Outcomes 2008 - Cleveland ClinicThis complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can

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© The Cleveland Clinic Foundation 2009

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

Please visit us on the Web at clevelandclinic.org.

Neurological Institute

2008Outcomes

65315_CCFBCH_Cover_ACG 1 7/7/09 3:31:47 PM

137Neurological Institute

Resources for Physicians

Cleveland Clinic Secure Online Services

Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

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DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].

MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

Critical Care Transport: Anywhere in the world

Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call 877.279.CODE (2633). For all other transfers, call 216.444.8302 or 800.553.5056.

CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.


Neurological Institute 1

Surgical OverviewTo promote quality improvement, Cleveland Clinic has created a series of Outcomes books similar to this one for many of its institutes. Designed for a physician audience, the Outcomes books contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a review of new technologies and innovations.

Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase

unavailable, we often report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques.

In addition to our internal efforts to measure clinical quality, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives:

(www.qualitycheck.org)

(www.hospitalcompare.hhs.gov)

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

quality/outcomes.

65315_CCFBCH_Text_ACG 1 7/7/09 3:37:41 PM

Outcomes 20082

Dear Colleague,

On behalf of Cleveland Clinic, I am pleased to present our 2008 Outcomes books. The primary purpose of our annual Outcomes book initiative is to promote quality improvement at Cleveland Clinic, thereby optimizing the care we provide to our

accountability, transparency and results.

requiring hospitals to report more and more quality and patient safety data. We view our Outcomes books as voluntary supplements to the required public reporting and an opportunity to share selected innovations with colleagues across the country.

Designed for the physician reader, each book in the annual series focuses on care provided by one of our patient-centered

content informative.



Institute Overview 06

Quality and Outcomes Measures

Brain Tumors 12

Cerebrovascular Diseases 28

Epilepsy 36

Neuroimaging 82

Neurosurgical Anesthesia 88

Innovations 100

Contact Information 132

Cleveland Clinic Overview 136

what’s inside


Outcomes 2008

Chairman’s Letter

Dear Colleagues,

Clinic’s Neurological Institute. We strive continuously to enhance our monitoring of quality measures and outcomes because we view this initiative as an integral part of our clinical practice. In sharing

specialized care.

which we can monitor longitudinally to encourage continuous improvement. This is the core of ©, through which we are capturing outcomes and quality measures in each

patient’s electronic medical record.

Our work is incomplete, however, if we focus solely on traditional medical parameters and neglect

we are working toward incorporating measurement of this critical component of the healthcare

treatment. We will manage your discomfort and pain. We will respond when you need us. These simple precepts serve to remind us that the practice of even the most sophisticated medicine is a human endeavor.

We believe our statistics support the assertion that, in terms of both outcomes and patient

of a new, laser-based system for minimally invasive treatment of brain tumors, development of

4



patients taking Natalizumab, development of an improved monitoring system for deep brain stimulators

implementation of new paradigms to improve the

nation’s few dedicated biofeedback programs for chronic insomnia patients.

satisfaction is an essential piece in our never-ending drive to strengthen our clinical programs and our ability to conduct research with the potential to improve patients’ lives. We look forward to the opportunity to partner with you in delivering the highest level of neurological care.

Chairman, Neurological Institute

5


Institute Overview

The multidisciplinary Cleveland Clinic Neurological Institute

specialists dedicated to the treatment of adult and pediatric patients with neurological and psychiatric disorders. The

to care. Our unique, fully integrated model strengthens our current standard of care, allows us to measure quality and outcomes on a continual basis and enhances our ability to conduct research.

U.S.News & World Report’ssurvey has consistently ranked our neurology and neurosurgery programs among the top 10 in the nation. In 2008, our pediatric neurology and neurosurgery programs

neurosurgery, pediatric neurology/neurosurgery and psychiatry programs are also ranked best in Ohio.

6 — Cleveland Clinic’s national ranking for neurology and neurosurgery in U.S.News & World Report’s 2008 “America’s Best Hospitals” survey.

4 — U.S.News & World Report’s national pediatric specialty ranking for our pediatric neurology and neurosurgery programs.

6 Outcomes 2008


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

neurosurgeons, orthopaedic surgeons, psychiatrists, psychologists, physiatrists, neuroradiologists and others into the comprehensive care of neurological and psychiatric disease:

We provide care across the spectrum of neurological disorders, including primary and metastatic tumors of the brain, spine and nerves; pediatric and adult epilepsy; headache, facial pain

tremor and dystonia; neurocognitive disorders; cerebral palsy and spasticity; hydrocephalus; metabolic and mitochondrial disease; fetal and neonatal neurological problems; multiple sclerosis; stroke; cerebral aneurysms; brain and spinal vascular malformations; carotid stenosis; intracranial atherosclerosis; nerve and muscle diseases, including amyotrophic lateral sclerosis, peripheral neuropathy, myasthenia gravis and myopathies; sleep disorders; and mental/behavioral health disorders and chemical dependencies.



Outcomes 2008

Institute Overview

Expert, Specialized Diagnosis

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

disease, ensuring accurate, in-depth interpretations.

neuropsychological testing facilities, electromyography laboratory, autonomic laboratory and cutaneous nerve laboratory.

The Latest Treatment Modalities

advance such innovations as deep brain stimulation (brain pacemakers), epilepsy surgery, stereotactic spine radiosurgery, endovascular treatment of cerebral aneurysms and vascular malformations, and neuroendoscopy. Distinctive services such as our three-week outpatient program for sufferers of

process of bringing novel therapeutic agents from the laboratory to the patient, while maintaining the

providing the most advanced and highest quality of care to our patients.

Relevant Research

programs in translational research, clinical trials of drug and device interventions, neuroimaging research, epidemiology and health outcomes, behavioral and psychiatric research, and research into better diagnostic methods. Typically, more than 100 clinical research trials are under way at

research grants and contracts.

8



Convenient Care in the Community

We are committed to making access to world-class care convenient for all patients. Our Neurological Institute regional centers

community.

multiple specialists and provides a convenient suburban location where they may undergo procedures and use additional services required for their diagnosis and care. In addition, Cleveland Clinic neurologists oversee inpatient care at a number of Cleveland Clinic hospitals.

locations throughout the community for patients’ convenience and comfort.

Integrated Nursing Services

Nursing in the institute integrates inpatient and ambulatory nursing, enhancing the continuum of patient care. This unique structure also lends itself to greater information sharing and process improvement opportunities. Through continuing education programs, we are able to broaden nursing educational opportunities from basic nursing instruction to subspecialization in neurological nursing, enabling nurses, like our physician colleagues, to provide specialized care.

Pioneering the Collection of Data and Outcomes

©

Division, is designed to harness routinely collected electronic clinical and administrative data to allow us to optimize patient care and outcomes. Data from multiple electronic sources, including imaging results and clinical information collected during

that can be accessed and queried by healthcare personnel. An integral part of this initiative is the standardization of clinical

guides clinical care, quality improvement and research.

and to advancing medical education and research in all areas of neurology, neurosurgery and psychiatry.


Outcomes 200810

Institute Overview

2008 Statistical Highlights

Inpatient Facilities (Main Campus)

Initial Outpatient Visits 9,711

Total Outpatient Visits 138,713

Admissions 7,132 Brain Tumor Neuro-Oncology 813

Cerebrovascular 1,113

Epilepsy 1,283



Inpatient Days 37,658

Neurocognitive 2,083

Surgical/Interventional Procedures 5,596 Brain Tumor Neuro-Oncology 822

Neuroimaging Studies*

32,023

* studies performed on main campus, Cleveland Clinic satellites, and

family health centers

11


Outcomes 2008

Brain Tumor Diagnosis Distribution (N = 1,915)

2008

Brain Tumor Procedures (N = 822)

2008

Among patients diagnosed in 2008, gliomas were the most common type of brain tumor.

169, 9% Pituitary169, 9% Pituitary147, 8% Schwannoma147, 8% Schwannoma

336, 18% Meningioma336, 18% Meningioma

419, 22% Metastasis419, 22% Metastasis

844, 44% Glioma844, 44% Glioma

100%100%

82, 10% Novalis® Radiosurgery82, 10% Novalis® Radiosurgery57, 7% Infratentorial Craniotomy57, 7% Infratentorial Craniotomy51, 6% Brain Biopsy51, 6% Brain Biopsy

99, 12% Pituitary Surgery99, 12% Pituitary Surgery

215, 26% Supratentorial Craniotomy215, 26% Supratentorial Craniotomy

318, 39% Gamma Knife® Radiosurgery318, 39% Gamma Knife® Radiosurgery

100%100%

Brain Tumors

12



Brain Tumor Surgical Site Infection Rates

Enrollment of Patients with Brain Tumors in Clinical Trials

encountered and, in the case of brain tumor surgery, neither the respiratory nor the alimentary tracts are entered. N = number of clean cases per year.

Clinical research trials remained an important therapeutic option for many of our brain tumor patients.

10

5

002005

(N = 593)2006

(N = 604)2007

(N = 502)2008

(N = 451)

Rate per 100 Clean Cases (Percent)

500

400

300

200

100

02004 2005 2006 2007 2008

Number of Patients Enrolled

Therapeutic TrialsGenetic Trials

13


Outcomes 2008

Supratentorial Craniotomy: Survival

only those patients with available data are included in the calculation.

100

80

60

40

20

0

100

80

60

40

20

0

Number of Surgeries

2004 2005 2006 2007 2008

Percent Survival 30-Day 180-Day

100

75

50

25

0

400

300

200

100

0

Percent Survival Number of Surgeries30-Day 180-Day

2004 2005 2006 2007 2008

Brain Biopsy: Survival

Brain Biopsy

Supratentorial Craniotomy

Brain Tumors

14



Supratentorial Craniotomy: Inpatient Mortality

Supratentorial Craniotomy: Length of Stay (LOS)

severity of patient illness.

10

8

6

4

2

0

Percent Mortality

ActualExpected

2004(N = 263)

2005(N = 284)

2006(N = 299)

2007(N = 273)

2008(N = 215)

8

6

4

2

02004

(N = 263)2005

(N = 284)2006

(N = 299)2007

(N = 273)2008

(N = 215)

Days

Actual Mean LOSExpected Mean LOS

15


Outcomes 2008

Supratentorial Craniotomy: Karnofsky Performance Scale (KPS) N = 176

2008

Supratentorial Craniotomy: Survival by tumor type

Glioma: Survival

100

80

60

40

20

0Declined Improved No Change

Percent of Patients

100

80

60

40

20

0

150

120

90

60

30

0


2004 2005 2006 2007 2008

Brain Tumors

16



Meningioma: Survival

Metastasis: Survival

Thirty and 180-day survivals were high in 2008 for supratentorial craniotomies independent of tumor type.

100

80

60

40

20

0

80

60

40

20

0


2004 2005 2006 2007 2008

100

80

60

40

20

0

50

40

30

20

10

0


2004 2005 2006 2007 2008

17


Outcomes 2008

Infratentorial Craniotomy: Survival

Infratentorial Craniotomy

Infratentorial Craniotomy: Inpatient Mortality

100

80

60

40

20

0

100

80

60

40

20

0


2004 2005 2006 2007 2008

10

8

6

4

2

02004

(N = 74)2005

(N = 98)2006

(N = 66)2007

(N = 53)2008

(N = 57)

Percent Mortality

ActualExpected

0 0 0 0

Brain Tumors

18



Infratentorial Craniotomy: Length of Stay (LOS)

Infratentorial Craniotomy: KPS Status (N = 27)

8

6

4

2

02004

(N = 74)2005

(N = 98)2006

(N = 66)2007

(N = 53)2008

(N = 57)

Days


100

80

60

40

20


Percent of Patients

2008

19


Outcomes 2008

Glioma: Survival

Infratentorial Craniotomy: Survival by Tumor Type

Meningioma: Survival

100

75

50

25

0

25

20

15

10

5

0

Number of Surgeries

2004 2005 2006 2007 2008


100

75

50

25

0

25

20

15

10

5

0

Number of Surgeries

2004 2005 2006 2007 2008


Brain Tumors

20



Metastasis: Survival

Schwannoma: Survival

Thirty-day survival for infratentorial craniotomy remained at 100 percent independent of

100

75

50

25

0

20

15

10

5

0

Number of Surgeries

2004 2005 2006 2007 2008


100

75

50

25

0

10

8

6

4

2

0

Number of Surgeries

2004 2005 2006 2007 2008


21


Outcomes 2008

Pituitary Surgery: Survival

Pituitary Surgery

Pituitary Surgery: Inpatient Mortality

Inpatient mortality following pituitary surgery remained at zero percent. Expected mortality is based on national normative data and APR-DRGs, a method of adjusting for severity of patient illness.*

Among patients who underwent pituitary surgery, 30- and 180-day survival rates remained stable at more than 95 percent. For 180-day survival rates in 2008, data were available only for the first six months; only those patients with available data are included in the calculation.

100

75

50

25

0

100

75

50

25

0

Number of Procedures

2004 2005 2006 2007 2008


1.2

1.0

0.8

0.6

0.4

0.2

0.02004

(N = 67)2005

(N = 60)2006

(N = 99)2007

(N = 81)2008

(N = 99)

Percent Mortality

0 0 0 0 0

ActualExpected

Brain Tumors

22

65315_CCFBCH_Text_ACG 22 7/10/09 10:13:00 AM


Pituitary Surgery: Length of Stay

Pituitary Surgery: KPS Status (N = 11)

4

3

2

1

02004

(N = 67)2005

(N = 60)2006

(N = 99)2007

(N = 81)2008

(N = 99)

Days

Actual Mean (LOS)Expected Mean (LOS)

100

80

60

40

20


Percent of Patients

2008

23


Outcomes 2008

Stereotactic Radiosurgery: Gamma Knife®

Gamma Knife® Radiosurgery: Overall Survival

Gamma Knife® Radiosurgery: Meningioma Survival

patients with available data are included in the calculation.

100

75

50

25

0

400

300

200

100

02004 2005 2006 2007 2008

Number of Gamma Knife® ProceduresPercent Survival 30-Day 180-Day

100

80

60

40

20

0

50

40

30

20

10

0

Number of Gamma Knife® Procedures

2004 2005 2006 2007 2008


Brain Tumors

24



Gamma Knife® Radiosurgery: Metastasis Survival

Gamma Knife® Radiosurgery: Pituitary Tumor Survival

100

75

50

25

0

200

180

160

140

120


2004 2005 2006 2007 2008


100

75

50

25

0

20

15

10

5

0


2004 2005 2006 2007 2008


25


Outcomes 2008

Stereotactic Radiosurgery: Novalis®

Gamma Knife® Radiosurgery: Schwannoma Survival

Novalis® Stereotactic Radiosurgery: Survival

and 180-day survival for this type of treatment, used to treat malignant and metastatic tumors

available data are included in the calculation.

100

80

60

40

20

0

50

40

30

20

10

0


2004 2005 2006 2007 2008


100

75

50

25

0

100

75

50

25

0

Number of Novalis® Procedures

2004 2005 2006 2007 2008


Brain Tumors

26



Novalis® Stereotactic Radiosurgery: Treatment of Painful Spinal Metastases (N = 103)

2007 - 2008

Brief Pain Inventory (BPI) scores following spine radiosurgery in patients presenting with painful spinal metastases. Individual and mean patient scores + 1 s.e on the BPI, a 10-item self-rating pain scale, are plotted for baseline and various time periods — weeks 1-3 (W1-W3) and months 1, 3, 6 and 9 (M1, M3, M6, M9) — after spine radiosurgery. Higher scores indicate greater pain. Spine radiosurgery is a palliative treatment for pain, typically used in end-stage cancer patients. In 2007 and 2008, 103 patients with painful spinal metastases were treated with single fraction Novalis® spine radiosurgery. As early as week 1 after treatment, there was a statistically significant improvement in patient pain scores (P ≤ 0.001 for all time points except M9; P = 0.01 for M9). These results remained stable over time.

10

9

8

7

6

5

4

3

2

1

0

Baseline(N = 103)

W1(N = 69)

W2(N = 44)

W3(N = 50)

M1(N = 75)

M3(N = 54)

M6(N = 26)

M9(N = 19)

Brief Pain Inventory (BPI) Score

27


Outcomes 200828

“Get With The Guidelines” Stroke Performance and Quality Measures

Measure Description

Acute ischemic stroke patients who arrive at the ED within 120 minutes of onset of stroke symptoms and who receive IV tPA within 180 minutes of onset of stroke symptoms

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

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

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

Patients with ischemic stroke, TIA or hemorrhagic stroke who are nonambulatory and receive DVT prophylaxis by the end of hospital day 2

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

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

2008

88.9%

94.4%

99.7%

98.4%

97.0%

94.7%

91.5%

2007

60.0%

96.1%

98.6%

94.6%

93.6%

90.9%

100.0%

2006

85.0%

96.7%

96.2%

97.0%

91.3%

85.2%

85.0%

GWTG Stroke Performance Measure Goal

85.0%

85.0%

85.0%

85.0%

85.0%

85.0%

85.0%

National Cleveland Clinic

Average*

72.8%

97.0%

98.9%

98.4%

89.5%

88.3%

93.6%

Clinical Measure

IV tPA use (eligible < 2 hour arrival)

Early antithrombotics (< 48 hour arrival)

Antithrombotics at discharge

Anticoagulation for atrial fibrillation

Deep venous thrombosis (DVT) prophylaxis

Lipids measure (statin at discharge)

Smoking cessation counseling

Get With The GuidelinesSM (GWTG) is a hospital-based performance and quality improvement program for the American

hospital’s commitment to superior patient care using current, evidence-based guidelines. Cleveland Clinic was a 2008

improvement.

with acute stroke or transient ischemic attack. Circulation

Cerebrovascular Disease



Distribution of Major Cerebrovascular Procedures by Case Type

Ruptured Cerebral Aneurysm: Inpatient Mortality

The number of procedures for ruptured cerebral aneurysms increased 11 percent from

180

120

60

0


Ruptured Cerebral AneurysmNonruptured Cerebral AneurysmArteriovenous Malformation

2005 2006 2007 2008

30

20

10

0

Percent Mortality

ActualExpected

2005 2006 2007 2008


Outcomes 200830

Ruptured Cerebral Aneurysm: Length of Stay (LOS)

Nonruptured Cerebral Aneurysm: Inpatient Mortality

mortality seen in our patient population (patients may be spending more time in the hospital

20

15

10

5

0

Days


2005 2006 2007 2008

3

2

1

0

Percent Mortality

2005 2006 2007 2008

Actual Expected



Nonruptured Cerebral Aneurysm: Length of Stay

6

4

2

0

Days

2005 2006 2007 2008




Outcomes 2008

Conditions Treated with Endovascular Therapy (N = 366)

2008

Aneurysm 36%

Other 3%


32



Endovascular Procedures: Inpatient Mortality

Endovascular Procedures: Length of Stay

20

15

10

5

0

Percent Mortality

2005(N = 51)

2006(N = 72)

2007(N = 87)

2008(N = 86)

Actual Expected

20

15

10

5

0

Days

2005(N = 51)

2006(N = 72)

2007(N = 87)

2008(N = 86)



Outcomes 200834

Microsurgery: Inpatient Mortality

Microsurgery: Length of Stay

10

8

6

4

2

0

Percent Mortality

2005(N = 81)

2006(N = 79)

2007(N = 59)

2008(N = 45)

Actual Expected

10

8

6

4

2

0

Days

2005(N = 81)

2006(N = 79)

2007(N = 59)

2008(N = 45)





Aneurysm and Ischemic Stroke: Discharge Status

2008

Stroke: Inpatient Mortality

Stroke

30

20

10

0

Percent Mortality

2005 2006 2007 2008

Actual Expected

Ruptured Aneurysm Nonruptured Aneurysm Ischemic Stroke

A

Other 10% 2% 6%


Long-Term Seizure Freedom following Frontal Lobe Surgery for Epilepsy (N = 132)

1.0

0.8

0.6

0.4

0.2

0.0

Probability of Seizure Freedom

10 2 3 4 5 6

Years from Surgery

7 8 9 10 11 12

Time from Surgery 6 months 1 year 2 years 5 years

Epilepsy

Outcomes 200836


1.0

0.8

0.6

0.4

0.2

0.0


Years from Surgery

10 2 3 4 5 6 7 8 9

Long-Term Seizure Freedom following Parieto-Occipital Lobe Surgery for Epilepsy (N = 61)

Time from Surgery 6 months 1 year 2 years 5 years

Epilepsy surgery in the parieto-occipital lobe is relatively infrequent, compared to frontal and temporal lobe



Outcomes 200838

1.0

0.8

0.6

0.4

0.2

0.0


Years from Surgery

10 2 3 4 5 6 7 8 9 10

Long-Term Seizure Freedom following Temporal Lobe Surgery for Epilepsy (N = 550)

Time from Surgery 1 year 2 years 5 years 10 years

in seizure frequency). National seizure-free rates represent a weighted average of recent studies conducted in the .

Mil Med.

study. Neurology. Neurology.

Neurology.

Neurology.

Epilepsia.

JAMA.

Epilepsy



45

35

25

15

5

Quality of Life in Epilepsy (QOLIE-10) Score

After SurgeryBefore Surgery

Improvement in Quality of Life following Epilepsy Surgery (N = 22)

Quality of Life before and after Epilepsy Surgery

implemented practice of assessing a comprehensive set of health status measures allows us to evaluate our patients’ global state of health following surgery.

effects and mental effects of medication), mental health (energy, depression, overall quality of life) and role


Outcomes 200840

100

80

60

40

20

0

Percent of Patients

Before After

0

None Moderate

Problems Performing Typical Daily Activities

Severe

80

60

40

20

0

Percent of Patients

None Moderate

Mood Symptoms (Depression/Anxiety)

Severe

Before After

0

Functional Status before and after Epilepsy Surgery (N = 24)

Mood Symptoms before and after Epilepsy Surgery (N = 24)

through November 2008 and who had functional status data collected both before and after surgery.

through November 2008 and who had mood symptom data collected both before and after surgery.

Epilepsy



20

10

0Before

Surgery

After

Percent of Patients Driving

0

Driving before and after Epilepsy Surgery (N = 22)

Surgical Dates: January 2007 – November 2008

Regaining driving privileges is a major goal for most epilepsy patients. Following epilepsy surgery, 14 percent of patients were able to return to driving. Mean follow-up was 5.7 months after surgery. Information is based on 22 adult patients who had epilepsy surgery from January 2007 through November 2008 and who provided driving status both before and after surgery (P = 0.04, chi-square test).

41

65315_CCFBCH_Text_ACG 41 7/10/09 10:13:50 AM

90

70

50

30

10

-10

LSSS

After SurgeryBefore Surgery

Improvement in Seizure Severity following Epilepsy Surgery (N = 19)

In addition to seizure severity, the average seizure frequency was reduced from 12.3 seizures per month before surgery to 2.2

Epilepsy

Outcomes 200842


40

20

0Preoperative Postoperative

Stimulator OffPostoperativeStimulator On

Average Unified Parkinson’s Disease Rating Scale (UPDRS) Score

Parkinson’s Disease: Improvement in Motor Scores with Deep Brain Stimulation (DBS) (N = 27)

2008

Movement Disorders



Outcomes 2008

1200

800

400

0Before DBS After DBS

Mean Levodopa Equivalent Dose (Milligrams)

Parkinson’s Disease: Reduction in Medication Dose with DBS (N = 27)

2008

Movement Disorders

44



Intrathecal Baclofen Therapy

after the surgery. The hardware was removed, and the patient opted to have the pump reimplanted a few months later. No patients chose to discontinue the therapy.

Diagnosis/Indication for ITB Number of Patients

Cerebral Arteritis 1

Multiple Sclerosis


4

3

2

1

0Before After

Treatment

Spasticity Score

2008

increase in tone) at baseline and after ITB therapy

10 , paired t-test) reduction in spasticity after

was 160 days.

Multiple Sclerosis

46 Outcomes 2008



4

3

2

1

0Before After

Treatment

Spasm Frequency Score

10

8

6

4

2

0Before After

Treatment

Mean Pain Score

Spasm Frequency before and after ITB (N=17)

2008

Pain Scores before and after ITB (N = 17)

2008

, paired


Outcomes 2008

bothersome spasticity, which may interfere with activities of daily living, sleep and quality

patients after ITB.

25

20

15

10

5

0Before After

Treatment

Mean Gait Speed (Seconds)

Gait Speed before and after ITB Timed 25-Foot Walk (N = 7)

2008

test, following ITB for the patients who remained ambulatory.

Multiple Sclerosis

48



Natalizumab (Tysabri®) Therapy

administer Natalizumab.

1.0

0.8

0.6

0.4

0.2

0.00 252015105

Months from Treatment Initiation

Probability of Remaining on Natalizumab

Time to Tysabri® Treatment Discontinuation (N = 195)


Outcomes 200850

Reasons for Discontinuing Natalizumab (N = 51)

Number of Reason for Discontinuation Patients Details

Allergy 6

Antibodies 2 Two patients developed neutralizing antibodies against Natalizumab.

Infections 2 Two patients developed infections that were neither severe nor due to opportunistic organisms.

related to Natalizumab.

Other 6 One patient became pregnant, one patient moved and was not able to continue Natalizumab for logistical reasons and four patients had a change in insurance resulting in lack of coverage for Natalizumab therapy.

Deceased 1 One patient died; the cause was not related to Natalizumab.

Multiple Sclerosis



Multiple Sclerosis (MS) Literacy Assessment and Patient Education

100

75

50

25

0Before After

Percent Correct

Health Literacy Test Results before and after Patient Education (N = 47)

Average percentage correct on 11 multiple choice questions assessing health literacy improved following the

participant attending a single educational session.


52

6

4

2

0Initial Follow-up

Visit

Mean MG-ADL* Score

Myasthenia Gravis Functional Status (N = 12)

2008

Myasthenia Gravis

Neuromuscular Disease

Outcomes 2008


53

headache and chronic daily headache may receive intravenous infusion

patients treated in 2008.

40

30

20

10

00-24 25-49 50-74

Percent Pain Reduction

75-100

Percent of Patients

Infusion Therapy for Headache

Pain Reduction Immediately following Infusion Therapy (N = 196)

2008

Pain/Headache



Outcomes 200854

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

a more comprehensive assessment of their pain, patients are asked to rate their current pain as well as pain over the preceding week. Current pain is the level of pain at that moment; average, least and worst levels of pain are reported for the preceding week. Information is

in 2008.

subscale scores are plotted with their standard deviations.

10

8

6

4

2

0

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

Current Average

Pain

Least Worst

AdmissionDischarge

30

20

10

0

Depression Anxiety Stress Scale (DASS) Score

AdmissionDischarge

Stress(0-42)

Anxiety(0-42)

Depression(0-42)

Pain Ratings before and after IMATCH (N = 64)

2008

Stress, Anxiety and Depression before and after IMATCH (N = 64)

2008

Pain/Headache



80

60

40

20

0

Disability Score

AdmissionDischarge

Pain Disability Index(0-70)

Headache Impact Test(36-78)

5

4

3

2

1

0Whole Program Medical

TreatmentPsychological

Treatment

Program Components

Physical TherapyTreatment

Average Satisfaction Score

Functional Status before and after IMATCH (N = 64)

2008

Patient Satisfaction with IMATCH (N = 64)

2008


56

Cleveland Clinic Chronic Pain Rehabilitation Program

to the treatment of patients with chronic pain. These patients typically have pain that is

distress as well.

were disabled.

300

200

100

02004 2005 2006 2007 2008

Number of Patients

Chronic Pain Rehabilitation Program Admissions

Pain/Headache

Outcomes 2008


57

100

75

50

25

02004 2005 2006 2007 2008

Percent of Patients Completing Program

10

8

6

4

2

0

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

AdmissionDischarge6-month Follow-up

2004 2005 2006 20082007

Chronic Pain Rehabilitation Program Completion Rate

Pain Intensity before and after CPRP



Outcomes 200858

Depression scores, as measured with the DASS depression subscale, show improvement following treatment. Higher scores indicate more severe depression.

Anxiety scores, as measured with the DASS anxiety subscale, show improvement following treatment. Higher scores indicate more severe anxiety.

30

20

10

0

Mean Depression Anxiety Stress Scale Score

2006 20082007


20

10

0

Mean Depression Anxiety Stress Scale Score

2006 20082007


Depression before and after CPRP

Anxiety before and after CPRP

Pain/Headache



scores indicate greater disability.

improvement, as it suggests that their lives are less affected by their pain.

60

40

20

0

Mean Pain Disability Index (PDI)

2004 2007 200820062005


25

20

15

10

5

0

Mean Hours of Rest

Admission6-Month Follow-up

2006 2007 2008

Functional Status before and after CPRP

Activity Level before and after CPRP


60

as the number of headache days in the previous three months. Comparing group means for headache frequency between visit 1 and visit 2, there was an improvement

assessment on at least two occasions in 2008.

40

30

20

10

0

Mean

Visit 1Visit 2

PedsMIDAS Headache Frequency Rescue Doses

Pediatric Headache

Headache Disability (N = 46)

2008

Pediatric Neurology

Outcomes 2008


61

number of complete and partial school days missed in the preceding three months

12

8

4

0Visit 1 Visit 2

School Days Missed

School Days Missed (N = 17)

2008



Outcomes 200862

*mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard

200

150

100

50

0New Patient Consults Diagnosis Established via Muscle,

Genetic or CSF* Testing

Number of Patients

Pediatric Neurometabolic Clinic

The term idiopathic developmental delay

remained largely without a diagnosis. With advances in technology and improving diagnostic skills, the ability to reach conclusive diagnoses in this population has steadily improved. While there is no national standard for diagnostic yield in this patient population, tertiary care centers such as ours have the potential

Neurometabolic Clinic Diagnostic Yield

Pediatric Neurology


63

Cleveland Clinic is one of very few medical centers in the country that provide high-quality

Pediatric Electromyography (EMG)

Pediatric EMG

70

60

50

40

30

20

10

0

Number of Studies

Total EMGsEMGs with OR/Sedation

2004 2005 2006 20082007



Outcomes 200864

patient illness.*

Pediatric Congenital Malformation: Length of Stay (LOS)

Chiari Malformation: Length of Stay

8

6

4

2

0

40

30

20

10

0

Days (Mean LOS) Number of ProceduresActual Expected

2005 2006 2007 2008

80

60

40

20

0

8

6

4

2

0


2005 2006 2007 2008

Pediatric Neurosurgery



such as laminectomy with section of the spinal accessory nerve and implantation of a drug infusion device.

Chiari Malformation: Inpatient Mortality

Spasticity: Length of Stay

5

4

3

2

1

0

Percent Mortality

2005

0 0 0

2006 2007 2008

Actual MortalityExpected Mortality

100

75

50

25

0

8

6

4

2

0


2005 2006 2007 2008


Outcomes 200866

Pediatric Hydrocephalus: Length of Stay

50

40

30

20

10

0

10

8

6

4

2

0


2005 2006 2007 2008

Pediatric Neurosurgery



scores, a measure of depression severity, were compared from baseline to one year after the

Change in Depressive Symptoms with Group Medication Management (N = 29)

10

5

0Baseline 1 Year

Mean PHQ-9** Score

Women’s Mental Health Management Group for Depression

Psychiatric Disorders


Outcomes 200868

on this measure.

100

75

50

25

0

Percent of Patients

Baseline1 Year

Not at all Somewhat Very Extremely

0% 0%




Depressive Symptoms before and after Treatment (N = 202)

2008

Inpatient Treatment for Depression

40

30

20

10

0

Mean Scale Score

AdmissionDischarge

Hamilton DepressionScale

Montgomery-AsbergDepression Rating Scale

69


Outcomes 200870

scores of less than eight are considered normal.

Binge Eating

Binge Eating Disorder (BED). BED has been associated with poorer surgery outcomes, including weight regain, and is thus an important factor to assess and treat for bariatric surgery patients.*,

satisfaction questionnaire.

Illness Severity and Manic Symptoms before and after Treatment (N = 202)

2008

7

6

5

4

3

2

1

0

Mean Scale Score

Clinical Global ImpressionSeverity Scale

Young Mania Rating Scale

AdmissionDischarge




whom information is available.

Binge Eating before and after Therapy (N = 168)

2008

30

20

10

0

Number

Before TreatmentAfter Treatment

Average BES Average Number ofBinge Eating Episodes

Eat

Weight Disord.

a review. Psychosom Med.

Addict Behav.


Outcomes 200872

Patients with 2 or More Binge Eating Episodes per Week before and after Therapy (N = 168)

2008

160

120

80

40

0Before After

Treatment

Number of Patients

binge eating disorder (two or more binges per week). Only 61 patients (36 percent) met the

with 33 percent afterward.




Adult Sleep Studies

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

The number of pediatric sleep studies has doubled in the past three years.

Pediatric Sleep Studies

4,000

3,000

2,000

1,000

0

Number of Studies

PSG/EEGCPAP/BiPAPSplitMSLT/MWT

2007 200820062005

400

300

200

100

0

Number of Studies

2006 2007 2008

Sleep Disorders


Sleep Apnea

15

10

5

0

Epworth Sleepiness Scale Score

Before CPAP/BiPAPAfter CPAP/BiPAP

Average Median

Sleepiness before and after Treatment (N = 217)

2008

Sleep Disorders

Outcomes 200874



60

40

20

0

Fatigue Severity Scale Score

Average Median


Fatigue before and after Treatment (N = 212)

2008


76

10

8

6

4

2

0

Patient Health Questionnaire-9 Score

Average Median


Depressive Symptoms before and after Treatment (N = 212)

2008

Sleep Disorders

Outcomes 2008


77

30

20

10

0

Functional Outcomes of Sleep Questionnaire Score

Average Median


Functional Status before and after Treatment (N = 216)

2008



Outcomes 200878

4

3

2

1

0

Mean FOSQ Subscale Score

GeneralProductivity

SocialOutcomes

ActivityLevel

Vigilance IntimateRelationships


Functional Status Domains before and after Treatment (N = 216)

Sleep Disorders



Degenerative spine disease is the most common diagnosis among patients who undergo surgery.

1,000

750

500

250

0Lumbar Cervical Thoracic


1,400

1,200

1,000

800

600

400

200

0


Degenerative Deformity Fracture/Trauma

OtherTumor

Spine Surgical Cases

2008

Distribution of Spine Surgical Cases by Disease Category

2008

Spinal Diseases


approach for diagnosis, treatment, patient satisfaction and quality for patients with

tumor cases through a logic-based decision-making process. The annual increase in patients and cases studied is attributed to the unique team approach.

300

200

100

0

Patients/Cases

200620072008

Total Cases StudiedTotal Patients Studied

Patients and Cases Studied in Tumor Board Review

Spinal Diseases

80 Outcomes 2008


81

Outpatient visits trended upward during the 2005 - 2008 period in the Center for Spine Health, representing an overall increase of 34 percent in patient volume.

32,000

24,000

16,000

8,000

0

Total Visits

2005 2006 2007

Year

2008

Center for Spine Health Total Outpatient Visits

2008



Outcomes 200882

Image-guided procedures include spinal arteriograms, Wada tests, diagnostic and

and placement of subarachnoid drains.

The number of cerebral angiographies performed increased by 33 percent in 2008

700

600

500

400

300

200

100

0


DiagnosticTherapeutic

2006 2007 2008

4,000

3,000

2,000

1,000

0


2006 2007 2008

Image-Guided Procedures

Cerebral Angiography

Neuroimaging


* Computed Tomography

50,000

40,000

30,000

20,000

10,000

0

Number of Studies

Head CT*Brain MRI**Neurovascular Ultrasound

2006 2007 2008

Cross-Sectional Imaging Studies



Outcomes 200884

studies as an overall measure of quality assurance. Neuroradiology staff members reinterpret representative samples of their

report is placed into one of three categories: (1) agree with the initial report, (2) mostly agree with the initial report, with no

Because the review takes place daily, the delay in patient care is minimized.

100

80

60

40

20

0

Percent of Studies Reviewed

Strongly DisagreeMostly AgreeAgree

Ultrasound CT

Type of Imaging Study

MRI

Neuroradiology Interobserver Variability

2008

Neuroimaging



Median Turnaround Time (Minutes)

Jan(N = 2,198)

Feb(N = 2,655)

Mar(N = 2,667)

Apr(N = 2,915)

May(N = 2,866)

Jun(N = 2,638)

Jul(N = 2,515)

Aug(N = 2,693)

Sep(N = 2,544)

Oct(N = 2,946)

Nov(N = 2,634)

Dec(N = 2,752)

0 25 50 75 100

Month (Number of Reports)

Neuroradiology Report Turnaround Time: CT

2008


Outcomes 200886

Median Turnaround Time (Minutes)

Jan(N = 3,339)

Feb(N = 3,625)

Mar(N = 3,963)

Apr(N = 4,035)

May(N = 3,973)

Jun(N = 3,966)

Jul(N = 4,002)

Aug(N = 3,768)

Sep(N = 3,876)

Oct(N = 4,277)

Nov(N = 3,662)

Dec(N = 3,973)

0 25 50 75 100


Neuroradiology Report Turnaround Time: MRI

2008

Neuroimaging



Median Time to Notification (Minutes)


Jan(N = 7)

Feb(N = 16)

Mar(N = 21)

Apr(N = 18)

May(N = 29)

Jun(N = 13)

Jul(N = 14)

Aug(N = 19)

Sep(N = 17)

Oct(N = 29)

Nov(N = 19)

Dec(N = 10)

0 10 20 30

Brain Attack Head CT Reporting

2008


100

80

60

40

20

0

Percent of Patients

VomitingNausea OnlyNo Nausea or Vomiting

Q1(N = 119)

Q2(N = 149)

Q3(N = 103)

Q4(N = 110)

Nausea and Vomiting within 24 Hours of Craniotomy

2008

in the hospital to evaluate the early postoperative period. One outcome measure, collected from medical record review, is postoperative nausea and vomiting. The department features the management of postoperative nausea and vomiting in its clinical quality improvement program.

Neurosurgical Anesthesia

Outcomes 200888


100

80

60

40

20

0

Percent of Patients

VomitingNausea OnlyNo Nausea or Vomiting

Q1(N = 215)

Q2(N = 167)

Q3(N = 172)

Q4(N = 161)

Nausea and Vomiting within 24 Hours of Spine Surgery

2008

second postoperative day in the hospital to evaluate the early postoperative period. Information on postoperative nausea and vomiting is collected from medical record review.



100

75

50

25

0

Percent of Patients Responding with Highest Rating

Q1(N = 35)

Q2(N = 41)

Q3(N = 22)

Q4(N = 21)

Patient Satisfaction with Anesthesia Care for Craniotomy

2008

During rounds on the second postoperative day, patients are asked to respond to the

Neurosurgical Anesthesia

Outcomes 200890


100

75

50

25

0

Percent of Patients Responding with Highest Rating

Q1(N = 117)

Q2(N = 84)

Q3(N = 80)

Q4(N = 71)

Patient Satisfaction with Anesthesia Care for Major Spine Surgery

2008

rating.



Outcomes 200892

Surgical Quality Improvement

Hospital Compare: Surgical Care Improvement Project (SCIP)

SCIP - Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision (N = 902)

data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also

0 20

* Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

86

95



SCIP - Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time (N = 813)

SCIP - Prophylactic Antibiotic Selection for Surgical Patients (N = 937)

0 20


40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

84

82

0 20


40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

92

95


Outcomes 200894

Surgical Quality Improvement

SCIP - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (N = 677)

SCIP - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery (N = 677)

0 20


40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

84

96

0 20


40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

81

95



SCIP - Surgery Patients with Appropriate Hair Removal (N = 1,386)

0 20

* Source: www.hospitalcompare.hhs.gov, discharges January - June 2008

40 60 80 100

Percent of Patients

NationalAverage*

ClevelandClinic

95

94

Neurosurgery Morbidity (N = 80)

0

10

20

30Percent

ObservedExpected

National Surgical Quality Improvement Project


Outcomes 200896

way that elevates Cleveland Clinic’s reputation as one of the world’s best hospitals.

patient- and family-based programs that support this mission.

Outpatient – Neurological Institute

100

80

0

60

40

20

Percent

Excellent Very Good Good Fair Poor

Source: Quality Data Management, a national hospital survey vendor

2008 (N = 6,221)2007 (N = 5,584)

Overall Rating of Outpatient Care and Services

Patient Experience



Recommend Outpatient Provider

100

80

0

60

40

20

Percent

Excellent Very Good Good Fair Poor


2008 (N = 6,221)2007 (N = 5,584)

100

80

0

60

40

20

Percent

ExtremelyLikely


Very Likely SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2008 (N = 6,221)2007 (N = 5,584)

Rating of Outpatient Provider


Outcomes 200898

100

80

0

60

68%62%

40

20

Percent

Rate Hospital Would Recommend

% respondentschoosing 9 or 10

% respondents choosing'definitely yes'

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

For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.

2008 total survey respondents = 1,1132007 total survey respondents = 732

78% 73%

HCAHPS Overall Assessment

Inpatient – Neurological Institute

reporting are available at www.hospitalcompare.hhs.gov.

Patient Experience



100

80

0

60

40

20

Percent

DischargeInformation

Doctor Communication

Nurse Communication

PainManagement

RoomClean

CommunicationNew Medications

Responsivenessto Needs

Quiet atNight

Respondents choosing 'always' or 'yes'

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

For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS.

2008 total survey respondents = 1,1132007 total survey respondents = 732

HCAHPS Domains of Care


Outcomes 2008

Innovations

42 — Number of new Neurological Institute clinical research trials in 2008.

1,690 — Number of patients enrolled in Neurological Institute clinical research trials.

Before-and-after treatment views of a magnetic resonance

system.

A Novel, Minimally Invasive Therapy for Brain Tumors Brain Tumor and Neuro-Oncology Center (BTNC)

laser-based system in a human for the minimally invasive (laser interstitial

Inc. (Winnipeg, Canada), is used to coagulate tumors through a special laser probe, precisely directed into the tumor, with the heating process monitored by specialized software and thermal

tumors and spare patients more invasive interventions.

100

round, whitish area, indicated by an arrow) in the deep portion of the left temporal lobe. The image to the right shows the lesion having been essentially eradicated by

(arrow). The markers to the right in each

vertical line indicates an interval of 1 cm.



Distribution of patients by type of primary cancer in study of

Cranial Radiosurgery for the Older Old

While cancer can occur at any age, its incidence increases directly with age. By the year 2030, the proportion of the

as 28 percent. With improvements in health and nutrition,

With respect to cancer that spreads to the brain from a site elsewhere (such as lung, breast or kidney cancer), data

age was associated with a poorer prognosis, irrespective of whether the patient received surgery, whole brain radiation

shown to play effective roles in the treatment of brain metastasis.

the sole treatment for these brain metastases, meaning that whole brain radiation was generally not given or was given only with nonresponsiveness, which was rare, or later, when

one or more brain metastases produced results comparable to the results found in younger patients, nearly all of whom

months, with more than a third surviving one year and

brain — remained the principal challenge, although recent innovations in therapies for these cancers appear to be improving overall survival as well.

followed by patients with tumors of the kidney and genitourinary

older patients. Cancer.

9% Melanoma (N = 4)9% Melanoma (N = 4)7% Lung (SLC) (N =3)7% Lung (SLC) (N =3)7% Breast (N = 3)7% Breast (N = 3)7% Unknown (N = 3)7% Unknown (N = 3)

11% GI Tract (N = 5)11% GI Tract (N = 5)

20% GU Tract (N = 9)20% GU Tract (N = 9)

39% Lung (NSCLC) (N = 17)39% Lung (NSCLC) (N = 17)

100%100%


Outcomes 2008102

Innovations

Stereotactic Radiosurgery of Spinal Tumors

The development of metastases to the spinal column occurs

lead to instability of the spinal column or compression of the spinal cord or nerve roots, and may be associated with disabling pain, neurological dysfunction and paralysis. Early treatment to prevent complications and enhance function is essential.

Traditional treatment options include surgery, conventional radiation therapy, chemotherapy and comprehensive pain management. Now, Cleveland Clinic’s Brain Tumor and

modality that delivers a high dose of radiation to spinal metastases in a conformal fashion, precisely enveloping the

spread beyond the target.

procedure with minimal recovery time. This highly selective, precise radiation therapy results in effective relief of pain —

In our recently reviewed series of more than 100 treated

this observation is not likely to be due to chance alone.])

consistent after therapy, even at 12 months following

perceived to be radioresistant, such as renal cell carcinoma and melanoma.

therapy. (A) The scan shows a painful metastasis to the right side

lumbar vertebral body. The tumor measures nearly 6 cm. (green

taking high doses of morphine but had poor pain control. After a

by one month, he needed only an over-the-counter medication,

ibuprofen, and by three months, he was permanently off all pain

medication. (B)

reduction in the size of the tumor, a reduction that has been

long-standing.



Integrating Molecular Genetic Information for Tailored Treatment of Patients with Oligodendroglioma

The discovery of a genetic alteration in oligodendrogliomas that was prognostic of improved response to treatment and

radiation and chemotherapies.

provided by analysis of this alteration, also referred to as

Neuro-Oncology*, the

the use of a chemotherapy-only treatment for patients with

anaplastic gliomas. These studies, which are opening in

patients with grade III gliomas.

1p-deleted grade III oligodendroglioma. The image on the left shows

the patient before the start of chemotherapy with no radiation;

and white arrows). The inset, top, shows the relative loss of one

copy of chromosome 1p in the tumor tissue of a patient with the

deletion (arrow shows the bottom copy missing in the tumor, T,

column), compared with the normal (N) signal in blood cells.

Neuro Oncol. Advance


104

Innovations

Epilepsy CenterEnhanced Localization Ability with Magnetoencephalography (MEG)

launched in 2008, has enhanced the center’s clinical capabilities

to better identify epileptic sources in patients where the area of

the epileptic focus, b) help guide the placement of intracranial recording electrodes or c) ascertain that the patient is not a surgical candidate.

Our Neurocomputing and Clinical Neurophysiology teams have

advanced. These new developments include the following:

would otherwise obscure the brain activity.

direct correlation of the patient’s physical actions with the

online database to facilitate ongoing quality assessment.

17 — Number of years we have hosted our International Epilepsy Symposium.

Outcomes 2008



Mellen Center for Multiple Sclerosis Treatment and ResearchPlasma Exchange as Treatment for Rare Natalizumab Complication

unknown, and treatment options are limited. A drug called

from entering the brain and attacking nerves, but the drug

Natalizumab have suffered an uncommon, but usually fatal

leukoencephalopathy).

Neurology,*

This study showed that monoclonal antibodies can be

needed to effectively remove Natalizumab from the bodies of

with Natalizumab, which would improve the overall safety of this therapy.

and restoring leukocyte function. Neurology

Optical Coherence Tomography (OCT) to Monitor Axonal Injury

OCT is a rapid, noninvasive, painless test that generates

utilization of OCT to measure the thickness of the retinal

form the optic nerve, which connects the eye to the brain) and the volume of the macula (the nerve cell bodies

treatment trials.


Outcomes 2008106

Innovations

Innovative Study Recruitment Method

(N = 1,611). This novel recruitment method can dramatically accelerate research in chronic disease management.

Center for Neuroimaging

Correcting Motion-Corrupted High-Angular Resolution Diffusion-Weighted Imaging (HARDI) Data

error on the diffusion direction is below 0.2 degrees.

(B) tensor-reference motion correction.



Activation Data

most common method of assessing connectivity is to measure the temporal correlation between two functional brain regions. Due to individual variation in functional localization in the human brain, a standard technique for

imposes a serious limitation on the ability to analyze functional connectivity in the human brain in studies in which

on combining anatomic landmarks with a regional measure of temporal coherence. This measure, derived from

The high-resolution anatomic image on the left shows a slice through the anterior mesial temporal lobe. The red region is the


108

Innovations

Monitoring System for Deep Brain Stimulators during fMRI

important effort in understanding the mechanisms of this important therapy. To date, all

which, when placed over the implant on the patient’s chest, determines the state of the

Development of Post-Processing Labs to Incorporate Qualitative and Quantitative Data for Routine Clinical Use

acquisition devices throughout Cleveland Clinic health system to two post-processing labs. In CT, 2-D and 3-D reconstructions of the original data are produced and forwarded to digital reading stations for interpretation and storage in a central archive so referring

one lab to produce and store qualitative maps (e.g., perfusion) for the neuroradiologists and the referring services. The other lab produces quantitative data (e.g., brain volumes, hippocampal volumes, white matter disease burden) that is incorporated into a standardized report form to aid in interpretation and longitudinal clinical follow-up.

Outcomes 2008


109

Working with Patients to Improve fMRI Studies

preoperative localization of motor, speech generation and receptive speech areas with an

interviews every patient to individualize the study when indicated, review the nature of the study with the patient, provide instructions for the paradigms, and emphasize the

prescan patient interview in improving scan quality showed that an intensive intervention can

are freely available to any institution.

simpler paradigms are now available incorporating pictures and simpler language. This has

than by a small subset of research scientists.

positive regions.

Attention No Attention



Outcomes 2008

Innovations

110

Initiation of a Lateralization Score for fMRI Studies for Judging Hemispheric Dominance for Speech

and brain tumor patients. The important issue is to identify the essential eloquent (primary) cortical areas governing language and motor activity, so the surgeon can provide adequate margins to minimize post-surgical morbidity. Often, this issue is resolved by determining language lateralization, a process hitherto

10

8

0Right LeftfMRI Lateralization Index

6

2

4

Number

Wada LeftWada BilateralWada Right



Sleep Disorders Center

Multidisciplinary Continuous Positive Airway Pressure (CPAP) Compliance Group Therapy

psychological reasons. The noncompliance rates are estimated to be in the range of

receive tips from professionals while also learning from other patients. They have

the problem, they are given detailed individual treatment plans. The feedback from patients has been very positive.

Biofeedback for Chronic Insomnia

daytime fatigue, increase in workplace and driving accidents, and overall increase in the utilization of healthcare services. Although hypnotic medicines are effective in some patients, they are not always safe for long-term use.

that has a dedicated biofeedback program for chronic insomnia. Biofeedback is a technique in which a patient is trained to improve his or her health by developing a greater awareness and voluntary control over the physiological processes affected by

biofeedback, respiratory biofeedback, thermal biofeedback and neurofeedback.

28 — Number of dedicated beds with state-of-the-art monitoring equipment for overnight sleep studies.

111


Outcomes 2008

Innovations

Center for Spine Health (CSH)

dramatically decreases the time it takes to perform an intraoperative localizing X-ray for anterior

of a conventional radiograph. Digital imaging provides information equivalent in accuracy to

900

0Conventional Radiograph

N = 10Digital X-Ray

N = 8

600

300

Average Time (Seconds)

Time Savings with Digital Intraoperative X-Rays for Anterior Cervical Fusions

On average, digital intraoperative X-rays for anterior cervical fusions take about one-eighth the time of conventional radiographs.

112



Delaying Recurrences of Myxopapillary Ependymomas

The Utility of Repeated Postoperative Radiographs

regular intervals in asymptomatic patients following single-level anterior cervical decompression fusion and plating do not appear to be warranted and do not alter the

of postoperative radiographs will reduce the amount of

save about $1,000 per patient, reducing the overall cost of healthcare.

obtaining repeated postoperative radiographs following single-level anterior

cervical decompression, fusion, and plate placement. J Neurosurg Spine.

9 — Percent of new Center for Spine Health patients who eventually have spinal surgery.

113


Outcomes 2008

Selected Publications

The Neurological Institute staff authored more than 470 publications in 2008.For a complete list go to www.clevelandclinic.org/quality/outcomes.

Brain Tumor and Neuro-Oncology Center

institutional phase II study of temozolomide administered twice daily in the treatment of recurrent high-grade gliomas. Cancer.

radiosurgery effectively treats recurrences from whole-brain radiation therapy. Cancer.

with sporadic pituitary adenomas. Clin Endocrinol (Oxf).

Appl Immunohistochem Mol Morphol.

of the treatment of trigeminal neuralgia with gamma knife radiosurgery. Stereotact Funct Neurosurg. 2008;86(3):

and bevacizumab in progressive primary brain tumors, J Neurooncol. 2008

radiosurgical treatment of brain metastases in older patients. Cancer.

glioblastoma survivors: a preliminary feasibility study. Genomics.

114



correlation of serum alpha-subunit concentration and magnetic resonance imaging following pituitary surgery in patients with nonfunctional pituitary macroadenomas. Endocr Pract.

in clinoidal meningiomas: rationale for aggressive skull base approach. Acta Neurochir (Wien). 2008

Cerebrovascular Center

Wingspan in-stent restenosis. Neurosurgery. 2008

hemorrhagic risks after intra-arterial revascularization in acute stroke. Neurosurgery.

convenience for rational neurovascular studies. J Cereb Blood Flow Metab.

vasculogenesis and neurogenesis on rat brain development. Neurobiol Dis.

AJNR Am J Neuroradiol.

imaging in the intensive care unit. Radiol Manage. 2008

Neurology.

in cryptogenic TIA or stroke. Neurology. 2008 Nov

wingspan in-stent restenosis. AJNR Am J Neuroradiol. 2008

and monocular blindness after endovascular treatment of large and giant paraophthalmic aneurysms. Neurosurgery.


Outcomes 2008116


Epilepsy Center

seizure genes in systemic lupus erythematosus. Epilepsia.

on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord. 2008

patients with medically refractory temporal lobe epilepsy. Epilepsy Res.

with epilepsy: pharmacokinetic interactions, contraceptive options, and management. Int Rev Neurobiol. 2008;83:

Epilepsia.

impact, mechanisms, and prevention. Cleve Clin J Med.

white matter degeneration of the corpus callosum in patients with intractable temporal lobe epilepsy: A diffusion tensor imaging study. Epilepsy Res.

medications after successful epilepsy surgery in children. Pediatr Neurol.

temporal visual language center: cortical stimulation Neurology. 2008 Nov

J Magn Reson. 2008

Mellen Center for Multiple Sclerosis Treatment and Research

is associated with increased levels of ligand in circulation and tissues. Blood.

Neurogenesis in the chronic lesions of multiple sclerosis. Brain.

Mult Scler. 2008



atrophy in multiple sclerosis: a longitudinal study. Ann Neurol.

Arch Neurol.

functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp.

Neurology.

orthosis in ambulatory multiple sclerosis patients. Arch Phys Med Rehabil.

Annu Rev Neurosci.

Ann Neurol.

Center for Neuroimaging

information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol.

in association with moya moya disease and bilateral morning glory disc anomaly — broadening the clinical spectrum of midline defects. J Neurol.

functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp.

imaging in the intensive care unit. Radiol Manage. 2008

Neurology. 2008


Outcomes 2008118


Center for Neurological Restoration

patients. Brain.

brain stimulation in essential tremor. J Clin Neurophysiol.

Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia.

nucleus deep brain stimulation protocols in a data-driven computational model. J Neurophysiol. 2008

in movement disorders. Neurotherapeutics. 2008

illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet.

J Neurosurg Anesthesiol.

Neurosurgery.

study on suicide outcomes following subthalamic stimulation Brain.

neuronal activity. J Neurosci.

Neuromuscular Center

J Pain Symptom Manage.

microdissection. Mol Vis.

Mil Med. 2008

Intrathecal baclofen for spasticity-related pain in amyotrophic

relief. Muscle Nerve.

Oncology (Williston Park).



dyspnea. Muscle Nerve.

Neurology. 2008 Nov

Epilepsia. 2008

J Neurol Sci. 2008

Neurological Center for Pain

in the acute treatment of menstrually related migraine. Headache.

combination for the treatment of migraine. Expert Rev Neurother.

119


Outcomes 2008


serotonin syndrome: a review. Expert Opin Drug Saf. 2008

management using integrated print and video materials: a multisite randomized controlled trial. Pain.

Headache.

screening tool for obstetric and gynecology clinics: the menstrual migraine assessment tool. Headache. 2008

Center for Pediatric Neurology and Neurosurgery

implications of endoscopic third ventriculostomy for the treatment of hydrocephalus. Eur J Obstet Gynecol Reprod Biol.

syndrome in a genotypic male. Ophthalmic Genet. 2008

hydrocephalus in the patient with gait disturbance. Geriatrics.

120



Neurology.

of suspected mitochondrial disease. Mol Genet Metab. 2008

Epilepsy surgery in epidermal nevus syndrome variant with hemimegalencephaly and intractable seizures. J Neurol.

in association with moya moya disease and bilateral morning glory disc anomaly — broadening the clinical spectrum of midline defects. J Neurol.

Pediatr Neurol.

in autism spectrum disorder patients: a cohort analysis. PLoS ONE.

Department of Psychiatry and Psychology

on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord. 2008

Curr Opin Organ Transplant. 2008

Br J Psychiatry.

Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia.

sociocultural ideals predicts weight gain. Body Image. 2008

illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet.

heart-brain medicine. Cleve Clin J Med.

and bipolar disorders. Ann Clin Psychiatry. 2008 Dec;20

Cleve Clin J Med. 2008

Psychiatr Clin North Am.

J Clin Anesth.


122 Outcomes 2008



long-term mortality after prolonged mechanical ventilation. Lung.

Epilepsia.

assessment in bariatric surgery patients. Obes Surg. 2008

pulmonary risk assessment and perioperative management in bariatric surgery patients. Obes Surg.

Sleep Breath.

obstructive sleep apnea in adults with epilepsy: a randomized pilot trial. Neurology.

in patients with pulmonary hypertension. J Heart Lung Transplant.

Epilepsia.

Center for Spine Health

stimulation for cervical fusion. Spine J. 2008

J Am Acad Orthop Surg. 2008

Spinal Disord Tech.

of chronic low back pain with opioid analgesics. Spine J.

fusion in a workers’ compensation population. Neurosurgery.

instrumentation in the management of scoliosis. Neurosurgery.

J Orthop Res. 2008

marrow mesenchymal stem cells and nucleus pulposus cells Spine.



stem cells and nucleus pulposus cells. Spine J. 2008

an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis. Spine J.

Neurosurgical Anesthesiology

spine surgery. Anesthesiology.

lumbar spine surgery. J Neurosurg Anesthesiol. 2008

disruption under general anesthesia: a retrospective review. J Neurosurg Anesthesiol.

J Neurosurg Anesthesiol.

of remifentanil to prevent movement during craniotomy in the absence of neuromuscular blockade. J Neurosurg Anesthesiol.

123


124124 Outcomes 2008

Staff Listing

Chairman

Vice Chairman, Clinical Areas

Vice Chairman, Research and Development

Department of Neurological Surgery

Chairman, Department of Neurological Surgery

Department of Neurology

Chairman, Department of Neurology

Department of Physical Medicine and Rehabilitation

Chairman, Department of Physical Medicine and Rehabilitation

Kristin Carlin, DO

Department of Psychiatry and Psychology

Chairman, Department of Psychiatry and Psychology



Brain Tumor and Neuro-Oncology Center

Director, Brain Tumor and Neuro-Oncology Center


Outcomes 2008126126

Staff Listing

Lou Ruvo Center for Brain Health Randolph Schiffer, MD Director, Center for Brain Health Cynthia S. Kubu, PhD, ABPP-CN

Richard Lederman, MD, PhD

Richard Naugle, PhD

Michael Parsons, PhD

Alexander Rae-Grant, MD, FRCP (C)

Stephen Rao, PhD

Patrick Sweeney, MD

Janice Zimbelman, PhD

Center for Neuroimaging Thomas Masaryk, MD Director, Center for Neuroimaging Todd Emch, MD

Stephen E. Jones, MD, PhD

Mark Lowe, PhD

Michael T. Modic, MD, FACR

Doksu Moon, MD

Micheal Phillips, MD

Janet Reid, MD

Paul Ruggieri, MD

Alison Smith, MD

Todd Stultz, DDS, MD

Andrew Tievsky, MD

Center for Neurological Restoration Ali Rezai, MD Director, Center for Neurological Restoration Anwar Ahmed, MD

Jay Alberts, PhD

Kenneth Baker, PhD

Scott Cooper, MD, PhD

Milind Deogaonkar, MD

Darlene Floden, PhD

Ilia Itin, MD

Cynthia S. Kubu, PhD, ABPP-CN

Richard Lederman, MD, PhD

Andre Machado, MD, PhD

Donald Malone Jr., MD

Cameron McIntyre, PhD

Samer Narouze, MD

Mayur Pandya, DO

Michael Stanton-Hicks, MD

Patrick Sweeney, MD

Stewart Tepper, MD

Jerrold Vitek, MD, PhD

Weidong Xu, MD

Jianyu Zhang, MD

Center for Pediatric Neurology and Neurosurgery Elaine Wyllie, MD Director, Center for Pediatric Neurology Mark Luciano, MD, PhD Director, Center for Pediatric Neurosurgery Bruce Cohen, MD

Xiao Di, MD, PhD



Stephen Dombrowski, PhD

Gerald Erenberg, MD

Neil Friedman, MBChB

Debabrata Ghosh, MD, DM

Gary Hsich, MD

Irwin Jacobs, MD

Manikum Moodley, MD

Sumit Parikh, MD

A. David Rothner, MD

Center for Regional Neurology Stephen Samples, MD Director, Center for Regional Neurology A. Romeo Craciun, MD

Sheila Rubin, MD

Jennifer Ui, MD

Joseph Zayat, MD

Center for Regional Neurological Surgery

Michael Mervart, MD Director, Center for Regional Neurological Surgery Samuel Borsellino, MD

Samuel Tobias, MD

Center for Spine Health

Edward Benzel, MD Director, Center for Spine Health Gordon Bell, MD Associate Director, Center for Spine Health

Daniel Mazanec, MD Associate Director, Center for Spine Health Lilyana Angelov, MD

Thomas Bauer, MD, PhD

William Bingaman, MD

Edwin Capulong, MD

Alfred Cianflocco, MD

Edward Covington, MD

Russell DeMicco, DO

Frederick Frost, MD

Lars Gilbertson, PhD

Augusto Hsia Jr., MD

Serkan Inceoglu, PhD

Iain Kalfas, MD

Tagreed Khalaf, MD

Ajit Krishnaney, MD

Thomas Kuivila, MD

Eric Mayer, MD

Robert McLain, MD

Thomas Mroz, MD

R. Douglas Orr, MD

Anantha Reddy, MD

Judith Scheman, PhD

Richard Schlenk, MD

Kalyani Shah, MD

Michael Steinmetz, MD

Santhosh Thomas, DO

Deborah Venesy, MD

Fredrick Wilson, DO

Adrian Zachary, DO, MPH


Referral Contact Information

Outcomes 2008128

Cerebrovascular Center

Director, Cerebrovascular Center

Epilepsy Center Imad Na Director, Epilepsy Center

Staff Listing

128



Mellen Center for Multiple Sclerosis Treatment and Research

Director, Mellen Center for Multiple Sclerosis Treatment and Research Erik B

Neurological Center for Pain Edward Co Director, Neurological Center for Pain

Neuromuscular Center

Director, Neuromuscular Center


Outcomes 2008130130


Director, Sleep Disorders Center

Department of Neurosciences, Lerner Research Institute

Chairman, Department of Neurosciences, Lerner Research Institute

Staff Listing

Biomedical Engineering, Lerner Research Institute

Cell Biology

Anatomic Pathology

Neuroanesthesiology

Section Head, Neurological and Spine Surgery Anesthesiology Section Head, Neuro-Endovascular Anesthesiology

clevelandclinic.org/staff.




Outcomes 2008132132

Contact Information

General Patient Referral

Neurological Institute Appointments/Referrals

On the Web at clevelandclinic.org/neuroscience

Additional Contact Information

General Information

Hospital Patient Information

Patient Appointments

Medical Concierge

Complimentary assistance for out-of-state patients and families

[email protected]

Global Patient Services/International Center

Complimentary assistance for international patients and families

clevelandclinic.org/gps

Cleveland Clinic in Florida

For address corrections or changes, please call



Institute Locations

Cleveland Clinic Neurological Institute physicians see

when calling.

Main Campus

Neurological Institute Regional Centers

Euclid Hospital

Fairview Hospital

Hillcrest Hospital

Huron Hospital

Lakewood Hospital

Lutheran Hospital

Marymount Hospital

Cleveland Clinic Children’s Hospital Shaker Campus


Outcomes 2008134134

Cleveland Clinic Family Health Centers

Avon Lake Family Health Center

Beachwood Family Health and Surgery Center

Chagrin Falls Family Health Center

Independence Family Health Center

Crown Center II

Lorain Family Health and Surgery Center

Institute Locations



Solon Family Health Center

Strongsville Family Health and Surgery Center

Westlake Family Health Center

Willoughby Hills Family Health Center

Cleveland Clinic Wooster

135


Outcomes 2008136136

Cleveland Clinic Overview

bundling all clinical specialties into integrated practice units called institutes. An institute combines all the

under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the

point-of-care service, institutes will improve the patient

acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs

multispecialty care hospital and clinic, is scheduled to open in late 2012.

associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total

federal agencies, non-federal societies and associations, endowment funds and other sources. In an effort to bring research from bench to bedside, Cleveland Clinic

at any given time.

offers all students full tuition scholarships. The program will

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1

clevelandclinic.org



Resources for Physicians

Cleveland Clinic Secure Online Services

Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to GoogleTM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart.

DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].

MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

Critical Care Transport: Anywhere in the world

Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call 877.279.CODE (2633). For all other transfers, call 216.444.8302 or 800.553.5056.

CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.


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© The Cleveland Clinic Foundation 2009

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

Please visit us on the Web at clevelandclinic.org.


2008Outcomes


Documents

Outcomes 2008 - Cleveland ClinicThis complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can