Neurological Institute - Cleveland Clinic...At Cleveland Clinic’s Neurological Institute, ... The interplay between process and outcome may be illustrated by the most basic axiom

Neurological Institute

Outcomes

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To 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 volumes 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 necessarily mean we 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:

Our commitment to providing accurate, timely information about patient care also will help patients and referring physicians make informed healthcare decisions.

quality/outcomes.

2

Dear Colleague:

It is my great pleasure to introduce the 2009 Cleveland Clinic Outcomes books. These books are compiled annually to promote quality improvement and better patient care. Each book includes outcomes, volumes and other data, along with recent innovations and

We release Outcomes books in print and online as part of our commitment to quality, transparency and better patient care. This year, we are making additional data available

offers data in advance of national and state public reporting sites, in key areas, including heart attack, heart failure, stroke and infection prevention.

informative and enlightening.

Prefer an e-version?

Visit clevelandclinic.org/OutcomesOnline, and

we’ll remove you from the hard copy mailing list

and email you when next year’s books are online.

Chairman’s Letter 04

Institute Overview 06

Quality and Outcomes Measures

Outcomes Overview 14

Brain Tumors 16

Cerebrovascular Disease 33

Cognitive Disorders 40

Epilepsy 42

Hydrocephalus and Related Conditions 60

Movement Disorders 63

Multiple Sclerosis 64

Neuromuscular Disease 74

Pain / Headache 76

Pediatric Neurological Disorders 86

Psychiatric Disorders 88

Sleep Disorders 96

Spinal Disease 100

Physical Medicine and Rehabilitation 106

Neuroimaging 108

Neurosurgical Anesthesia 110

Surgical Quality Improvement 112

Patient Experience 116

Selected Publications 120

Innovations 130

Staff Listing 144

Contact Information 154

Institute Locations 155

Cleveland Clinic Overview 158

Resources for Physicians 159

what’s inside

Outcomes 2009

Chairman’s Letter

Dear Colleagues,

This question is at the heart of the universal lament that “healthcare costs too much.” Value is outcomes divided by cost, so it stands to reason that if we drive better outcomes and reduce costs, the value we deliver will increase.

At Cleveland Clinic’s Neurological Institute, © to

subject patient encounters to validated health status measures and outcomes metrics, which we can monitor longitudinally to foster continuous improvement. This ongoing

underlies our presentation of the institute’s 2009 outcomes data.

If we are serious about moving the needle on value, however, we must look even deeper. Thus, within

The interplay between process and outcome may be illustrated by the most basic axiom in medicine: Frequent hand washing prevents the spread of infection. By observing the process, we improve the outcome. Yet, we know that this relationship is not invariable; process improvement does not always equate to better outcomes. If we fail to measure, we will never know.

4

5Neurological Institute

In the Neurological Institute and throughout Cleveland Clinic, process is integrated in disease-

evidence-based, standardized encounters with embedded outcome and quality measurements over the longitudinal course of patient care.

adhere to system-wide, rather than the randomness of multiple protocols at scattered sites. We are committed to improving, managing and measuring the variability in clinical practice and to upgrading the continuity and coordination of care across disciplines, venues and time.

time. As an example, stroke patients will experience a seamless care path, not a series of handoffs, from the Emergency Department through rehabilitation and home care.

measurement and reporting of outcomes data with a view to standardizing evidence-based neurological

patients and payers demand and deserve. We welcome any opportunity to work with you in meeting these goals.

Chairman, Neurological Institute

Outcomes 20096

Chairman LetterInstitute Overview

6

The multidisciplinary Cleveland Clinic Neurological Institute includes more than 250 medical and surgical staff physician specialists dedicated to the diagnosis, treatment and rehabilitation of adult and pediatric patients with neurological and

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 Reportprograms among the top 10 in the nation. In 2009, our pediatric neurology and neurosurgery programs were ranked number

in Ohio.

The institute model allows our patients to better access the care they need through specialized, multidisciplinary, disease-

physiatrists, neuroradiologists and others into the comprehensive care of neurological and psychiatric disease:

Brain Tumor and Neuro-Oncology Center

Cerebrovascular Center

Epilepsy Center

Center for Neuroimaging

Neuromuscular Center

Neurological Institute 7

Institute Overview

7

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 syndromes and

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; mental/behavioral health disorders and chemical dependencies.

Expert, Specialized Diagnosis

Our Neurological Institute physicians draw on advanced diagnostic capabilities and experience.

angiography, interventional neuroradiology, and carotid and transcranial Doppler ultrasound. Our

disease, ensuring accurate, in-depth interpretations.

Additional diagnostic tools are found in our epilepsy monitoring units, sleep laboratories, neuropsychological testing facilities, electromyography laboratory, autonomic laboratory and cutaneous nerve laboratory.

The Latest Treatment Modalities

therapy for brain tumors, epilepsy surgery, stereotactic spine radiosurgery, endovascular treatment of cerebral aneurysms and vascular malformations, and neuroendoscopy. Distinctive services such

quality care to our patients.

Outcomes 2009

Institute Overview

8

Relevant Research

We conduct research directly related to conditions experienced by our patients, including 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. In 2009, there were more than 220 active clinical research projects in the Neurological Institute, and we were awarded more than $21 million in neurologically based research grants and contracts.

Outcomes 200988

Convenient Care in the Community

We are committed to making access to world-class care convenient for all patients. Neurological Institute services are available at Cleveland Clinic health system regional hospitals and family health centers throughout the community. As a result, patients can easily access specialists who treat the most complex neurological conditions, including aneurysm and stroke, brain tumor, epilepsy, headache, multiple sclerosis, behavioral disorders, physical impairments and disabilities, sleep disorders and spine disorders. This patient-centered approach is predicated on the notion that those we serve are entitled to a uniformly high level of care. Whether a patient needs emergency or continuing care, location should never be an issue.


Meeting an Imminent Challenge

The incidence of neurocognitive disorders such as Alzheimer’s disease is

diagnosis and treatment of these syndromes. The center’s staff offers a multimodal program that includes physical exercise, cognitive rehabilitation and cognitive-enhancing medications.

performed and digitally transferred to Cleveland and other Cleveland Clinic sites for interpretation at one of the world’s leading neuroimaging academic centers. Believing that someday, Alzheimer’s disease and its spectrum disorders can be successfully treated and even prevented, the center infuses education and research into all its programs.

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 educational opportunities from basic nursing instruction to subspecialization in neurological nursing, enabling nurses, like their physician colleagues, to provide specialized care.

Pioneering the Collection of Data and Outcomes©, a joint initiative of the Neurological Institute, the Imaging Institute and the Information Technology

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.

Institute Overview

Outcomes 200910

At Cleveland Clinic’s Neurological Institute, we are dedicated to maximizing patient care outcomes and the patient experience and to advancing medical education and research in all areas of neurology, neurosurgery, psychiatry and rehabilitation.

2009 Statistical Highlights

Inpatient Facilities (Main Campus)

Neuro ICU Beds 22

Chemical Dependency Unit Beds 13

Inpatient Facilities (Regional)


** Initial visits for patients new to Cleveland Clinic

Initial Outpatient Visits** 11,256

Cerebrovascular 361

Neurology 630

Total Outpatient Visits 143,401

Brain Tumor and Neuro-Oncology 7,057

Cerebrovascular 2,595

Epilepsy 7,121

Neuromuscular 5,132

Institute Overview

12 Outcomes 2009

Admissions 17,060

Brain Tumor and Neuro-Oncology 967


Epilepsy 1,432

Neurological Restoration 294

Neurology 758

Pediatric Neurology 164

Pediatric Neurosurgery 508

Psychiatry and Psychology 9,538

Regional Neurological Institute 84

Spine 1,343

Subacute Rehab 763

Inpatient Days 113,895

Brain Tumor and Neuro-Oncology 4,203


Epilepsy 6,964

Neurological Restoration 1,132

Neurology 3,653

Pediatric Neurology 620

Pediatric Neurosurgery 2,539

Psychiatry and Psychology 67,822

Regional Neurological Institute 507

Spine 6,595

Subacute Rehab 12,677

*

*

* Includes totals from the following Cleveland Clinic regional hospitals: Euclid, Fairview, Lakewood, Lutheran, Marymount and South Pointe


Surgical/Interventional Procedures 8,016

Epilepsy 522

Neuroimaging Studies**

Outcomes 200914

Clinic Neurological Institute patients are assessed for overall health status, including quality of life and presence of psychiatric comorbidity such as depression.

mobility, self-care, usual activities, pain/discomfort and anxiety/depression. A score of 1.0 indicates the best imaginable health state and 0 the worst imaginable health state.

A cross-sectional analysis of quality of life across multiple neurological disease categories suggests the lowest quality of life for patients with chronic pain and the highest for those with sleep disorders.

Quality of Life by Neurological Disease Category

2009

Pain

Spinal Disease

Movement Disorders

Neuromuscular Disorders

Multiple Sclerosis

Headache

Cognitive Disorders

Psychiatric & Psychological Disorders

Cerebrovascular Disease

Epilepsy

Sleep Disorders

(N = 1,182)

(N = 5,038)

(N = 1,536)

(N = 2,901)

(N = 4,037)

(N = 4,034)

(N = 840)

(N = 3,406)

(N = 1,410)

(N = 2,600)

(N = 2,626)

Neurological Disease Category

0 0.2 0.4 0.6

Mean EQ-5D Index Score

0.8 1.0

Outcomes Overview


A cross-sectional analysis of depressive symptoms across multiple neurological disease categories suggests at least mild depression in all neurological diseases, with the most severe depression in those with chronic pain.

Depressive Symptoms by Neurological Disease Category

2009

depression, respectively.


Multiple Sclerosis

Epilepsy

Neuromuscular Disorders

Movement Disorders

Spinal Disease

Headache

Sleep Disorders

Psychiatric & Psychological Disorders

Pain

Neurological Disease Category

0 5 10

Mean PHQ-9 Score

15

(N = 1,395)

(N = 3,862)

(N = 2,562)

(N = 2,803)

(N = 1,523)

(N = 4,084)

(N = 4,010)

(N = 2,597)

(N = 3,405)

(N = 1,160)

Outcomes 2009

Brain Tumor Diagnosis Distribution (N = 2,001)

2009

Brain Tumor Procedures (N = 904)

2009

® radiosurgery was the most common, followed by supratentorial craniotomy, Novalis® stereotactic radiosurgery and pituitary surgery.

state-of-the-art surgical intervention and conducting clinical research to enhance patient outcomes. BTNC

166, 8% Pituitary166, 8% Pituitary119, 6% Schwannoma119, 6% Schwannoma

489, 24% Metastasis489, 24% Metastasis

348, 17% Meningioma348, 17% Meningioma

879, 44% Glioma879, 44% Glioma

100%100%

55, 6% Infratentorial Craniotomy55, 6% Infratentorial Craniotomy

74, 8% Pituitary Surgery74, 8% Pituitary Surgery

254, 28% Supratentorial Craniotomy254, 28% Supratentorial Craniotomy

66, 7% Brain Biopsy66, 7% Brain Biopsy

95, 11% Novalis® Radiosurgery95, 11% Novalis® Radiosurgery

360, 40% Gamma Knife® Radiosurgery360, 40% Gamma Knife® Radiosurgery

100%100%

Brain Tumors

16


Brain Tumor Surgical Site Infection Rates

alimentary tract is entered. N = number of clean cases per year.

10

5

02005593N =

2006604

2007502

2008451

2009530

Rate per 100 Clean Cases (%)

17

Outcomes 2009

N = number of brain biopsies per year.

Brain Biopsy: Survival

Brain Biopsy

100

80

60

40

20

02005

78N =2006101

200765

200851

200966

Survival (%)

30-Day180-Day

Brain Tumors

18


Supratentorial Craniotomy: Inpatient Mortality

Supratentorial Craniotomy: Length of Stay (LOS)

Inpatient mortality remained lower than expected among patients who underwent supratentorial craniotomies in 2009. N = number of supratentorial craniotomies performed for brain tumor per year. For this and all subsequent graphs, expected mortality is based on national normative data and All

of adjusting for severity of patient illness.1

remained lower than expected among patients who underwent supratentorial craniotomies. For this and all subsequent graphs,

national normative data and 1

10

8

6

4

2

0

Mortality (%)

ActualExpected

2005280N =

2006298

2007273

2008230

2009277

8

6

4

2

0

N = 2005280

2006298

2007273

2008230

Mean LOS (Days)

2009277

Actual Expected

Supratentorial Craniotomy

19

Supratentorial Craniotomy: Karnofsky Performance Scale (KPS) N = 162

2009

100

80

60

40

20

0Declined Improved No Change

Patients (%)

Outcomes 2009

Brain Tumors

20


Supratentorial Craniotomy: Survival by Tumor Type

Meningioma: Survival

Glioma: Survival

Metastasis: Survival

100

80

60

40

20

0

Survival (%)

2009113

2005103N =

2006112

2007115

200888

30-Day180-Day

200934

100

80

60

40

20

0

Survival (%)

200551N =

200634

200730

200825

30-Day180-Day

100

80

60

40

20

0

Survival (%)

200929

200545N =

200632

200732

200823

30-Day180-Day

21

Outcomes 2009

Infratentorial Craniotomy

Infratentorial Craniotomy: Length of Stay (LOS)

Infratentorial Craniotomy: Inpatient Mortality

With the exception of two deaths in 2007, there were no inpatient deaths following infratentorial craniotomy from 2005 through 2009. N = number of infratentorial craniotomies performed for brain tumor per year.

8

6

4

2

02005

89N =2006

732007

692008

66

Mean LOS (Days)

200971

Actual Expected

10

8

6

4

2

02005

89N =2006

732007

692008

66

Mortality (%)

ActualExpected

200971

00 0 0

Brain Tumors

22

Infratentorial Craniotomy: Change in KPS Status within 30 Days of Operative Procedure (N = 35)

100

80

60

40

20


Patients (%)

2009


Outcomes 2009

Glioma: Survival

Infratentorial Craniotomy: Survival by Tumor Type

Meningioma: Survival

100

95

90

85

802009

82005

11N =2006

52007

102008

9

Survival (%)

30-Day180-Day

100

75

50

25

02009

72005

15N =2006

62007

52008

5

Survival (%)

30-Day180-Day

Brain Tumors

24


Metastasis: Survival

Schwannoma: Survival

100

75

50

25

02009

112005

11N =2006

92007

62008

15

Survival (%)

30-Day180-Day

100

75

50

25

02009

22005

6N =2006

32007

22008

3

Survival (%)

30-Day180-Day

25

Outcomes 2009

Pituitary Surgery: Survival

Pituitary Surgery

Pituitary Surgery: Inpatient Mortality

There have been no inpatient deaths following pituitary surgery.

patients with available data are included in the calculation. N = number of pituitary tumor surgeries per year.

1.2

1.0

0.8

0.6

0.4

0.2

0.02005 2006 2007 2008 2009

Mortality (%)

0 0 0 0 0

ActualExpected

100

75

50

25

02009

742005

60N =2006

992007

812008

99

Survival (%)

30-Day180-Day

Brain Tumors

26


Pituitary Surgery: Length of Stay (LOS)

Pituitary Surgery: Change in KPS Status within 30 Days of Operative Procedure (N = 52)

100

80

60

40

20


Patients (%)

2009

4

3

2

1

02005 2006 2007 2008

Mean LOS (Days)

2009

Actual Expected

27

Outcomes 2009OutOutOutOutOuOutOutOuO comcomcomcomcommmcomes eses ssss s 2002000020020200999999999

Stereotactic Radiosurgery: Gamma Knife®

Gamma Knife® Radiosurgery: Meningioma Survival

® radiosurgery

® procedures performed for each tumor type.

100

95

90

85

802009

232005

18N =2006

322007

272008

41

Survival (%)

30-Day180-Day

100

75

50

25

02005

5N =2006

102007

172008

162009

14

Survival (%)

30-Day180-Day

Gamma Knife® Radiosurgery: Schwannoma Survival

Brain Tumors

28

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Gamma Knife® Radiosurgery: Metastasis Survival

100

90

80

70

60

502005136N =

2006133

2007149

2008151

2009217

Survival (%)

30-Day180-Day

Gamma Knife® Radiosurgery: Pituitary Tumor Survival

100

80

60

40

20

02005

20N =2006

442007

242008

372009

36

Survival (%)

30-Day180-Day

29

Stereotactic Radiosurgery: Novalis®

®

those patients with available data are included in the calculation.

Novalis® Stereotactic Radiosurgery: Survival

Outcomes 2009

100

80

60

402005

6N =2006

642007

802008

812009

95

Survival (%)

30-Day180-Day

Brain Tumors

30


Novalis® Stereotactic Radiosurgery: Treatment of Painful Spinal Metastases (N = 29)

the spinal axis. Treatment goals for these patients include symptomatic relief of pain, and this is typically

life, an improvement maintained over many months.

Time Interval Post SRS Brief Pain Inventory (Scores out of 10)

Mean Decrease in BPI P-value

1 week 1.75 0.01

1 month 2.26 0.003

3 months 1.79 0.26

31

Outcomes 2009

Glioblastoma Multiforme

Approximately 10,000 cases of glioblastoma are diagnosed each year in the United States. In 2009, 95 patients with newly diagnosed glioblastoma, the most common type of malignant primary brain tumor, underwent initial surgical resection and treatment at our center. The

national benchmarks.

CC = Cleveland Clinic

Ref = Software: Surveillance Research Program, National Cancer Institute SEER*Stat software (www.seer.cancer.gov/seerstat) version 6.6.0 Data: Surveillance, Epidemiology and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence - SEER 17 Regs Limited-Use + Hurricane Katrina Impacted Louisiana Cases, Nov 2008 Sub (1973-2006).

Glioblastoma Multiforme: Survival (N = 358)

2001 – 2005

100

80

60

40

20

00 12 24 36

Months since Diagnosis

48 60 72

Survival (%)

CCRef

32

Brain Tumors


Get With The Guidelines® (GWTG)

patients hospitalized with acute stroke or transient ischemic attack. Circulation

Clinical Measure Measure Description GWTG Stroke Performance Award Goal

National Average*

2007 2008 2009

Cleveland Clinic

IV rt-PA 2 Hour

Early Antithrombotics

Acute stroke patients who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom IV rt-PA was initiated at this hospital within 180 minutes (3 hours) of time last known well.

85.0% 72.8% 66.7% (4/6)

88.9% (8/9)

78.6% (11/14)

Patients with ischemic stroke or TIA who receive antithrombotic therapy by the end of hospital day 2.

85.0% 97.0% 97.7% (173/177)

95.3% (261/274)

97.5% (392/402)

Antithrombotics at Discharge

Patients with ischemic stroke or TIA prescribed antithrombotic therapy at discharge (e.g., warfarin, aspirin, other antiplatelet drug).

85.0% 98.9% 98.6% (352/357)

99.7% (346/347)

99.3% (534/538)

Anticoagulation for Atrial Fibrillation/ Atrial Flutter

85.0% 98.4% 97.2% (35/36)

98.4% (62/63)

98.7% (78/79)

DVT Prophylaxis Patients with ischemic stroke, TIA or a hemorrhagic stroke and who are non-ambulatory who receive DVT prophylaxis by end of hospital day 2.

85.0% 89.5% 93.5% (217/232)

97.4% (261/268)

94.8% (507/535)

Lipids Measure (Statin at Discharge)

Ischemic stroke or TIA patients with LDL > 100, or LDL not measured, or on cholesterol-reducer prior to admission, discharged on cholesterol-reducing drugs.

85.0% 88.3% 83.2% (228/274)

88.1% (230/261)

97.2% (350/360)

Smoking Cessation Counseling

Patients with ischemic, TIA or hemorrhagic stroke with a history of smoking cigarettes, who are, or whose caregivers are, given smoking cessation counseling during hospital stay.

85.0% 93.6% 100% (101/101)

92.4% (109/118)

92.9% (234/252)

Dysphagia Screening Patients with ischemic or hemorrhagic stroke who undergo screen for dysphagia with an evidence-based bedside testing protocol approved by the hospital before being given any food, fluids, or medications by mouth.

85.0% -- -- 67.9% (256/377)

73.7% (490/665)

Stroke Education Patients with ischemic, TIA or hemorrhagic stroke or their caregivers who were given education and/or educational materials during the hospital stay.

85.0% -- -- 41.4% (164/396)

80.6% (286/355)

Rehabilitation Considered

Patients with ischemic or hemorrhagic stroke who were assessed for rehabilitation services.

85.0% -- 83.3% (30/36)

98.5% (393/399)

96.5% (684/709)

Patients with ischemic stroke or TIA with atrial fibrillation/flutter who are discharged on anticoagulation therapy.

Get With The Guidelines (GWTG) Stroke Performance and Quality Measures


Outcomes 200934

Improvement in National Institutes of Health (NIH) Stroke Scale Scores by Stroke Mechanism

2009

Ischemic Stroke: Length of Stay (LOS)

12

10

8

6

4

2

0Large Artery

Atherosclerosis9N =

Cardioembolism

15

Small ArteryOcclusion

3

UndeterminedEtiology

10

NIH Stroke Scale Score

Baseline30-Day Follow-Up

1

10

8

6

4

2

02007434N =

2009561

2008498

Mean LOS (Days)

Actual Expected


Improvement in Naatiional

2009

Ischchemee ic Strokee: LLenength o

12

10

8

6

4

2

0Large Artery

Atherosclerosis9N =

Ca

NIH Stroke Scalee Score

10

88

6

4

2222

022007434N =

MMean LOS (Dayss)

Ischemic Stroke: Inpatient Mortality

Among inpatients treated for ischemic stroke at Cleveland Clinic, actual mortality remained below expected. 1

20

15

10

5

02007434N =

2008498

2009561

Mortality (%)

ActualExpected


Outcomes 2009

Intracerebral Hemorrhage: Inpatient Mortality

40

30

20

10

02007139N =

2009172

2008161

Mortality (%)

Actual Expected

Intracerebral Hemorrhage: Length of Stay (LOS)

was below expected following intracerebral hemorrhage.

10

8

6

4

2

02007139N =

2009172

2008161

Mean LOS (Days)

ActualExpected

36



Subarachnoid Hemorrhage: LOS

Subarachnoid Hemorrhage: Inpatient Mortality

15

10

5

02007110N =

2009143

2008128

Mean LOS (Days)

Actual Expected

30

20

10

02007110N =

2009143

2008128

Mortality (%)

Actual Expected

Inpatient mortality due to subarachnoid hemorrhage has been consistently below the expected rate.

37

Outcomes 200938

1990-1991 and 26.5 percent in 2000-2001.2

hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke

Intracerebral Hemorrhage, Subarachnoid Hemorrhage and Ischemic Stroke: Discharge Status

2009



Inpatient Rehabilitation for Stroke

Cleveland Clinic inpatient rehab units return to a higher level of function in a shorter time than the national average.

2.5

2.0

1.5

1.02007449N =

2009482

2008478

FIM Change/LOS

Cleveland ClinicNational Average

3939

Outcomes 200940

Cognitive Disorders

the family members of those who suffer from them. The physicians and staff at the center are working toward the development of early diagnosis and the advancement of knowledge concerning mild cognitive disorders, which could one day allow us to delay or prevent their onset.

Cognitive Testing and Training

training sessions. The involvement of family or other supportive associates is important in


P

Effects of Cognitive Training on Neuropsychological Test Performance (N = 9)

2009

Immediate Memory

Visuospatial/Constructional Skill

Language

Attention

Delayed Memory

Total

Neuropsychological Test ScoreBefore TrainingAfter Training

0 20 40 60 80 100

Outcomes 200942

Epilepsy

As a result of Cleveland Clinic Epilepsy Center’s commitment to the comprehensive care of patients with epilepsy, and our belief that the disease burden extends beyond a “seizure count,” we are integrating various measures of overall health with every outpatient visit. The same detailed assessment is provided to both the large group of patients treated with anti-epileptic medications alone and to the smaller group with refractory seizures who undergo epilepsy surgery.

Improvement in Quality of Life in Adult Epilepsy Patients1, a 10-item, validated, patient-completed

P

50

40

30

20

10

0Initial Follow-up

Visit

QOLIE-10 ScoreQuality of Life

Improved

Quality of Life in Adult Patients Treated with Medications Only (N = 362)


P

Epilepsia.

50

40

30

20

10

0Before After

Surgery

QOLIE-10 ScoreQuality of Life

Improved

Quality of Life in Adult Patients Following Epilepsy Surgery (N = 154)

Outcomes 200944

Epilepsy

Improvement in Seizure Severity in Adult Epilepsy Patients2, a validated, patient-completed

questionnaire developed to quantify the patient’s own perception of change in seizure severity. severe seizures. Again, seizure severity improved in both the medical and surgical groups.

P

Seizure Severity in Adult Patients Treated with Medications Only (N = 238)

100

80

60

40

20

0Initial Follow-up

Visit

LSSS ScoreSeizure Severity

Improved


Seizure Severity in Adult Patients Following Epilepsy Surgery (N = 151)

100

80

60

40

20

0Before After

Surgery


Improved

surgery, with 65 percent of patients being completely seizure-free at the last follow-up, based on at least six months

Outcomes 200946

Epilepsy

Improvement in Depression in Adult Epilepsy Patients3, which represents a validated, patient-completed

medical and surgical groups.

P25th and 75th quartiles. The main improvement was observed in patients with moderate to severe depression at their

Depressive Symptoms in Adult Patients Treated with Medications Only (N = 556)

20

10

0

27

Initial

Visit

Follow-up

PHQ-9 ScoreDepression

Improved


P

J Gen Intern Med. 2001

Depressive Symptoms in Adult Patients Following Epilepsy Surgery (N = 68)

20

10

0

27

Before

Surgery

After

PHQ-9 ScoreDepression

Improved

Outcomes 200948

Epilepsy

Improvement in Anxiety in Adult Epilepsy Patients

, which represents a patient-completed

P

follow-up ranged from 3.0 to 10.0 months.

Arch Intern Med.

Anxiety Symptoms in Adult Patients Treated with Medications Only (N = 270)

20

10

0

GAD-7 ScoreAnxiety

ImprovedInitial

Visit

Follow-up


Change in Driving Status in Adult Epilepsy Patients

Driving Status in Adult Patients Treated with Medications Only (N = 454)

80

60

40

20

0Initial Follow-up

Visit

Patients Driving (%)

DrivingNot Driving

P

Driving Status in Adult Patients Following Epilepsy Surgery (N = 112)

100

80

60

40

20

0Before

Surgery

After

Patients Driving (%)

DrivingNot Driving

Outcomes 200950

Epilepsy

Improvement in Seizure Severity in Pediatric Epilepsy Patients2

severe seizures.

Seizure Severity in Pediatric Patients Treated with Medications Only (N = 387)

100

80

60

40

20

0Initial

Visit

Follow-up

LSSS Score

Seizure Severity

Improved

P <


Seizure Severity in Pediatric Patients Following Epilepsy Surgery (N = 28)

70

60

50

40

30

20

10

0Before After

Surgery


Improved

Encouraging treatment outcomes were observed in our pediatric epilepsy patients.

underwent epilepsy surgery, seizure severity dropped

P

the median and the 25th and 75th quartiles.

Outcomes 20095252

Epilepsy

Improvement in Healthcare Utilization in Pediatric Epilepsy Patients

0.5

0.4

0.3

0.2

0.1

0Rescue Meds

99N =ER Visits

99Hospitalizations

103

Average Number over Three Months

Initial VisitLast Follow-up Visit

Healthcare Utilization in Pediatric Patients Treated with Medications Only

October 2008 – December 2009


School and Work Status of Pediatric Epilepsy Patients Following Epilepsy Surgery (N = 18)

Improvement in Functional Outcome in Pediatric Epilepsy Patients

12

9

6

3

0School Work

Days Missed

Number of Days

Initial VisitLast Follow-up Visit

Outcomes 200954

100

80

60

40

20

00 1 2 3 4 5 6 7 8 9 10 11 12

Years from Surgery

Seizure-free (%)

Pediatric Epilepsy PatientsCombined Cohort Adult Epilepsy Patients

Epilepsy

Seizure Freedom Following Epilepsy Surgery

the following curves. Whenever possible, our data were compared with national published data. We used the widely accepted 5

Long-Term Seizure Freedom in Adult and Pediatric Patients Following Epilepsy Surgery (N = 1,418)


6. Erickson JC, Ellenbogen RG, Khajevi K, Mulligan L, Ford GC, Jabbari B. Temporal lobectomy for refractory epilepsy in the U.S. military. Mil Med. 2005;170:201-205; 7. Spencer SS, Berg AT, Vickrey BG, et al. Predicting long-term seizure outcome after resective epilepsy surgery: the multicenter study. Neurology. 2005;65:912-918; 8. Kelley K, Theodore WH. Prognosis 30 years after temporal lobectomy. Neurology. 2005;64:1974-1976; 9. Yoon HH, Kwon HL, Mattson RH, Spencer DD, Spencer SS. Long-term seizure outcome in patients initially seizure-free after resective epilepsy surgery. Neurology. 2003;61:445-450; 10. Foldvary N, Nashold B, Mascha E, et al. Seizure outcome after temporal lobectomy for temporal lobe epilepsy: a Kaplan-Meier survival analysis. Neurology. 2000;54:630-634; 11. Salanova V, Markand O, Worth R. Longitudinal follow-up in 145 patients with medically refractory temporal lobe epilepsy treated surgically between 1984 and 1995. Epilepsia. 1999;40:1417-1423; 12. Sperling MR, O’Connor MJ, Saykin AJ, Plummer C. Temporal lobectomy for refractory epilepsy. JAMA. 1996;276:470-475.

The graph illustrates the percent of adult and pediatric patients who were seizure-free up to 10 years following a temporal lobe resection. National averages represent a weighted average of recent studies conducted in the United States.6-12

Time from Surgery 1 Year 2 Years 5 Years 10 Years 15 Years

% Seizure-free (Cleveland Clinic) 77% 72% 63% 57% 40%

% Seizure-free (national average) 72% 54% 59% 51% None available

100

80

60

40

20

00 1 2 3 4 5 6 7 8 9 10

Years from Surgery

Seizure-free (%)

Cleveland Clinic Epilepsy CenterNational Average

Long-Term Seizure Freedom Following Temporal Lobe Surgery (N = 750)

Surgical Dates: 1996 – 2009

Outcomes 200956

Epilepsy

Long-Term Seizure Freedom Following Frontal Lobe Surgery (N = 304)

lobe epilepsy operated on between 1997 and 2009.

100

80

60

40

20

00 1 2 3 4 5 6 7 8 9 10

Years from Surgery

Seizure-free (%)


Long-Term Seizure Freedom Following Posterior Quadrant Resection (N = 96)

patients with medically refractory epilepsy between 1997 and 2009.

100

80

60

40

20

00 1 2 3 4 5 6 7 8

Years from Surgery

Seizure-free (%)

Outcomes 200958

Epilepsy

Long-Term Seizure Freedom Following Hemispherectomy (N = 190)

following a hemispherectomy. Thirteen of the patients were adults and the remaining 177 were children

100

80

60

40

20

00 1 2 3 4 5 6 7 8

Years from Surgery

Seizure-free (%)


Outcomes 200960

Hydrocephalus and Related Conditions

Pediatric Hydrocephalus: Length of Stay (LOS)

Pediatric Hydrocephalus: Inpatient Mortality

1

In patients treated for pediatric hydrocephalus at Cleveland Clinic, actual inpatient mortality has

1

10

8

6

4

2

02005

382006

472007

322008

332009

35

0000

N =

Mortality (%)

Actual Expected

8

6

4

2

02005

382006

472007

322008

332009

35N =

Mean LOS (Days)

Actual Expected


Adult Hydrocephalus: LOS

Adult Hydrocephalus: Inpatient Mortality

6

4

2

02005243

2006203

2007220

2008241

2009254

00

N =

Mortality (%)

Actual Expected

10

8

6

4

2

02005243

2006203

2007220

2008241

2009254N =

Mean LOS (Days)

Actual Expected

Outcomes 200962

Hydrocephalus and Related Conditions

Chiari Malformation: LOS

Chiari Malformation: Inpatient Mortality

Actual mean LOS has remained shorter than expected following surgery for Chiari malformation.

8

6

4

2

02005

422006

592007

562008

802009

73

00

N =

Mortality (%)

Actual Expected

8

6

4

2

02005

422006

592007

562008

802009

73N =

Mean LOS (Days)

Actual Expected

Actual inpatient mortality consistently remained below expected levels following surgery for Chiari malformation, with no inpatient deaths in 2008 or 2009.


Motor Improvement Following Deep Brain Stimulation (N = 10)

2009

parameters are optimized.

and other activities.

20

0

-20

-40

-60

-80

-100

50 100

Days since Electrode Implantation

150

Change in Motor Impairment (%)Im

provement

Movement Disorders

Outcomes 200964

Demographic Patients

Multiple Sclerosis

Changes in Health Status over Time

Mellen Center Patient Characteristics

Demographic Patients


Quality of Life in 5-Year Increments since MS Diagnosis

2009

1.0

0.8

0.6

0.4

0.2

0.00-5 6-10 11-15

Years since Diagnosis

16-20 >20829N = 621 436 248 198

EQ-5D Score

values for individuals with disease P <

course of the disease, consistent with what is known about emotional well-being for

over time and is not consistent with other disease characteristics.

Depression in 5-Year Increments since MS Diagnosis

2009

10

8

6

4

2

00-5 6-10 11-15


16-20803 600 420 229N =

Mean PHQ-9 Score

Outcomes 200966

Multiple Sclerosis

Lower Extremity Function in 5-Year Increments since MS Diagnosis

2009

14

12

10

8

6

4

2

00-5 6-10 11-15


16-20 >20813N = 655 438 225 169

T25FW (Seconds)

Upper Extremity Function in 5-Year Increments since MS Diagnosis

2009

40

30

20

10

00-5 6-10 11-15


16-20 >20540N = 470 360 178 140

9-Hole Peg Test (Seconds)

The 9-Hole Peg Test is a validated quantitative measure of upper extremity (arm and hand) function. The task requires the patient to use one hand to pick up nine pegs from a container, one at a time; place them in the holes of a standard-sized board; then return each peg to the container as quickly as possible.

The T25FW is a validated quantitative measure of lower extremity function. The patient is instructed to walk a clearly marked 25-foot course as quickly and safely as possible, and clinical personnel use a stop watch to calculate the time required to take the walk.

Both the Timed 25-Foot Walk and the 9-Hole Peg Test show worsening over time, with walking deteriorating sooner and at a more rapid pace than hand function. We hope that the availability of increasingly effective treatments will show slowed progression over time.


The MSPS is an 11-item, validated, self-reported measure of MS-related disability. It is used routinely by the North American Research Committee on Multiple Sclerosis (NARCOMS). Total scale scores range from 0 (no problem) to 41 (unable to perform). MSPS scores show worsening with each half-decade of disease duration.

MS-Related Disability in 5-Year Increments since Diagnosis

2009

Disease-Modifying Therapy for Multiple Sclerosis

A major initiative at the Mellen Center in 2009 was to monitor and document patients’ adherence to their disease-modifying therapies. These injectable medications are proven to slow MS disease progression, and it is important that they be taken routinely. We set a target goal of patients achieving greater than 75 percent

usually at six-month intervals. A random sample of patients’ charts from January to December 2009 was reviewed and it was determined that, based on self-report, more than 98 percent met the goal of > 75 percent adherence; only 1.6 percent were below our goal. Most notably, 73.4 percent were 100 percent adherent.

Adherence to Injectable Disease-Modifying Therapy since Previous Visit

2009

40

30

20

10

00-5 6-10 11-15


16-20 >20838N = 640 442 239 203

Mean MSPS Score

100

75

50

25

0100 99-90 89-75

Adherence (%)

<75466N = 146 19 10

Patients (%)

Outcomes 200968

Multiple Sclerosis

Treatment with Natalizumab (Tysabri®)

Natalizumab (Tysabri®) is the newest approved disease-modifying therapy for MS. While it is associated with a rare complication (progressive multifocal leukoencephalopathy) that has occurred in 1 in 1,000 cases, it has also demonstrated the ability to improve some measures of MS health status. We evaluated health status before treatment initiation and again six months after treatment initiation, using the Multiple Sclerosis Performance Scale (MSPS) and the Timed 25-Foot Walk (T25FW).

Patients showed an improvement in MS-related disability (lower scores indicate less disability) after six months of treatment (P = 0.02).

Disability before and after Tysabri® Treatment (N = 14)

Treatment Start Dates: July 1, 2008 – June 30, 2009

20

15

10

5

0Before

Treatment

6 Months After

MSPS Score


Data suggest an improvement in walking performance (decrease in walking times with the Timed 25-Foot Walk) following six months of treatment, but we were not able to demonstrate a statistically

P = 0.08), likely due to small sample size.

Walking Times before and after Tysabri® Treatment (N = 11)

Treatment Start Dates: July 1, 2008 – June 30, 2009

14

12

10

8

6

4

2

0Before

Treatment

6 Months After

T25FW (Seconds)

Outcomes 200970

Diagnosis/Indication for ITB Number of Patients

Multiple Sclerosis 34

Motor Neuron Disease 5

Cerebral Palsy 8

Traumatic Brain Injury 2

Spinal Cord Injury 4

Stroke 3

Myelopathy 4

Adrenomyeloneuropathy 1

Anoxic Brain Injury 1

Cerebral Arteritis 1

Total 63

Multiple Sclerosis

Intrathecal Baclofen Therapy

Intrathecal baclofen (ITB) therapy is approved by the Food and Drug Administration (FDA) for the treatment of severe spasticity of spinal or cerebral origin that is refractory to other treatment modalities. The Mellen Center has been using this therapeutic modality since its approval, with more than 300 patients treated since 1990. The intrathecal infusion device (baclofen pump) is implanted by neurosurgeons in the Center for Neurological Restoration at Cleveland Clinic. Patient selection, testing and postoperative management are performed in the Mellen Center Spasticity Clinic.

From January 1, 2007, to December 31, 2009, 63 patients underwent implantation of a baclofen pump. Forty-seven of

of causes unrelated to ITB therapy, 10 are managed closer to home and one chose to discontinue ITB therapy. Four patients who received a baclofen pump between 2007 and 2009 developed complications requiring surgery: three infections around the hardware leading to explantation of the hardware (one patient opted to have the pump reimplanted a few months later) and one catheter malfunction leading to successful surgical revision. Two patients discontinued the therapy after infection. No patient discontinued the therapy in the absence of complication. Average follow-up period was 394 days.


4

3

2

1

0Before

Treatment

After

Spasticity Score

4

3

2

1

0Before

Treatment

After

Spasm Frequency Score

2007 – 2009

Spasm Frequency before and after ITB (N = 44)

2007 – 2009

Ashworth Scale (0 = no increase in tone, 4 = severe increase in tone) at baseline and after ITB therapy showed a statistically

P < 1x10-5, paired t-test) reduction in spasticity after treatment. Average follow-up was 394 days.

Mean Spasm Frequency Scale scores (0 = no spasms, 4 = more than 10 spasms/hour) at baseline and at most recent follow-up visit after ITB therapy showed a

P = 0.0001, paired t-test) reduction in spasm frequency after treatment. Average follow-up was 394 days.

72 Outcomes 2009

Multiple Sclerosis

Pain Scores before and after ITB (N = 40)

2007 – 2009

10

8

6

4

2

0Before

Treatment

After

Mean Pain Score

Pain scores (0 = no pain, 10 = worst pain possible) before and after ITB therapy showed a trend (P = 0.07, paired t-test) toward reduction in pain after treatment. Average follow-up was 394 days.


Ambulating after ITB

The Mellen Center has developed expertise in the use of ITB therapy in ambulatory patients. ITB therapy in this

sleep and quality of life in general. However, a common concern about ITB is that it may cause increased weakness with loss of function. Before baclofen pump implantation, 25 of 47 patients (53 percent) were ambulatory (able to walk 25 feet). Five patients with progressive neurologic conditions were non-ambulatory at the last follow-up visit.

2007 – 2009

10

8

6

4

2

0Before

Treatment

After

Mean Gait Speed (Seconds)

with the Timed 25-Foot Walk Test, for the patients who remained ambulatory. Overall, our observations suggest that ITB therapy relieves spasticity without compromising ambulation in most patients.

74 Outcomes 2009

Neuromuscular Disease

in myasthenia gravis (MG). The graph shows the average scores of 96 patients with diagnoses of MG who were seen in the outpatient clinic by neuromuscular staff and who had complete MG-ADL assessments on at least two occasions in 2008 and 2009. Average time between visits was 247 days. Higher scores indicate greater disability.

Myasthenia Gravis Functional Status (N = 96)

2008 – 2009

6

4

2

0Initial

Visit

Follow-up

Mean MG-ADL* Score

* Myasthenia Gravis Activities of Daily Living


The graph shows the average score of 90 patients with diagnoses of MG who were seen in the outpatient clinic by neuromuscular staff and who had complete PHQ-9 assessments on at least two occasions in 2008 and 2009. Average time between visits was 237 days. Higher scores indicate greater depression.

10

8

6

4

2

0Initial

Visit

Follow-up

Mean PHQ-9 Score

Depression Scores in Myasthenia Gravis (N = 90)

2008 – 2009

Outcomes 200976 Outcomes 200976

Pain / Headache

The percent of patients with HIT-6™ scores above 60 (considered severe impact)

in 2009 (P

greater negative impact on patients’ lives.

last visit was 116.5 days.

Headache Disability at First and Last Visit: New Headache Patients (N = 633)

2009

100

80

60

40

20

0First

Visit

Last

Patients with HIT-6™ 60 (%)

The Headache Program, within the Neurological Center for Pain, utilizes the Headache Impact Test™ (HIT-6™) as a standard health status measure for

captures the impact of headache and its treatment on functional health and well-being.


Chronic Daily Headache

Headache Disability at First and Last Visit: Percent of All Chronic Daily

2009

Headache Disability at First and Last Visit: All Chronic Daily Headache Patients

2009

676665646362616059

AllN =

Patients

New Established679 290 389

Mean HIT-6™ Score

First VisitLast Visit

100

80

60

40

20

0First

Visit

Last

Patients with HIT-6™ 60 (%) The percent of patients with HIT-6™ scores above 60 (considered severe impact) due to chronic daily headache

last visit in 2009 (P < 0.0001). Data

chronic daily headache. Higher scores

patients’ lives. Average interval duration

154.5 days.

Mean HIT-6™ score decreased for all patients seen with chronic daily headache (P < 0.0001).

Outcomes 200978

Pain / Headache

Infusion Therapy for Headache

Headache patients with status migrainosis, transformed migraine, cluster headache and chronic daily headache may receive intravenous infusion therapy with a number of different medications, including dihydroergotamine, magnesium, antiemetics, Robaxin®, Depacon®, Toradol®

7

6

5

4

3

2

1

0Pain Dizziness

Mean Score

Before InfusionAfter Infusion

Pain and dizziness improved following infusion therapy (P < 0.0001). Both pain and dizziness were assessed on a scale of 0 to 10, with 0 indicating no pain and no dizziness.

Improvement in Pain and Dizziness Following Infusion Therapy (N = 142)

2009


Interdisciplinary Method for the Assessment and Treatment of Chronic Headache (IMATCH)

One of only a few such programs in the country, IMATCH is an intensive multidisciplinary outpatient

and/or psychological status.

Pain Ratings before and after IMATCH (N = 68)

2009

Pain scores (mean + s.d.) decreased following completion of the IMATCH program. To obtain a more comprehensive assessment of their pain, patients were 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 based on patients who completed IMATCH in 2009.

10

8

6

4

2

0

Pain Score(0 = No Pain, 10 = Worst Possible Pain)

AdmissionDischarge

Current Least

Pain

Average Worst

Outcomes 200980

Pain / Headache

Stress, Anxiety and Depression before and after IMATCH (N = 69)

2009

30

25

20

15

10

0

Depression Anxiety Stress Scale (DASS) Score

AdmissionDischarge

Stress Anxiety

DASS Scale (0 - 42)

Depression

Scores on measures of stress, anxiety and depression all decreased following IMATCH, indicating improvement. Mean DASS-42 subscale scores are plotted with their standard deviations.

Pain disability decreased (lower scores indicate less severe disability) following completion of the IMATCH program.

Functional Status before and after IMATCH (N = 69)

2009

80

60

40

20

0

Disability Score

AdmissionDischarge

Pain Disability Index(0 - 70)

Headache Impact Test(36 - 78)


As part of IMATCH, patients are seen daily by physical therapists in the Department of Physical Medicine and Rehabilitation for group cardiovascular, strengthening and stretching exercises. Patients also meet twice each week with physical therapists specially trained in the treatment of headaches and neck pain for individualized exercise and manual techniques aimed at reducing their symptoms. Disability is measured with the Headache Disability Index (HDI), the Dizziness Handicap Index (DHI) and the Neck Disability Index (NDI).

2009

100

80

60

40

20

0

Score (%)

AdmissionDischarge

Headache Disability Dizziness Handicap

Index

Neck Disability

Improvement is seen across all disability measures (P < 0.001).

2009

5

4

3

2

1

0

Satisfaction Score

WholeProgram

MedicalTreatment

PsychologicalTreatment

PhysicalTherapy

Treatment

Average scores on the Treatment Helpfulness Questionnaire indicate high rates of patient satisfaction. The minimum patient satisfaction score is -5 (indicating that the patient found the treatment highly detrimental) and the maximum is +5 (highly helpful), with 0 indicating no effect of treatment.

Outcomes 200982

Pain / Headache

Cleveland Clinic Chronic Pain Rehabilitation Program

The Chronic Pain Rehabilitation Program (CPRP), within the Neurological Center for Pain, is a comprehensive, interdisciplinary program designed to treat patients with disabling chronic pain. In 2009, the program celebrated its 30th anniversary.

Each year, a number of patients enroll in the CPRP but fail to complete the full daily, three- to four-week program for a variety of medical and non-medical reasons. While these reasons are tracked, they are not the focus of the data presented; the outcomes presented focus on those patients who complete the full rehabilitation program.

In recognition of the increasing number of patients with both chronic pain and addiction, and the dearth of pain treatment

help patients with both pain and addiction. Although this is not a chemical dependency treatment program, patients in this track receive education about addiction and the role it has played in their lives and their pain. This education helps them start to plan the substance abuse treatment that follows completion of the CPRP.

CPRP Patient Characteristics

Number of Patients Enrolled 234 207 229

Number of Patients Completing 192 184 171

Percent Female 67.5 62.8 65.1

Mean Age (s.d.) 46.64 (13.23) 43.4 (15.02) 48.1 (13.09)

CPRP Patient Characteristics


Pain Intensity before and after CPRP

Depression before and after CPRP

10

8

6

4

2

0

Mean Pain Score(0 = No Pain, 10 = Worst Possible Pain)

AdmissionDischarge6-Month Follow-up1-Year Follow-up

2007 20092008

Mean pain scores decreased following participation in the Chronic Pain Rehabilitation Program. A two-point

Depressive symptoms, as measured with the Depression Anxiety Stress Scale (DASS) depression subscale, improved following participation in the CPRP. Higher scores indicate more severe depression. Mean admission scores suggest moderate depression, while all discharge and follow-up scores suggest mild depression or no depression. One-year follow-up was not yet available for 2009.

25

20

15

10

5

0

Mean Depression Score


2007 20092008

Outcomes 20098484

Pain / Headache

Anxiety before and after CPRP

16

12

8

4

0

Mean Anxiety Score


2007 20092008

Anxiety symptoms, as measured with the DASS anxiety subscale, improved following participation in the CPRP. Higher scores indicate more severe anxiety. Mean admission scores suggest moderate anxiety, while mean discharge scores are in the normal range or show mild anxiety.

Functional status, as measured with the Pain Disability Index (PDI), improved at discharge, six months and one year after participation in the CPRP compared with prior to treatment. Higher scores on the 0-70 scale indicate greater disability. One-year follow-up was not yet available for 2009.

Functional Status before and after CPRP

50

40

30

20

10

0

Mean Pain Disability Index


2007 20092008


CPRP Outcomes by Pain Subtype

Pain Intensity before and after CPRP for Fibromyalgia vs. Other Chronic Pain (N = 440)

January 2007 – May 2009

Pain Disability before and after CPRP for Fibromyalgia vs. Other Chronic Pain (N = 440)

January 2007 – May 2009

and patients with other chronic pain disorders attained clinically

patients with other chronic pain

reductions in disability due to pain.

10

8

6

4

2

0Fibromyalgia

119N =Other Chronic Pain Disorders

321

Mean Pain Score(0 = No Pain, 10 = Worst Possible Pain)

AdmissionDischarge

50

40

30

20

10

0Fibromyalgia Other Chronic Pain Disorders

Mean Pain Disability Index

AdmissionDischarge

86 Outcomes 2009

Pediatric Neurological Disorders

Pediatric Neurometabolic Clinic

of the population with unexplained neurologic and developmental symptoms, including autism and epilepsy. Until recently, this population of children and adults, some with progression of their symptoms for unexplained reasons, remained largely without a diagnosis. With advances in technology and improving diagnostic skills, the ability to reach a conclusive diagnosis 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 to reach a diagnosis in 30 to 50 percent of cases.1

Neurometabolic Clinic Diagnostic Yield

2009

400

300

200

100

0New Patient Consults Diagnosis Established via

Muscle, Genetic or CSF* Testing

Number of Patients

In 2009, our Neurometabolic Clinic evaluated more than 300 patients presenting with unexplained neurologic and/or developmental symptoms, and we were able to establish a diagnosis in 82 patients, or 26 percent.

1. van Karnebeek CD, Scheper FY, Abeling NG, Alders M, Barth PG, Hoovers JM, Koevoets C, Wanders RJ, Hennekam RC. Etiology of mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005 Jul;110(4):253-267.

Outcomes for pediatric epilepsy can be found in the Epilepsy section. Outcomes for pediatric hydrocephalus can be found in the Hydrocephalus section.


Pediatric Electromyography (EMG)

80

60

40

20

02005 2006 2007 2008 2009

Number of Studies

Total EMGsEMGs with OR/Sedation

Cleveland Clinic is one of only a few medical centers in the country that provide high-quality EMG with the option of sedation for the pediatric population, resulting in a more comprehensive examination and less discomfort for the patient.

Pediatric Headache

Patients treated for headache are assessed over time with the Pediatric Migraine Disability Assessment Score (PedsMIDAS©).

Pediatric Neuromuscular Disease

70

60

50

40

30

20

10

0PedsMIDAS©

48N =Headache Frequency

88

PedsMIDAS© Score/Number of Headaches

Pediatric patients treated for headache in 2008 and 2009 showed an improvement in headache disability, as measured by the PedsMIDAS©, and in headache frequency over a three-month period. Headache frequency

in the previous three months. Comparing group means for headache frequency between visit one and visit two, the improvement was 57 percent.

Improvement in Headache Disability

2008 – 2009

8888 Outcomes 200988

Psychiatric Disorders

Outpatient Treatment for Depression

Improvement in Depressive Symptoms (N = 139)

2009

Adult patients presenting for initial evaluation of

occurred 90 or more days from the initial evaluation P

psychotherapy and/or medication management. Iterative

20

10

0Initial

Visit

Follow-up

Mean PHQ-9 Score


Women’s Mental Health Management Group for Depression

group “good” to “excellent.”

Overall Experience

Confidence with Follow-up/Prescriptions

Comfort Level with Privacy/Confidentiality

Satisfaction with Time between Patient and MD

Needs/Questions Addressed by MD

Comfort Level with Room

Friendliness/Helpfulness - Nursing Staff

Friendliness/Helpfulness - Clerical Staff

Satisfaction with Appointment Date

Experience in Scheduling

Patient Survey Items

0 1 2 3

Patient Satisfaction Score (0 = Poor, 5 = Excellent)

4 5

Patient Satisfaction with Shared Medical Appointments for Depression (N = 43)

2009

90 Outcomes 2009


Patient Satisfaction with Shared Medical Appointments for Depression (N = 43)

2009

Depressive Symptoms before and after ECT (N = 71)

2009

100

80

60

40

20

0Would Recommend Will Follow Up

Patients (%)

In 2009, 78 percent of participants responded that they would recommend the group to others, and 67 percent said they would schedule a follow-up visit in the group.

Electroconvulsive Therapy (ECT)

Cleveland Clinic offers electroconvulsive therapy (ECT) services at its main campus as well as at Lutheran Hospital for both inpatients and outpatients. ECT is an effective, safe, traditional form of neuromodulation therapy. ECT may be recommended for individuals with a diagnosis of depression, mania, psychosis or schizophrenia. The ECT service includes a team of specially trained professionals, including psychiatrists, anesthesiologists and nurses.

P < 0.05) with ECT.

40

30

20

10

0Hamilton Depression Scale Beck Depression Inventory

Mean Scale Score

Before TreatmentAfter Treatment


Inpatient Treatment for Depression

The Mood Disorders Inpatient Unit at Lutheran Hospital, a Cleveland Clinic hospital, opened in late January 2008. Data are from patients seen on the unit in 2009.

Both the Hamilton Depression Scale (Ham-D) and the Montgomery-Asberg Depression Rating Scale (MADRS) are widely accepted and validated instruments to measure severity of depression and response to treatment. Both instruments are used, as the MADRS may be more sensitive than the Ham-D to changes produced by treatment, and the Ham-D is more commonly used among patients with bipolar disorder. Mean group scores on admission and discharge are displayed for patients admitted to the Mood Disorders Unit in 2009. For both

admission to discharge (P < 0.05).

Depressive Symptoms before and after Treatment (N = 200)

2009

40

30

20

10

0Hamilton Depression Scale Montgomery-Asberg

Depression Rating Scale

Mean Scale Score

AdmissionDischarge

92 Outcomes 2009


The Clinical Global Impression (CGI) Severity Scale is a seven-point scale that requires the clinician to rate the severity of the patient’s illness at the time of assessment, relative to other patients with the same diagnosis. Higher scores indicate greater severity of illness. In 2009, patients treated on the Mood

P < 0.05). A CGI score of 3 equates to “mildly ill.” The Young Mania Rating Scale (YMRS) measures the presence of manic or hypomanic symptoms. Depressed patients did not experience excessive activation with treatment for their

considered normal.

Illness Severity and Manic Symptoms before and after Treatment (N = 200)

2009

7

6

5

4

3

2

1

0Clinical Global Impression

Severity ScaleYoung Mania Rating Scale

Mean Scale Score

AdmissionDischarge


Alcohol and Drug Rehabilitation

The Alcohol and Drug Rehabilitation Center (ADRC) provides a multidisciplinary team approach to the evaluation and treatment of chemical dependency. The ADRC is designed to help patients confront and overcome their chemical and/or alcohol dependency, and to assist them in developing strategies for maintaining a chemical-free lifestyle.

Patient Satisfaction with the ADRC Program: Would Recommend

100

80

60

40

20

0

Respondents (%)

Definitely YesProbably YesProbably NoDefinitely No

2006222N =

2009203

2008279

2007227

More than 85 percent of patients would recommend the ADRC program to family and friends.

Outcomes 200994


Patient Satisfaction with the ADRC Program: Helpfulness of Staff

Patient Satisfaction with the ADRC Program: Courtesy and Respect Shown by Physicians

100

80

60

40

20

0

Respondents (%)

ExcellentVery GoodGoodFairPoor

2006206N =

2009196

2008261

2007210

In 2009, more than 60 percent of patients rated the staff “excellent” in helpfulness, arranging for additional care and services.

In 2009, more than 75 percent of patients rated the courtesy and respect shown by physicians “excellent.”

100

80

60

40

20

0

Respondents (%)


2006206N =

2009196

2008261

2007210

95Neurological Institute 95Neurological Institute

Patient Satisfaction with the ADRC Program: Courtesy and Respect Shown by Nurses

Patients Treated for Opioid Dependence with Buprenorphine

In 2009, 65 percent of patients rated the courtesy and respect shown by nurses “excellent.”

100

80

60

40

20

0

Respondents (%)


2006217N =

2009201

2008273

2007216

Treatment of Opioid Dependence

Buprenorphine (Subutex®) and buprenorphine/naloxone (Suboxone®) offer a safer and arguably more effective treatment alternative to methadone for dependence on opioids such as heroin, Oxycontin®, Percocet® and Vicodin®. Buprenorphine attenuates withdrawal symptoms and decreases cravings by partially stimulating the opioid receptor while blocking the

long-term medication-assisted treatment with buprenorphine has increased more than fourfold since 2005.

350

300

250

200

150

100

50

0

Number of Patients

20062005 200920082007

Outcomes 200996 Outcomes 2009

Sleep Disorders

4,000

3,000

2,000

1,000

0

Number of Studies

PSG/EEGCPAP/BiPAPSplitMSLT/MWT

2007 2008 200920062005

500

400

300

200

100

0

Number of Studies

2006 2007 2008 2009

Adult Sleep Studies

Pediatric Sleep Studies

There has been a progressive increase in the number of pediatric sleep studies performed over the past four years.

PSG/EEG = Polysomnography alone or in combination with standard electroencephalography

CPAP = Continuous positive airway pressure titration study / BiPAP = Bilevel positive airway pressure titration study

Split = Combination PSG and positive airway pressure (PAP) titration

MSLT = Multiple sleep latency test / MWT = Maintenance of wakefulness test


Sleep Apnea

Sleepiness and Fatigue before and after Treatment

2009

50

40

30

20

10

0Epworth Sleepiness Scale

323N =Fatigue Severity Scale

319

Mean Scale Score


Sleepiness, as measured with the Epworth Sleepiness Scale (ESS), decreased among sleep apnea patients who were

Lower ESS scores indicate less sleepiness (ESS score < 10 is normal). Fatigue, as measured with the Fatigue Severity Scale (FSS), decreased in patients who were compliant with PAP treatment. Lower scores indicate less fatigue.

98 Outcomes 2009

Sleep Disorders

Depressive symptoms, as measured with the PHQ-9, improved in patients who were compliant with PAP treatment. Lower scores indicate fewer depressive symptoms, with PHQ-9 scores < 5 suggesting minimal depression. Functional status, as measured by the Functional Outcomes of Sleep Questionnaire (FOSQ), improved among sleep apnea patients who were

of sleep disorders on activities of daily living. Higher scores indicate higher levels of quality of life.

Depressive Symptoms and Functional Status before and after Treatment

2009

Functional Status before and after Treatment (N = 324)

2009

20

10

0PHQ-9314N =

FOSQ324

Mean Scale Score


4

3

2

1

0

Mean Subscale Score

Before PAPAfter PAP

General SocialOutcomes

ActivityLevel

FOSQ Subscale

Vigilance IntimateRelationships

Sleep apnea patients who were compliant with PAP showed improvement in various domains of functional status as measured by FOSQ subscales. Higher scores indicate higher levels of functioning.


Total Sleep Time before and after Treatment (N = 325)

2009

Patients who were compliant with PAP treatment reported an increase in total sleep time.

7.0

6.8

6.6

6.4

6.2

6.0Before Treatment After Treatment

Mean Total Sleep Time (Hours)

Insomnia

Total Sleep Time before and after Sleep Psychology for Insomnia (N = 48)

2009

Patients who were evaluated and treated for insomnia by a sleep psychologist had

of nearly one hour, from 5.7 to 6.5 hours (P = 0.007), after less than four months of treatment. The primary treatment was cognitive behavioral therapy. The average number of visits was 3.7 and the average

106.2 days.

7.0

6.5

6.0

5.5

5.0Initial Follow-up

Visit

Mean Total Sleep Time (Hours)

Outcomes 2009100

Spinal Disease

The Center for Spine Health provides comprehensive surgical and medical management of spinal disorders, including spinal injections, acupuncture and osteopathic manipulation therapy.

Of note, there were 10 spine surgeons in 2007 and only nine surgeons in 2008 and 2009.

Spine Surgical Cases

Spine Nonsurgical Procedures

2,500

2,000

1,500

1,000

500

02007 2008 2009

Number of Surgeries

1,000

750

500

250

02007 2008 2009

Number of ProceduresSpinal InjectionsOsteopathic ManipulationAcupuncture


Lumbar Disc Herniation

Improvement in Quality of Life Following Discectomy for Lumbar Disc Herniation (N = 65)

2009

Improvement in Depressive Symptoms Following Discectomy for Lumbar Disc Herniation (N = 25)

2009

1.0

0.8

0.6

0.4

0.2

0Pre- Post-

Surgery

EQ-5D Score

There was an improvement in quality of life, as measured with the EQ-5D*, following lumbar discectomy (P < 0.0001). The majority of patients were referred for leg pain from a symptomatic disc herniation.

15

10

5

0Pre- Post-

Surgery

PHQ-9 Score

There was also an improvement in depressive symptoms, as measured with the PHQ-9*, following lumbar discectomy (P < 0.0001).

* Both the EQ-5D and PHQ-9 are explained in more detail in the Outcomes Overview.

Outcomes 2009102

Spinal Disease

The Pain Disability Questionnaire (PDQ) measures the effects of pain on 15 aspects of patient function, including work, recreation, travel, need for medical visits, reliance on social support, income, lifting and personal care. On each item, patients rate their performance from 0 to 10 (worst), with cumulative scores ranging from 0 to 150. Higher scores indicate greater disability due to pain.

There was an improvement in patients’ functional status, as measured with the PDQ, following lumbar discectomy (P < 0.0001).

150

100

50

0Pre- Post-

Surgery

PDQ Score

Improvement in Pain Disability Following Discectomy for Lumbar Disc Herniation (N = 50)

2009


Disc Herniation (N = 15)

2009

50

40

30

20

10

0Pre- Post-

Surgery

ODI Score

following lumbar discectomy (P = 0.015).

The Oswestry Back Disability Index (ODI) assesses the patient’s back or leg pain and its impact on nine additional dimensions of life, including personal care, social life, sitting, walking, sleeping, sex life and ability to travel. The score ranges from 0 to 100. Higher scores indicate greater levels of spinal disability.

104 Outcomes 2009

Spinal Disease

Lumbar Spinal Stenosis

Improvement in Quality of Life Following Conservative Therapy for Lumbar Spinal Stenosis (N = 112)

2009

Improvement in Depressive Symptoms Following Conservative Therapy for Lumbar Spinal Stenosis (N = 87)

2009

1.0

0.8

0.6

0.4

0.2

0Initial Follow-up

Visit

EQ-5D Score

There was an improvement in quality of life, as measured with the EQ-5D, following conservative management of spinal stenosis (P < 0.0001). Conservative management may include exercise-oriented physical therapy, medications, spinal injections and acupuncture. Average duration between initial and follow-up visits was 99 days.

There was an improvement in depressive symptoms, as measured with the PHQ-9, following conservative management of spinal stenosis (P < 0.0001).

15

10

5

0Initial Follow-up

Visit

PHQ-9 Score


Improvement in Pain Disability Following Conservative Therapy for Lumbar Spinal Stenosis (N = 70)

2009

Conservative Therapy for Lumbar Spinal Stenosis (N = 56)

2009

There was an improvement in patients’ functional status, as measured with the PDQ, following conservative therapy for spinal stenosis (P < 0.006).

pain disability, as measured with the ODI, following conservative therapy for spinal stenosis (P = 0.003).

30

20

10

0Initial Follow-up

Visit

ODI Score

100

75

50

25

0Initial Follow-up

Visit

PDQ Score

106 Outcomes 2009

Physical Medicine and Rehabilitation

Outpatient Physical Medicine and Rehabilitation

Improvement in Quality of Life Following Outpatient Physical Medicine and Rehabilitation (N = 245)

2009

Improvement in Depressive Symptoms Following Outpatient Physical Medicine and Rehabilitation (N = 238)

2009

Spine-related diagnoses (spondylosis, lumbago, back pain, disc disorders, spinal stenosis) accounted for more than 45 percent of all outpatient encounters

offers full cross-disciplinary rehabilitation for patients with physical, psychosocial, cognitive and vocational impairments. At follow-up, there was an improvement in quality of life (P < 0.0001), as measured by the EQ-5D. Mean duration between visits was 60.3 days.

At follow-up, there was an improvement in depressive symptoms (P < 0.01), as measured with the PHQ-9. Mean duration between visits was 61.3 days.

1.0

0.8

0.6

0.4

0.2

0Initial Follow-up

Visit

Mean EQ-5D Index Score

20

15

10

5

0Initial Follow-up

Visit

Mean PHQ-9 Score


Occupational Rehabilitation Program

Work Conditioning Program

(N = 23)

2009

2007 – 2009

The Occupational Rehabilitation Program (accredited by the Commission on Accreditation of Rehabilitation Facilities [CARF]) is a multidisciplinary, individualized, comprehensive

assist the injured worker in return to work through progressive physical conditioning, work simulation, and vocational and psychosocial interventions. An on-site job analysis and recommendations for accommodation or adaptations to the work environment, while minimizing the risk of reinjury, are also part of this service. Patients in this program had primarily musculoskeletal (spine, upper extremity and lower extremity) diagnoses. “Work ready” indicates the percentage of patients who, after completing the Occupational Rehabilitation Program and three months after discharge from the program, either returned to work, were undertaking a job search, were involved in education/training or were unemployed but capable of working.

Work Conditioning is a CARF-accredited program (three to

reconditioning and job simulation/real work tasks to help the injured worker regain optimal function for return to work. (Some patients progress from work conditioning to an occupational rehabilitation program prior to return to work.) Patients in this program had primarily musculoskeletal (spine, upper extremity and lower extremity) diagnoses. “Work ready” indicates the percentage of patients who, after completing the Work Conditioning Program, either returned to work, were undertaking a job search, were involved in education/training or were unemployed but capable of working.

90

85

80

75

70Work Ready at

DischargeWork Ready at

3 Monthsafter Discharge

Patients (%)

90

85

80

75

702007

38N =2008

402009

36

Patients Work Ready (%)

Outcomes 2009108

Neuroimaging

2009

target turnaround time is 45 minutes.

(N = 12)

(N = 8)

(N = 17)

(N = 14)

(N = 17)

(N = 11)

(N = 15)

(N = 18)

(N = 18)

(N = 37)

(N = 21)

(N = 22)

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

0 5 10

Median Turnaround Time (Minutes)

15 20

Jan


Critical Results Reporting

2009

Although a number of neuroradiology results yield information urgently important to clinical care, Cleveland Clinic has determined that acute intracranial hemorrhage and severe intracranial mass effect are considered “critical,” and results should be communicated to a responsible licensed

160

140

120

100

80

60

40

20

0

Median Time to Notification (Minutes)

Jan32N =

Feb28

Mar24

Apr24

May8

Jun15

Jul19

Aug11

Sep29

Oct31

Nov13

Dec27

Target = 90 Minutes

Outcomes 2009110

Neurosurgical Anesthesia

Representatives of the Department of General Anesthesiology visit craniotomy and major spine surgery inpatients on their second postoperative day in the hospital to evaluate the early postoperative period. One outcome measure, collected from medical record review, is postoperative nausea or vomiting (PONV). The department features the management of PONV in its clinical quality improvement program.

Nausea and Vomiting within 24 Hours of Craniotomy (N = 440)

2009

Nausea and Vomiting within 24 Hours of Spine Surgery (N = 712)

2009

100

75

50

25

0Q4

Patients (%)

Q3

Calendar Quarter

Q2Q1

Neither Nausea nor VomitingNausea OnlyVomiting

100

75

50

25

0Q4

Patients (%)

Q3

Calendar Quarter

Q2Q1

Neither Nausea nor VomitingNausea OnlyVomiting


percentages by calendar quarter of craniotomy and major spine surgery patients responding, “Agree very much,” the highest rating, are shown.

Patient Satisfaction with Anesthesia Care for Craniotomy (N = 118)

2009

Patient Satisfaction with Anesthesia Care for Spine Surgery (N = 420)

2009

100

75

50

25

0Q1

18N =

Q3

28

Q2

37

Q4

36

Patients (%)

Calendar Quarter

100

75

50

25

0

Patients (%)

Q1

85N =

Q3

101

Q2

121

Q4

113

Calendar Quarter

Outcomes 2009

Surgical Care Improvement Program (SCIP) – National Hospital Quality Measures andOverall Appropriateness of Care

Process Measures (often referred to as “core” measures)are available online at hospitalcompare.hhs.gov, a consumer-oriented website hosted by the Centers

submit surgery process-of-care data that show how consistently recommended care was provided to adult patients, irrespective of payer. Cleveland

care data appear on the opposite page.

Appropriateness of Care Measure To supplement

generates “appropriateness of care” data. We calculate how often we provided every recommended surgical care process intervention for which each individual patient was eligible. The results, also shown on the opposite page, are generated on a per-patient, “all or nothing” basis.

112

Surgical Quality Improvement


Cleveland Clinic data source: hospitalcompare.hhs.govVisit

hospitalcompare.hhs.gov

Notes: An overall “appropriateness of care” average is not available for the group of measures shown above.

711814

0 20 40 60 80 100

Percent of Patients

1,124

1,4621,362

997903

766

1,028938

466

536546

495

443677

495

443677

956

740

N

Cleveland Clinic 2008

Benchmark*Cleveland Clinic 2007

Cleveland Clinic 2009

Prophylactic Antibiotic Received within 1 HourPrior to Surgical Incision

Overall Appropriateness of Surgical Care

Appropriate Prophylactic AntibioticSelected for Surgical Patients

Surgery Patients on Beta-Blocker Therapy Prior toArrival Who Received a Beta-Blocker During

the Perioperative Period

Surgery Patients with Recommended VenousThromboembolism Prophylaxis Ordered

Surgery Patients Who Received AppropriateVenous Thromboembolism Prophylaxis within 24Hours Prior to Surgery to 24 Hours After Surgery

Prophylactic Antibiotic Discontinued within24 Hours After Surgery End Time

Outcomes 2009114

Surgical Quality Improvement

National Surgical Quality Improvement Project

Overall Multispecialty 30-Day Mortality (N = 4,562)

July 2008 – June 2009

Overall Multispecialty 30-Day Morbidity (N = 4,562)

July 2008 – June 2009

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is a national

abstraction methodology. Cleveland Clinic has participated in multispecialty NSQIP since May 2008, and the

Overall multispecialty mortality was lower than expected, and morbidity was higher than expected. For both

0

4

8

10

12

14

16

6

2

Percent

ExpectedObserved0

4

8

10

12

14

16

6

2

Percent

ExpectedObserved


Neurosurgery 30-Day Morbidity (N = 552)

July 2008 – June 2009

Neurosurgery morbidity was higher than expected; however,

0

4

8

10

12

14

16

6

2

Percent

ExpectedObserved

Outcomes 2009

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

2009 (N = 7,686)2008 (N = 6,221)

Overall Rating of Outpatient Care and Services

2008 – 2009

more than just delivering high-tech clinical care: It also involves addressing patients’

to ensure delivery of world-class care that is consistently patient-centered by partnering with caregivers to exceed the expectations of patients and families. We strive to exceed expectations through customized care for patients and engaged,

to create and sustain a culture in which everyone feels ownership and responsibility for delivering quality, empathetic and customized care for our patients.

research and implement innovative patient- and family-based programs to enhance the

with Human Resources on initiatives to improve employee awareness and engagement as they relate to providing a positive patient experience.

116

Patient Experience


Recommend Outpatient Provider

2008 – 2009

100

80

0

60

40

20

Percent

Excellent Very Good Good Fair Poor


2009 (N = 7,686)2008 (N = 6,221)

100

80

0

60

40

20

Percent

ExtremelyLikely


Very Likely SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2009 (N = 7,686)2008 (N = 6,221)

Rating of Outpatient Provider

2008 – 2009

117

Outcomes 2009118

100

80

0

6062% 65%

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, Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.

2009 total survey respondents = 1,4782008 total survey respondents = 1,113

73% 74%

HCAHPS Overall Assessment

2008 – 2009

Inpatient – Neurological Institute

With the support of the Centers for Medicare & Medicaid Services (CMS) and

survey (HCAHPS) was implemented in late 2006. Results collected for reporting are available at hospitalcompare.hhs.gov.

Patient Experience

100

80

0

60

40

20

Percent

DischargeInformation

Doctor Communication

Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

Respondents choosing “always” or “yes”

Source: Quality Data Management and Press Ganey, national hospital survey vendors

For comparison purposes, Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.

2009 total survey respondents = 1,4782008 total survey respondents = 1,113

HCAHPS Domains of Care

2008 – 2009


The Neurological Institute Voice of the Patient Advisory Council recently completed its second year.

Selected Publications

For a complete list of publications authored by

Neurological Institute staff in 2009, go to

clevelandclinic.org/quality/outcomes

Brain Tumor and Neuro-Oncology Center Angelov L, Doolittle ND, Kraemer DF, Siegal T, Barnett GH, Peereboom DM, Stevens G, McGregor J, Jahnke K, Lacy CA,

Ference S, Bell S, Sorenson L,

barrier disruption and intra-arterial methotrexate-based therapy for newly diagnosed primary CNS lymphoma: a multi-institutional experience. J Clin Oncol. 2009 Jul

Dasgupta A, Raychaudhuri B, Haqqi T, Prayson R, Vogelbaum M, Haque SJ.

required for the growth of U87 cell-derived tumours in mice. Eur J Cancer.

Rich JN. The hypoxic microenvironment maintains glioblastoma stem cells and promotes reprogramming towards a cancer stem cell phenotype. Cell Cycle. 2009 Oct

Lehtonen H, Sane T, Weil RJ, Vierimaa O, Salmela P, Tuppurainen K, Makinen M, Aaltonen LA, Karhu A. The expression of AIP-related molecules in elucidation of cellular pathways in pituitary adenomas. Am J Pathol. 2009

Outcomes 2009120


Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ. Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. J Neurosurg.

Prayson NF, Angelov L, Prayson RA. Microscopic thrombi in glioblastoma multiforme do not predict the development of deep venous thrombosis. Ann Diagn Pathol.

Spiotta AM, Bain MD, Lautzenheiser FK, Barnett GH. Neurological surgery at the Cleveland Clinic: a historical perspective. Neurosurgery.

Videtic GMM, Reddy CA, Chao ST, Rice TW, Adelstein DJ, Barnett GH, Mekhail TM, Vogelbaum MA, Suh JH. Gender, race, and survival: a study in non-small-cell lung cancer brain metastases patients utilizing the radiation therapy oncology group recursive partitioning

Int J Radiat Oncol Biol Phys. 2009

Vogelbaum MA, Berkey B, Peereboom D, Macdonald D, Giannini C, Suh JH, Jenkins R, Herman J, Brown P, Blumenthal DT, Biggs C, Schultz C, Mehta M. Phase II trial of preirradiation and concurrent temozolomide in patients with newly diagnosed anaplastic oligodendrogliomas and mixed anaplastic

Neuro Oncol. 2009


Hui FK, Tumialan LM, Tanaka T, Cawley CM, Zhang YJ. Clinical differences between angiographically negative, diffuse subarachnoid hemorrhage and perimesencephalic subarachnoid hemorrhage. Neurocrit Care.

Hussain MS, Moskowitz SI, Furlan AJ, Turner RD, Gonugunta V, Rasmussen PA, Masaryk TJ, Fiorella D. Mechanical thrombectomy for acute stroke with the alligator retrieval device. Stroke. 2009

Lin R, Vora N, Zaidi S, Aleu A, Jankowitz B, Thomas A, Gupta R, Horowitz M, Kim S, Reddy V, Hammer M, Uchino K, Wechsler LR, Jovin T. Mechanical approaches combined with intra-arterial pharmacological therapy are associated with higher recanalization rates than either intervention alone in revascularization of acute carotid terminus occlusion. Stroke. 2009 Jun;40(6):2092-2097.

Marchi N, Betto G, Fazio V, Fan Q, Ghosh C, Machado A, Janigro D. Blood-brain barrier damage and brain penetration of antiepileptic drugs: role of serum proteins and brain edema. Epilepsia.

Meyers PM, Schumacher HC, Higashida RT, Derdeyn CP, Nesbit GM, Sacks D, Wechsler LR, Bederson JB, Lavine SD, Rasmussen P. Reporting standards for endovascular repair of saccular intracranial cerebral aneurysms. Stroke. 2009

Meyers PM, Schumacher HC, Higashida RT, Derdeyn CP, Nesbit GM, Sacks D, Wechsler LR, Bederson JB, Lavine SD, Rasmussen P. Reporting standards for endovascular repair of saccular intracranial cerebral aneurysms. J Vasc Interv Radiol.

Outcomes 2009Outcomes 2009


Moskowitz SI, Liu J, Krishnaney AA. Postoperative complications associated with dural substitutes in suboccipital craniotomies. Neurosurgery. 2009 Mar;64

Moskowitz SI, Ahrens C, Provencio JJ, Chow M, Rasmussen PA. Prehemorrhage statin use and the risk of vasospasm after aneurysmal subarachnoid hemorrhage. Surg Neurol.

Rasmussen PA, Suri MF, Taylor RA,

Zaidat OO. Intracranial atherosclerotic disease: an update. Ann Neurol.

Epilepsy Center

Busch RM, Frazier TW, Iampietro MC, Chapin JS, Kubu CS. Clinical utility of the Boston Naming Test in predicting ultimate side of surgery in patients with medically intractable temporal lobe epilepsy: A double cross-validation study. Epilepsia.

Gonzalez-Martinez JA, Moddel G, Ying Z, Prayson RA, Bingaman WE, Najm IM. Neuronal nitric oxide synthase expression in resected epileptic dysplastic neocortex. J Neurosurg.

Jehi LE, O’Dwyer R, Najm I, Alexopoulos A, Bingaman W. A longitudinal study of surgical outcome and its determinants following posterior cortex epilepsy surgery. Epilepsia. 2009

Marchi N, Fan Q, Ghosh C, Fazio V, Bertolini F, Betto G, Najm I, Granata T, Janigro D.

of status epilepticus. Neurobiol Dis.

Mosher JC, Hamalaninen MS, Pantazis D, Hui HB, Burgess RC, Leahy RM. Generalized sidelobe canceller for magnetoencephalography arrays. Proc IEEE Int Symp Biomed Imaging.

Nagel SJ, Najm IM. Deep brain stimulation for epilepsy. Neuromodulation.

Oghlakian RO, Tilelli CQ, Hiremath GK, Alexopoulos AV, Najm IM. Single injection of a low dose of pentylenetetrazole leads to epileptogenesis in an animal model of cortical dysplasia. Epilepsia.

Tandon N, Alexopoulos AV, Warbel A, Najm IM, Bingaman WE. Occipital epilepsy: spatial categorization and surgical management. J Neurosurg.

Unnwongse K, Lachhwani D, Tang-Wai R, Matley K, O’Connor T, Nair D, Bingaman W, Wyllie E, Diehl B. Oral automatisms induced by stimulation of the mesial frontal cortex. Epilepsia.

Lou Ruvo Center for Brain Health

Schiffer RB. A model of Alzheimer’s disease and mild cognitive impairment based

2009 ICME International Conference on Complex Medical Engineering, CME 2009. 2009;4906629.

Brefczynski-Lewis J, Lowitszch S, Parsons M, Lemieux S, Puce A. Audiovisual non-verbal dynamic faces elicit

Brain Topogr. 2009

Chapin JS, Busch RM, Naugle RI, Najm IM. The Family Pictures subtest of the WMS-III: relationship to verbal and visual memory following temporal lobectomy for intractable epilepsy. J Clin Exp Neuropsychol.

122


Pizzi AM, Chapin JS, Tesar GE, Busch RM. Comparison of personality traits in patients with frontal and temporal lobe epilepsies. Epilepsy Behav.

Seidenberg M, Guidotti L, Nielson KA, Woodard JL, Durgerian S, Antuono P, Zhang Q, Rao SM. Semantic memory activation in individuals at risk for developing Alzheimer disease. Neurology.

Strober L, Rao S, Benedict RHB. Sensitivity of conventional memory tests in multiple sclerosis: comparing the Rao Brief Repeatable Neuropsychological Battery and the Minimal Assessment of Cognitive Function in MS. Mult Scler. 2009

Vendrame M, Alexopoulos AV, Boyer K, Gregas M, Haut J, Lineweaver T, Wyllie E, Loddenkemper T. Longer duration of epilepsy and earlier age at epilepsy onset correlate with impaired cognitive development in infancy. Epilepsy Behav.

Mellen Center for Multiple Sclerosis Treatment and Research

Bermel RA, Fox RJ. Picturing injury and recovery with diffusion tensor imaging: the eyes have it. Neurology. 2009

Cohen JA, Imrey PB,Fisher E, Fox RJ,

Goodman AD, Hara-Cleaver C, Hutton GJ, Mandell BF, Scott TF, Zhang H, Apperson-Hansen C, Beck GJ, Houghtaling PL, Karafa MT, Stadtler M. Results of the Avonex Combination Trial (ACT) in relapsing-remitting MS. Neurology.

Horenstein C, Lowe MJ, Koenig KA, Phillips MD.

tapping-related activation in premotor and primary motor cortex. Hum Brain Mapp.

Khatri BO, Man S, Giovannoni G, Koo AP, Lee JC, Tucky B, Lynn F, Jurgensen S, Woodworth J, Goelz S, Duda PW, Panzara MA, Ransohoff RM, Fox RJ.exchange in accelerating natalizumab clearance and restoring leukocyte function. Neurology.

Ransohoff RM, Khoury SJ. Localizing central nervous system immune surveillance: meningeal antigen-presenting cells activate T cells during experimental autoimmune encephalomyelitis. Ann Neurol.

Moll NM, Cossoy MB, Fisher E, Staugaitis SM, Tucky BH, Rietsch AM, Chang A, Fox RJ, Trapp BD, Ransohoff RM. Imaging correlates of leukocyte accumulation and CXCR4/

Arch Neurol. 2009

Nakamura K, Fisher E. Segmentation of brain magnetic resonance images for measurement of gray matter atrophy in multiple sclerosis patients. Neuroimage. 2009 Feb

Rani MRS, Xu Y, Lee JC, Shrock J, Josyula A, Schlaak J, Chakraborthy S, Ja N, Ransohoff RM, Rudick RA. Heterogeneous, longitudinally stable molecular signatures in response to interferon-beta. Ann N Y Acad Sci. 2009

Rudick RA, Polman CH. Current approaches to the

in patients with multiple sclerosis. Lancet Neurol. 2009

123



Woo HH, Welch BG, Niemann DB, Purdy PD, Aagaard-Kienitz B, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG. Target lesion revascularization after wingspan: assessment of safety and durability. Stroke. 2009

Horenstein C, Lowe MJ, Koenig KA, Phillips MD.

tapping-related activation in premotor and primary motor cortex. Hum Brain Mapp.

Moskowitz SI, Furlan AJ, Turner RD, Gonugunta V, Rasmussen PA, Masaryk TJ, Fiorella D. Mechanical thrombectomy for acute stroke with the alligator retrieval device. Stroke.

Moskowitz SI, Gonugunta VR, Rasmussen PA, Masaryk TJ, Fiorella D. Revascularization of symptomatic subacute cerebrovascular occlusions with a self-expanding intracranial stent system. Neurosurgery. 2009

Miocinovic S, Lempka SF, Russo GS, Maks CB, Butson CR, Sakaie KE, Vitek JL, McIntyre CC.theoretical characterization of the voltage distribution generated by deep brain stimulation. Exp Neurol. 2009

Talanow R, Ruggieri P, Alexopoulos A, Lachhwani D, Wu G.

Clin Nucl Med.

Center for Neurological Restoration

Johnson MD, Vitek JL, McIntyre CC. Pallidal stimulation that improves parkinsonian motor symptoms also modulates

treated monkey. Exp Neurol.

Lujan JL, Noecker AM, Butson CR, Cooper SE, Walter BL, Vitek JL, McIntyre CC.

stimulation surgeries. Stereotact Funct Neurosurg. 2009;87(4):229-240.

Machado A, Haber S, Sears N, Greenberg B, Malone D, Rezai A. Functional topography of the ventral striatum and anterior limb of the internal capsule determined by electrical stimulation of awake patients. Clin Neurophysiol. 2009

Machado AG, Baker KB, Schuster D, Butler RS, Rezai A. Chronic electrical stimulation of the contralesional lateral cerebellar nucleus enhances recovery of motor function after cerebral ischemia in rats. Brain Res.

Maks CB, Butson CR, Walter BL, Vitek JL, McIntyre CC. Deep brain stimulation activation volumes and their association with neurophysiological mapping and therapeutic outcomes. J Neurol Neurosurg Psychiatry. 2009

Malone DA, Jr., Dougherty DD, Rezai AR, Carpenter LL,

Machado AG, Kubu CS, Tyrka AR, Price LH, Stypulkowski PH,

Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry. 2009 Feb

124 Outcomes 2009

Marchi N, Betto G, Fazio V, Fan Q, Ghosh C, Machado A, Janigro D. Blood-brain barrier damage and brain penetration of antiepileptic drugs: role of serum proteins and brain edema. Epilepsia.

Mera TO, Johnson MD, Rothe D, Zhang J, Xu W, Ghosh D, Vitek J, Alberts JL. in MPTP-treated primates. J Neurosci Methods. 2009 Feb


Huang P, Zhao XS, Fields M, Ransohoff RM, Zhou L. Imatinib attenuates skeletal muscle dystrophy in mdx mice. FASEB J.

Liu HN, Sanelli T, Horne P, Pioro EP, Bilbao J, Zinman L, Robertson J. Lack of evidence of

amyotrophic lateral sclerosis. Ann Neurol. 2009

Shook SJ, Pioro EP. Racing against the clock: recognizing, differentiating, diagnosing, and referring the amyotrophic lateral sclerosis patient. Ann Neurol.

Thurtell MJ, Pioro EP, Leigh RJ. Abnormal eye movements in Kennedy disease. Neurology.

Viollet L, Gailey S, Thornton DJ, Friedman NR, Flanigan KM, Mahan JD, Mendell JR. Utility of cystatin C to monitor renal function in duchenne muscular dystrophy. Muscle Nerve.

Zhou L, Pioro EP.misdiagnosed with polyradiculopathy and myopathy. Amyotroph Lateral Scler.

Neurological Center for Pain

Bamford CC, Tepper SJ. Daily pharmacologic prophylaxis of episodic migraine. Tech Reg Anesth Pain Manag. 2009

Heckman BD, Holroyd KA, Tietjen G, O’Donnell FJ, Himawan L, Utley C, Watakakosol R, Stillman M. Whites and African-Americans in headache specialty clinics respond equally well to treatment. Cephalalgia. 2009

Heckman BD, Holroyd KA, Himawan L, O’Donnell FJ, Tietjen G, Utley C, Stillman M. Do psychiatric comorbidities

naturalistic longitudinal treatment study. Pain. 2009

Tepper SJ, Cleves C, Taylor FR. Patent foramen ovale and migraine: association, causation, and implications of clinical trials. Curr Pain Headache Rep.

Tepper SJ, Cleves C. Telcagepant, a calcitonin gene-related peptide antagonist for the treatment of migraine. Curr Opin Investig Drugs.

Tepper SJ, Rezai A, Narouze S, Steiner C, Mohajer P, Ansarinia M. Acute treatment of intractable migraine with sphenopalatine ganglion electrical stimulation. Headache.

Whyte CA, Tepper SJ. Adverse effects of medications commonly used in the treatment of migraine. Expert Rev Neurother.



Center for Pediatric Neurology and Neurosurgery

Amlie-Lefond C, Bernard TJ, Sebire G, Friedman NR, Heyer GL, Lerner NB, DeVeber G, Fullerton HJ. Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study. Circulation.

Chahine LM, Ghosh D.cerebellar hemispherectomy: support for the thalamus as the central oscillator. J Child Neurol. 2009 Jul;24(7):

Deshpande A, Dombrowski SM, Leichliter A, Krajcir N, Zingales N, Inoue M, Schenk S, Fukamachi K, Luciano MG. Dissociation between vascular endothelial growth factor receptor-2 and blood vessel density in the caudate nucleus after chronic hydrocephalus. J Cereb Blood Flow Metab.

Di X. pediatric Chiari type I. Minim Invasive Neurosurg. 2009

Di X, Ragab M, Luciano MG. Cine phase-contrast MR

Can J Neurol Sci.

Loddenkemper T, Cosmo G, Kotagal P, Haut J, Klaas P, Gupta A, Lachhwani DK, Bingaman W, Wyllie E. surgery in children with electrical status epilepticus in sleep. Neurosurgery.

Messiaen L, Yao S, Brems H, Callens T, Sathienkijkanchai A,

Bobele G, Cohen BH,

Leppig K, Lim C, McDonald M, Narayanan V, Pearn A, Pedersen R, Powell B, Shapiro LR, Skidmore D, Tegay D,

syndrome. JAMA.

Packer RJ, Jakacki R, Horn M, Rood B, Vezina G, MacDonald T, Fisher MJ, Cohen B. Objective response of multiply recurrent low-grade gliomas to bevacizumab and irinotecan. Pediatr Blood Cancer.

Parikh S, Hyland K, Lachhwani DK. Vitamins, not surgery: Pediatr Neurol.

2009 Jun;40(6):477-479.

Sarkis RA, Loddenkemper T, Burgess RC, Wyllie E. Childhood absence epilepsy in patients with benign focal epileptiform discharges. Pediatr Neurol.

Vendrame M, Alexopoulos AV, Boyer K, Gregas M, Haut J, Lineweaver T, Wyllie E, Loddenkemper T. Longer duration of epilepsy and earlier age at epilepsy onset correlate with impaired cognitive development in infancy. Epilepsy Behav.

Viollet L, Gailey S, Thornton DJ, Friedman NR, Flanigan KM, Mahan JD, Mendell JR. Utility of cystatin C to monitor renal function in duchenne muscular dystrophy. Muscle Nerve.

Outcomes 2009126

Department of Physical Medicine and Rehabilitation

Baharestani MM, Black JM, Carville K, Clark M,

Lahmann NA, Lubbers MJ, Lyder CH, Ohura T, Orsted HL, Reger SI, Romanelli M, Sanada H. Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus. Int Wound J. 2009

Chae J, Jedlicka L. Subacromial corticosteroid injection for poststroke shoulder pain: an exploratory prospective case series. Arch Phys Med Rehabil. 2009

Frost FS, Creasey GH, Nemunaitis GA. Lower thoracic spinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health-Sponsored clinical trial. Part II: clinical outcomes. Arch Phys Med Rehabil.

Wu JZ, Li ZM, Cutlip RG, An KN. A simulating analysis of the effects of increased joint stiffness on muscle loading in a thumb. Biomed Eng Online.

Yang Q, Fang Y, Sun CK, Siemionow V, Ranganathan VK, Khoshknabi D, Davis MP, Walsh D, Sahgal V, Yue GH. Weakening of functional corticomuscular coupling during muscle fatigue. Brain Res.

Yavuzsen T, Davis MP, Ranganathan VK, Walsh D, Siemionow V, Kirkova J, Khoshknabi D, Lagman R, LeGrand S, Yue GH. Cancer-related fatigue: central

J Pain Symptom Manage. 2009

Department of Psychiatry and Psychology

Ashton K, Drerup M, Windover A, Heinberg L. Brief, four-session group CBT reduces binge eating behaviors among bariatric surgery candidates. Surg Obes Relat Dis. 2009

Busch RM, Frazier TW, Iampietro MC, Chapin JS, Kubu CS. Clinical utility of the Boston Naming Test in predicting ultimate side of surgery in patients with medically intractable temporal lobe epilepsy: A double cross-validation study. Epilepsia.

Loddenkemper T, Cosmo G, Kotagal P, Haut J, Klaas P, Gupta A, Lachhwani DK, Bingaman W, Wyllie E. surgery in children with electrical status epilepticus in sleep. Neurosurgery.

Machado A, Haber S, Sears N, Greenberg B, Malone D, Rezai A. Functional topography of the ventral striatum and anterior limb of the internal capsule determined by electrical stimulation of awake patients. Clin Neurophysiol. 2009

Malone DA, Jr., Dougherty DD, Rezai AR, Carpenter LL,

Machado AG, Kubu CS, Tyrka AR, Price LH,

Salloway SP, Greenberg BD. Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry.

Pizzi AM, Chapin JS, Tesar GE, Busch RM. Comparison of personality traits in patients with frontal and temporal lobe epilepsies. Epilepsy Behav.

Seidenberg M, Guidotti L, Nielson KA, Woodard JL, Durgerian S, Antuono P, Zhang Q, Rao SM. Semantic memory activation in individuals at risk for developing Alzheimer disease. Neurology.


128 Outcomes 2009


Siemionow M, Papay F, Alam D, Bernard S, Djohan R,

Coffman K,

patient in the USA. Lancet.

Woodard JL, Seidenberg M, Nielson KA, Antuono P, Guidotti L, Durgerian S, Zhang Q, Lancaster M, Hantke N, Butts A, Rao SM. Semantic memory activation in amnestic mild cognitive impairment. Brain. (Pt 8):2068-2078.

Sleep Disorders Center

Aboussouan LS. Mechanisms of exercise limitation and pulmonary rehabilitation for patients with neuromuscular disease. Chron Respir Dis.

Ashton K, Drerup M, Windover A, Heinberg L. Brief, four-session group CBT reduces binge eating behaviors among bariatric surgery candidates. Surg Obes Relat Dis. 2009

Bae CJ, Lee JK, Foldvary-Schaefer N. The use of sleep studies in neurologic practice. Semin Neurol. 2009

Foldvary-Schaefer N, Grigg-Damberger M. Sleep and epilepsy. Semin Neurol.

Aboussouan L, Mokhlesi B. Determinants of hypercapnia in obese patients with obstructive sleep apnea: a systematic review and metaanalysis of cohort studies. Chest. 2009

Minai OA, Ricaurte B, Kaw R, Hammel J, Mansour M, McCarthy K, Golish JA, Stoller JK. Frequency and impact of pulmonary hypertension in patients with obstructive sleep apnea syndrome. Am J Cardiol.

Center for Spine Health

Abdullah KG, Steinmetz MP, Mroz TE. Morphometric and volumetric analysis of the lateral masses of the lower cervical spine. Spine.

Benzel EC. Interbody device footprint and endplate engagement characteristics: biomechanical implications. Spine J. 2009 Jul;9(7):607-608.

Gwinn DE, Iannotti CA, Benzel EC, Steinmetz MP.lordosis: analysis of sagittal spinal canal alignment in cervical spondylotic myelopathy. J Neurosurg Spine. 2009

Hiremath GK, Steinmetz MP, Krishnaney AA. Is it safe to use recombinant human bone morphogenetic protein in

Spine.

Kitab SA, Miele VJ, Lavelle WF, Benzel EC. Pathoanatomic basis for stretch-induced lumbar nerve root injury with a review of the literature. Neurosurgery.

McLain RF, Boehm CA, Rufo-Smith C, Muschler GF. Transpedicular aspiration of osteoprogenitor cells from the vertebral body: progenitor cell concentrations affected by serial aspiration. Spine J.

Mroz TE, Joyce MJ, Lieberman IH, Steinmetz MP, Benzel EC, Wang JC. The use of allograft bone in spine

Spine J.

Robertson DD, Sharma GB, Gilbertson LG, Kang JD. Bone densitometry within titanium lumbar interbody fusion cages: a computed tomography feasibility study. Spine. 2009

Siemionow K, Klimczak A, Brzezicki G, Siemionow M, McLain RF. acidic protein expression in satellite cells of the dorsal root ganglion. Spine.


Innovations

Brain Tumor and Neuro-Oncology Center

Revising Criteria for End Point Assessment in Gliomas

The evaluation of the effectiveness of clinical therapies used to treat brain tumors typically relies on the duration of patient survival or on radiographic

published criteria for response assessment in high-grade gliomas. These criteria provided an objective radiological assessment of tumor response and were based primarily on response criteria using enhancing tumor area (the product of the maximal cross-sectional enhancing diameters) as the primary tumor measure. These “Macdonald’s Criteria” enabled response rates to be compared between clinical trials, and have been used in most high-grade glioma studies since their introduction. As important as the Macdonald Criteria have been in allowing for uniformity in clinical trial assessments, they have a number of limitations, many of which have recently been reviewed in detail.2 These limitations, which have revealed themselves over the past two decades since publication of the

the criteria used to evaluate response and progression in neuro-oncology. In collaboration with other international experts, Michael Vogelbaum, MD, PhD, founded the Response Assessment in Neuro-Oncology (RANO) Working Group, which consists of neuro-oncologists, neurosurgeons, radiation oncologists, neuroradiologists, neuropsychologists and experts in quality of life measures, in collaboration with government and industry. The RANO Working Group includes members with leadership roles in the major neuro-oncology organizations and brain tumor cooperative groups in both

References

phase II studies of supratentorial malignant glioma. J Clin Oncol.

point assessment in gliomas: novel treatments limit usefulness of classical Macdonald’s Criteria. J Clin Oncol.

Outcomes 2009130


features, which may be inconsistent or subject to variable interpretation, to assign tumors to several categories. These classes

differences in clinical behavior or response to therapy.

We designed a model for integrating multiple modalities of molecular analyses, each focusing on different aspects of the underlying biology of low-grade gliomas, to investigate the relationships among these tumors. The model uses a series of unbiased class discovery algorithms to integrate genomic, transcriptomic and chromosomal data to identify discrete tumor

are capable of classifying novel tumors into the modeled subgroups with a high degree of accuracy. We subsequently used this model to begin the process of developing a molecular

clinically relevant biological characteristics of these tumors.

Our analysis suggests a three-class model for low-grade gliomas. Class I represents tumors with molecular similarity to pilocytic

for low-grade gliomas, and our work suggests a molecular

may serve as the basis for a molecular pathologic alternative to current grading schemes for low-grade gliomas and may highlight potential targets for future biologically based treatments or strategies for future clinical trials. This investigation was

journal Genomics.

Reference

analysis suggests a three-class model for low-grade gliomas: a proof- of-concept study. Genomics

Outcomes 2009

Innovations

Epilepsy Center

treatment options for patients with medically refractory focal epilepsy. It represents an innovative advance that departs from current methods of invasive long-term monitoring for refractory epileptic patients and brings patients closer to a surgical treatment by offering a unique approach to localizing the area of seizure generation (also called the epileptogenic zone).

a coherent hypothesis of the likelihood of localization of the epileptogenic zone. After a localizing hypothesis is formulated,

hypothesis. In this phase, the exploration is focused to sample the anatomic lesion (if present), the more likely structure(s) of ictal onset and the possible pathway(s) of propagation of the seizures. The desired targets are then reached with the precision of the stereotactic technique, allowing them to be recorded from lateral, intermediate or deep structures in a three-dimensional arrangement, thus accounting for the dynamic, multidirectional spatiotemporal organization of the epileptic seizures.

132

To date, 40 patients have been successfully implanted using this novel methodology. Many of these patients were not considered surgical candidates in the past. The epileptogenic zone was localized in all patients and no permanent morbidity was observed. In this group of 40 patients, 60 percent underwent resective surgery guided by the information provided

surgery. More traditional invasive monitoring using subdural grids is limited in the ability to map deep areas of the brain and

treatment option for patients with refractory focal epilepsy who are not candidates for invasive monitoring using subdural grids.


Innovations

Cleveland Clinic Lou Ruvo Center for Brain Health under construction in Las Vegas

Outcomes 2009134


During 2009, Cleveland Clinic’s Center for Brain Health established itself on two campuses, in Cleveland and Las Vegas. The center is dedicated to better diagnosis and treatment of cognitive loss disorders, including neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease, as well as cognitive loss syndromes associated with head injury, psychiatric disorders and stroke. We have established an integrated “multimodal” treatment program for these disorders, combining pharmacologic and nonpharmacologic therapies into a single therapeutic system. The nonpharmacologic therapies include cognitive rehabilitation

nonpharmacologic therapies have been recipients of NIH Challenge Grant

center’s operation. Cognitive-enhancing medications are also prescribed, and a variety of research projects aimed at improving such medical treatments are ongoing in the center.


Andre Machado, MD, PhD, was awarded an NIH/NIGMS grant titled, “Deep brain stimulation of the ventral anterior limb of the internal capsule for modulation of the affective sphere of chronic neuropathic pain.” Chronic neuropathic pain is a common cause of disability in the population. Most treatment options for patients with medically refractory neuropathic pain, such as spinal cord stimulation, thalamic deep brain stimulation and intrathecal infusion of narcotics, are aimed at producing analgesia

central thalamic pain syndrome, a particularly severe form of neuropathic pain characterized by relentless anesthesia dolorosa resulting from injury to the thalamic sensory pathways.


This work departs from the traditional goal of intervening in the sensory-discriminative neural pathways of pain transmission to produce analgesia. Instead, Cleveland Clinic researchers plan to target with deep brain stimulation (DBS)

that are related to the control of behavior and emotion. By electrically stimulating these networks, researchers expect to modulate the affective sphere of patients with otherwise intractable pain and, consequently, reduce pain-related disability. The hypothesis is that the improvement in pain-related disability associated with modulation of the affective pain sphere will not be dependent on analgesic effects. For this reason, the visual analog scale will be used as a secondary outcome measure to control for pain levels and analgesia, but the primary outcome measure of the study will be the Pain Disability Index. Patients enrolled in this research will undergo baseline and post-DBS double-blinded evaluations for a period of six months, followed by chronic open-label stimulation. The neural circuits of emotion control and the effects of DBS upon these networks will be studied at regular intervals with functional imaging techniques.

is synonymous with patients’ perceptions of treatment success. However, recent data hint that this is not always the case,

activities/goals, and underlying cognitive and personality attributes. This grant relies on a mix of quantitative and qualitative methods to better assess and understand patients’ goals with DBS. Qualitative data are gleaned largely from patients’ narratives, while the quantitative data consist of standardized personality and cognitive measures.

It is hypothesized that symptom reduction is only one component of a successful surgical intervention, and this study focuses on providing another, more patient-centered metric with which to evaluate and better understand treatment

neurosurgical populations. This was the only ethics award granted by the National Institute of Neurological Disorders and

and bioethic research methods. This mixed methodology has been made possible through the development of a unique

136 Outcomes 2009

Innovations


Developing Neuroprotective Treatments Using Stem Cell Transplantation

Jeffrey A. Cohen, MD, received funding from the U.S. Department of Defense to study mesenchymal stem cell (MSC) transplantation as a potential neuroprotective treatment in multiple sclerosis (MS). Intrinsic repair mechanisms exist in

in MS. In addition, the ability of MSCs to replace neural cells through transdifferentiation or, more likely, by augmenting intrinsic tissue repair mechanisms through paracrine elaboration of trophic factors, has focused substantial attention on MSC transplantation as a potential approach to neurorepair in MS.

This study, which will be carried out in collaboration with the Center for Stem Cell and Regenerative Medicine, is the

are to assess effects on MS disease activity and severity measured clinically, by MRI and by optical coherence

Up to 2 x 106

Figure shows the characteristic morphology of mesenchymal stem cells in culture.


Assessing the Role of Risk Tolerance in Patient Decision Making

threatening risks. This study will utilize a national registry of

patients’ decision-making process. The derived risk tolerance nomograms will help guide clinicians toward appropriate patients for risky therapies. An understanding of psychosocial factors behind decision-making will help guide educational efforts regarding new and emerging therapies. Utility

be applicable for future therapies, providing a guide to which

Standardizing MS Care

Center has developed a series of documents summarizing its approaches to common diagnostic and treatment issues in

and community physicians, and patients. The documents are useful for standardizing care and widely disseminating the center’s expertise.

137

Innovations


Continuing to Work with Patients to Improve Functional MRI Studies

138 Outcomes 2009

after

before

Including a New Picture-Rhyming Task

Clinical fMRI is routinely used to map the brain’s cortical surface controlling motion and language. While the motor regions

.


Innovations

Expanding the Number of Languages Available for fMRI

One of the most important tasks for clinical fMRI is language lateralization and localization. Because language activation is weaker compared with the motor or visual systems, we perform a standard set of three language tasks, which are presented visually and audibly while the patient is in the MRI scanner. These tasks cannot be accomplished if the patient does not

Outcomes 2009140

non-English language in the fMRI language task, which is now available

patients view pairs of words and push one button if they rhyme or another

button if they do not rhyme.

Implementing Whole Brain Volume Analysis

Whole brain volume analysis has been implemented in the preliminary assessment and longitudinal follow-up of patients

hippocampus, total gray matter, total brain volume and the ventricular volume. These data are then compared with a normalized database and issued in a standardized report for our referring physicians. These data are used as objective measures of disease severity, rate of disease progression and the impact of various forms of disease intervention.

Standardizing the Counting of Spinal Levels

to count levels in the same fashion typically used in the operating room or interventional suite: up from the lumbosacral junction in the thoracic and lumbar spine and down from the craniocervical junction in the cervical spine. To account for

followed and documented in all spine imaging reports and prior to all spine interventional procedures.


Implementing an Interventional MRI Suite

Cleveland Clinic has developed, installed and

suite attached to a conventional operating

the ceiling and moved into the operating room

for conventional diagnostic studies when it is not needed for interventional procedures. This facility will initially be utilized for intraoperative guidance of a variety of neurosurgical procedures, including but not limited to

placement of deep brain stimulators and laser ablation therapy for intracranial neoplasms.

Outcomes 2009142

Innovations

Minimizing Radiation Exposure with Computed Tomography



144 Outcomes 2009

Staff Listing

Chairman

Vice Chairman, Clinical Areas

Vice Chairman, Research and Development

Department of Neurological Surgery

144

Department of Neurology


Department of Neurology (cont’d)

Outcomes 2009146146

Staff Listing

Department of Psychiatry and Psychology

Department of Neurology (cont’d)

Department of Physical Medicine and Rehabilitation


Cynthia Kubu, PhD

Donald Malone Jr., MD

Michael McKee, PhD

David Muzina, MD

Richard Naugle, PhD

Mayur Pandya, DO

Michael Parsons, PhD

Leopoldo Pozuelo, MD

Kathleen Quinn, MD

Ted Raddell, PhD

Judith Scheman, PhD

Isabel Schuermeyer, MD

Jean Simmons, PhD

Barry Simon, DO

Catherine Stenroos, PhD

David Streem, MD

Adele Viguera, MD

John Vitkus, PhD

Cynthia White, PsyD

Brain Tumor and Neuro-Oncology Center Gene Barnett, MD, FACS Director

Manmeet Ahluwalia, MD

Lilyana Angelov, MD, FRCS(C)

Samuel Chao, MD

Bruce Cohen, MD

Todd Emch, MD

James Finke, PhD

Candece Gladson, MD

Amir Hamrahian, MD

Damir Janigro, PhD

Stephen Jones, MD, PhD

Joung Lee, MD

Mark Luciano, MD, PhD

Thomas Masaryk, MD, FACR

Doksu Moon, MD

Gennady Neyman, PhD

Michael Parsons, PhD

David Peereboom, MD

Gregory Plautz, MD

Richard Prayson, MD

Peter Rasmussen, MD

Baisakhi Raychaudhuri, PhD

Jeremy Rich, MD

Paul Ruggieri, MD

Burak Sade, MD

Susan Staugaitis, MD, PhD

147

Referral Contact Information

Outcomes 2009148

Epilepsy Center

Director

Staff Listing

Brain Tumor and Neuro-Oncology Center (cont’d)


Director

148



Director


Director

15015015515550000015515550000


Director

Staff Listing


Director


Director

Outcomes 2009

Neurological Center for Pain

Director

Center for Pediatric Neurology and Neurosurgery


Outcomes 2009152152

Staff Listing


Director

Center for Regional Neurology and Neurosurgery


Center for Spine Health

Director

Associate Director

Fredrick Wilson, DO

153

For a detailed list including staff photos, please visit clevelandclinic.org/staff.

Outcomes 2009154151515151515151515151515151511 4444444444

Contact Information

General Patient Referral

Neurological Institute Appointments/Referrals

On the Web at clevelandclinic.org/neuroscience

Additional Contact Information

General Information

Hospital Patient Information

General Patient Appointments

Request for Medical Records

Medical Concierge

Complimentary assistance for out-of-state patients and

[email protected]

Global Patient Services/International Center

Complimentary assistance for international patients and

clevelandclinic.org/gps

Cleveland Clinic Florida

For address corrections or changes, please call

154


Institute Locations

Cleveland Clinic Neurological Institute physicians see

when calling.

Main Campus

9500 Euclid Ave.

Avon Lake Family Health Center

Beachwood Family Health and Surgery Center

Broadview Heights Family Health Center

Brunswick Family Health Center

Chagrin Falls Family Health Center

Cleveland Clinic Children’s Hospital Shaker Campus

Cleveland Clinic Nevada

Cleveland Clinic Nevada

775.337.6200

Outcomes 2009156156

Euclid Hospital

Fairview Hospital

Hillcrest Hospital

Huron Hospital

216.761.3300

Independence Family Health Center

Crown Centre II

Lakewood Hospital

216.529.7110

Lorain Family Health and Surgery Center

Lutheran Hospital

Marymount Hospital

Solon Family Health Center

Institute Locations


Strongsville Family Health and Surgery Center

Westlake Family Health Center

Willoughby Hills Family Health Center

Wooster Family Health Center

1115115111115151515155515151515155555511115151111515551515555551111111151515155155551511111111515555111155551511511515155555151555551555151111555155111515151115511515515151115511111515111511115111555515551151555515151155555557777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777777157

Outcomes 2009158158

Cleveland Clinic Overview

multispecialty academic medical center that integrates clinical and hospital care with research and education. Today, nearly 2,000 Cleveland Clinic physicians and scientists practice in more than 100 medical specialties and subspecialties, annually recording more than 3 million patient visits and more than 70,000 surgeries.

In 2007, Cleveland Clinic restructured its practice, bundling all clinical specialties into integrated practice units called institutes. An institute combines all the

system under a single roof. Each institute has a single leader and focuses the energies of multiple professionals onto the patient. From access and communication to billing and point-of-care service, institutes are improving the patient experience at Cleveland Clinic.

Cleveland Clinic’s main campus, with 50 buildings

bed hospital, outpatient clinic, specialty institutes and supporting labs and facilities. Cleveland Clinic also operates 17 family health centers, nine regional

Clinic Canada. Cleveland Clinic Abu Dhabi

and clinic, is scheduled to open in 2012.

hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total annual research expenditures exceed $261 million from federal agencies, non-federal societies and associations, endowment funds and other sources. Cleveland Clinic physicians, scientists, fellows, residents and other employees are involved in more than 3,000 human-subject research activities at any given time.

ner

offers all students full-tuition scholarships. The program

in 2009.

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 since 1995.

For more information about Cleveland Clinic, please visit clevelandclinic.org.


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

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

prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients

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

clevelandclinic.org/mychart. DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic

secure access to your patients’ treatment progress while they are 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 Our secure online service provides access to our Cleveland Clinic specialists at the click of your mouse. Cleveland Clinic offers online medical second opinions for more than 1,000 life-threatening and

Consult offers an effective way of reaching our experts without the expense of travel and time away from work and family. For more information, visit eclevelandclinic.org/myconsult, email [email protected]

Critical Care Transport: Anywhere in the World Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across 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.

CME Opportunities: Live and Online Cleveland Clinic’s Center for Continuing Education

programs in the country. In 2009, it awarded more than

ccfcme.com

it houses programs that cover topics in 30 areas — if

with a worldwide reach. Among other resources, the

daily, and , a system for physicians to manage

courses are held in Cleveland, but outreach plans are under way. In 2010, the center offered 11 simultaneous

in Dubai, United Arab Emirates.

This project would not have been possible without the commitment and expertise of a team led by

© The Cleveland Clinic Foundation 2010

Cert no. SW-COC-001530

ClevelandClinic.org

Documents

Neurological Institute - Cleveland Clinic...At Cleveland Clinic’s Neurological Institute, ... The interplay between process and outcome may be illustrated by the most basic axiom