBCH_Text_ACG 133 7/7/09 3:44:33 PM
Outcomes 2008134134
Cleveland Clinic Family Health Centers
Avon Lake Family Health Center
Beachwood Family Health and Surgery Center
Chagrin Falls Family Health Center
Independence Family Health Center
Crown Center II
Lorain Family Health and Surgery Center
Institute Locations
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Solon Family Health Center
Strongsville Family Health and Surgery Center
Westlake Family Health Center
Willoughby Hills Family Health Center
Cleveland Clinic Wooster
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Cleveland Clinic Overview
bundling all clinical specialties into integrated practice units called institutes. An institute combines all the
under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the
point-of-care service, institutes will improve the patient
acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs
multispecialty care hospital and clinic, is scheduled to open in late 2012.
associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total
federal agencies, non-federal societies and associations, endowment funds and other sources. In an effort to bring research from bench to bedside, Cleveland Clinic
at any given time.
offers all students full tuition scholarships. The program will
Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1
clevelandclinic.org
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Resources for Physicians
Cleveland Clinic Secure Online Services
Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.
MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to GoogleTM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart.
DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].
MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.
Critical Care Transport: Anywhere in the world
Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call 877.279.CODE (2633). For all other transfers, call 216.444.8302 or 800.553.5056.
CME Opportunities: Live and Online
Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.
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9500 Euclid Avenue, Cleveland, OH, 44195
© The Cleveland Clinic Foundation 2009
Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.
Please visit us on the Web at clevelandclinic.org.
Neurological Institute
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