Orthopaedic & Rheumatologic Institute Outcomes

Transcription

1 Orthopaedic & Rheumatologic Institute 214 Outcomes

2 Measuring Outcomes Promotes Quality Improvement

3 Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its clinical institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with a focus on outcomes data and a review of new technologies and innovations. The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical and procedural techniques. In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data. The following reports are available to the public: Joint Commission Performance Measurement Initiative (qualitycheck.org) Centers for Medicare and Medicaid Services (CMS) Hospital Compare (HospitalCompare.hhs.gov), and Physician Compare (medicare.gov/physiciancompare) Cleveland Clinic Quality Performance Report (clevelandclinic.org/qpr) Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic s culture of continuous improvement and may help referring physicians make informed decisions. We hope you find these data valuable, and we invite your feedback. Please send your comments and questions via to: OutcomesBooksFeedback@ccf.org or scan here. To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.

4 Dear Colleague: Welcome to this 214 Cleveland Clinic Outcomes book. Every year, we publish Outcomes books for 14 clinical institutes with multiple specialty services. These publications are unique in healthcare. Each one provides an overview of medical or surgical trends, innovations, and clinical data for a particular specialty over the past year. We are pleased to make this information available. Cleveland Clinic uses data to manage outcomes across the full continuum of care. Our unique organizational structure contributes to our success. Patient services at Cleveland Clinic are delivered through institutes, and each institute is based on a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Institutes define quality benchmarks for their specialty services and report on longitudinal progress. All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic. org/qpr). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites. Our practice of releasing annual outcomes books has become increasingly relevant as healthcare transforms from a volume-based to a value-based system. We appreciate your interest and hope you find this information useful and informative. Sincerely, Delos M. Cosgrove, MD CEO and President

5 what s inside Chairman s Letter 4 Institute Overview 5 Quality and Outcomes Measures Orthopaedics Overview 6 Adult Total Shoulder Arthroplasty for Osteoarthritis 2 Adult Total Hip Arthroplasty for Osteoarthritis 22 Adult Unilateral Total Knee Arthroplasty for Osteoarthritis 24 Orthopaedic Surgical Quality Improvement 26 Osteoarthritis 72 Autoinflammatory Disease 73 Infusion Center 74 Institute Patient Experience 76 Cleveland Clinic Implementing Value-Based Care 78 Innovations 84 Contact Information 88 About Cleveland Clinic 9 Resources 92 Spinal Disease 28 Sports Medicine 36 Rheumatology Overview 42 Transplant 45 Osteoporosis 46 Gout 51 Rheumatoid Arthritis 54 Prefer an e-version? Visit clevelandclinic.org/outcomesonline, and we ll remove you from the hard copy mailing list and you when next year s books are online. Immunodeficiency 56 Psoriatic Arthritis 58 Vasculitis 62 Fibromyalgia 64 Progressive Systemic Sclerosis 66 Reversible Cerebral Vasoconstriction Syndrome 69

6 Chairman s Letter Dear Colleagues, Thank you for your interest in the 214 Outcomes for Cleveland Clinic s Orthopaedic & Rheumatologic Institute. Here we provide an overview of our ongoing efforts to measure our patients health and functional outcomes following the full range of surgical procedures and nonsurgical treatments. Our institute is committed to the best outcomes for patients, and we continually strive to make advancements. 214 was a productive year for us, and some of our standout advancements included: Care path implementation for total hip and knee arthroscopy, which standardized care processes to reduce variability and improve outcomes Successful execution of the Bundled Payments for Care Improvement initiative, an innovative payment model from the Centers for Medicare & Medicaid Services that includes financial and performance accountability for patient episodes of care Clinical integration of five orthopaedic programs within the National Orthopaedic and Spine Network as well as a Multidisciplinary Musculoskeletal Ultrasound Program across the Cleveland Clinic health system Development and implementation of the point of care OrthoMiDaS clinical data collection software and the Rheumatology Patient Reported Outcomes software, both of which allow us to keep our commitment to measuring patients health and functional outcomes We welcome your feedback, questions, and ideas for collaboration. Please contact me via at OutcomesBooksFeedback@ccf.org and reference the Orthopaedic & Rheumatologic Institute Outcomes book in your message. Sincerely, Joseph Iannotti, MD, PhD Chairman, Orthopaedic & Rheumatologic Institute 4 Outcomes 214

7 Institute Overview This year s Outcomes book profiles the clinical outcomes of patients treated by the institute s caregivers in 214. Patients with the most complex clinical problems from around the nation and the world come to the Orthopaedic & Rheumatologic Institute for care and expert opinions. These outcomes contributed to Cleveland Clinic s ranking among the nation s top 2 rheumatology programs and top 3 orthopaedics programs in U.S. News & World Report s America s Best Hospitals survey for The institute comprises Orthopaedic Surgery, Rheumatic and Immunologic Diseases, Musculoskeletal Physical Medicine and Rehabilitation, and Orthotics and Prosthetics. Current full-time faculty include 58 orthopaedic surgeons (53 orthopaedic, 5 spine), 31 rheumatologists, 12 musculoskeletal radiologists, 7 podiatrists, 9 sports and exercise medicine primary physicians, 5 nonoperative orthopaedists, and 4 physiatrists (PM&R physicians). The institute also is dedicated to the cultivation of new knowledge and innovation through basic, translational, and clinical research. One of its missions is to educate and train residents and fellows as well as colleagues at Cleveland Clinic and beyond contributing to the fields of orthopaedics and rheumatology. Total clinic visits 493,323 Total surgeries 21,6 Total 214 musculoskeletal and rheumatology funding basic, translational, and clinical research $4,946,165 Orthopaedic & Rheumatologic Institute 5

8 Orthopaedics Overview Adult Shoulder Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Surgery Total shoulder arthroplasty /48 51/ Osteoarthritis /45 52/ Other reasons /71 43/ Reverse total shoulder arthroplasty /66 43/ Hemiarthroplasty /44 45/ Revision of total shoulder arthroplasty /48 57/ Rotator cuff repair /42 53/ Capsulorrhaphy /28 68/ Biceps tenodesis /22 75/ Fracture treatment /5 56/ Proximal humerus /69 32/ Clavicle /25 77/ Other treatment /43 57/ Arthroscopic Surgery Rotator cuff repair /38 61/ Capsulorrhaphy /26 75/ Biceps tenodesis /37 64/ SLAP repair /19 8/ Subacromial decompression /42 6/ Debridement /36 55/ Other treatment /38 64/ Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care 6 Outcomes 214

9 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Surgery Total shoulder arthroplasty Osteoarthritis Other reasons Reverse total shoulder arthroplasty Hemiarthroplasty Revision of total shoulder arthroplasty Rotator cuff repair Capsulorrhaphy Biceps tenodesis Fracture treatment Proximal humerus Clavicle Other treatment Arthroscopic Surgery Rotator cuff repair Capsulorrhaphy Biceps tenodesis SLAP repair Subacromial decompression Debridement Other treatment Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) Orthopaedic & Rheumatologic Institute 7

10 Orthopaedics Overview Adult Hand and Upper Extremity Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Surgery Total elbow arthroplasty /78 29/ Ulnar nerve neuroplasty at elbow /43 52/ Elbow tenotomy /52 45/ Distal bicep repair /4 97/ Carpal tunnel release /63 37/ Without distal radial fracture /63 37/ With distal radial fracture /73 26/ Wrist arthrodesis /37 62/ Hand arthroplasty /8 25/ Palmar fasciectomy /25 81/ De Quervain's release /81 16/ Trigger finger release /64 4/ Finger arthrodesis /66 29/ Finger amputation /31 67/ Fracture treatment /54 45/ Humeral shaft /64 28/ Distal humerus /64 48/ Radial head Proximal ulna /58 42/ Radial or ulnar shaft /5 42/ Distal radius /74 2/ Scaphoid /39 63/ Hand or finger /32 74/ Mass excision /62 34/ Other treatment /42 56/ Arthroscopic Surgery Elbow treatment /16 72/ Wrist treatment Other treatment Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care 8 Outcomes 214

11 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Surgery Total elbow arthroplasty Ulnar nerve neuroplasty at elbow Elbow tenotomy Distal bicep repair Carpal tunnel release Without distal radial fracture With distal radial fracture Wrist arthrodesis Hand arthroplasty Palmar fasciectomy De Quervain's release Trigger finger release Finger arthrodesis Finger amputation Fracture treatment Humeral shaft Distal humerus Radial head Proximal ulna Radial or ulnar shaft Distal radius Scaphoid Hand or finger Mass excision Other treatment Arthroscopic Surgery Elbow treatment Wrist treatment Other treatment Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) Orthopaedic & Rheumatologic Institute 9

12 Orthopaedics Overview Adult Hip Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Surgery Hip resurfacing /29 78/ Total hip arthroplasty /55 47/ Osteoarthritis /56 48/ Rheumatoid arthritis /79 16/ Avascular necrosis /42 49/ Other reasons (eg, fracture) /61 4/ Conversion to total hip arthroplasty /49 4/ Hemiarthroplasty /64 33/ Revision of total hip arthroplasty /53 52/ Infection /43 55/ Other reasons /56 51/ Treatment of hip or pelvis fracture /69 41/ Other treatment /55 48/ Arthroscopic Surgery Treatment of labral tear /67 31/ Without osteoarthritis /68 31/ With osteoarthritis /59 28/ Other treatment /61 54/ Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care 1 Outcomes 214

13 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Surgery Hip resurfacing Total hip arthroplasty Osteoarthritis Rheumatoid arthritis Avascular necrosis Other reasons (eg, fracture) Conversion to total hip arthroplasty Hemiarthroplasty Revision of total hip arthroplasty Infection Other reasons Treatment of hip or pelvis fracture Other treatment Arthroscopic Surgery Treatment of labral tear Without osteoarthritis With osteoarthritis Other treatment Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) At Cleveland Clinic main campus, 24% of all total hip arthroplasty surgeries performed are revisions, which is approximately double the rate performed at all other Cleveland Clinic hospitals. Approximately 44% of all total hip arthroplasty revision surgeries across the Cleveland Clinic health system are performed at Cleveland Clinic main campus. Orthopaedic & Rheumatologic Institute 11

14 Orthopaedics Overview Adult Knee Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Surgery Unilateral total knee arthroplasty /62 38/ Osteoarthritis /62 39/ Rheumatoid arthritis /78 21/ Avascular necrosis Other reasons /53 43/ Bilateral total knee arthroplasty /59 42/ Partial knee arthroplasty /54 46/ Revision of total knee arthroplasty /57 46/ Infection /48 58/ Other reasons /6 42/ Treatment of periarticular knee fracture /64 4/ Other treatment /48 54/ Arthroscopic Surgery ACL reconstruction /37 59/ Meniscectomy /46 53/ Meniscus injury without osteoarthritis /42 55/ Meniscus injury with osteoarthritis /49 52/ Other reasons Meniscus repair /36 64/ Chondroplasty /55 41/ Other treatment /54 47/ Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care 12 Outcomes 214

15 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Surgery Unilateral total knee arthroplasty Osteoarthritis Rheumatoid arthritis Avascular necrosis Other reasons Bilateral total knee arthroplasty Partial knee arthroplasty Revision of total knee arthroplasty Infection Other reasons Treatment of periarticular knee fracture Other treatment Arthroscopic Surgery ACL reconstruction Meniscectomy Meniscus injury without osteoarthritis Meniscus injury with osteoarthritis Other reasons Meniscus repair Chondroplasty Other treatment Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) At Cleveland Clinic main campus, Cleveland Clinic Florida, and Lakewood Hospital, approximately 2% of all total knee arthroplasty surgeries performed are revisions, while all other Cleveland Clinic hospitals perform < 1%. Approximately 4% of all total knee arthroplasty revision surgeries across the Cleveland Clinic health system are performed at Cleveland Clinic main campus. Orthopaedic & Rheumatologic Institute 13

16 Orthopaedics Overview Adult Foot and Ankle Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Surgery Total ankle arthroplasty /43 43/ Ankle arthrodesis /46 44/ Osteoarthritis /48 39/ Rheumatoid arthritis Traumatic injury /45 55/ Other reasons /36 42/ Achilles tendon treatment /31 72/ Acute rupture repair /23 82/ Chronic reconstruction /58 41/ Foot arthrodesis /64 43/ Osteoarthritis /65 47/ Rheumatoid arthritis Deformity /65 33/ Other reasons /61 48/ Flat foot or cavus foot correction /82 16/ Big toe arthrodesis /79 22/ Osteoarthritis /78 17/ Rheumatoid arthritis /94 2/ Deformity /79 23/ Other reasons Cheilectomy /68 42/ Bunion correction /89 7/ Hammertoe correction /79 19/ Bunion and hammertoe correction /92 13/ Fracture treatment /54 45/ Tibia or fibula /45 58/ Ankle /64 36/ Foot or toes /49 39/ Amputation /38 65/ Below knee /35 58/ Foot /36 74/ Toes /4 59/ Excision of leg or ankle tumor /56 33/ Excision of foot or toe tumor /69 43/ Other treatment /6 44/ Arthroscopic Surgery Osteochondritis dissecans lesion repair /48 55/ Other treatment /56 46/ Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. 14 Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care Outcomes 214

17 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Surgery Total ankle arthroplasty Ankle arthrodesis Osteoarthritis Rheumatoid arthritis Traumatic injury Other reasons Achilles tendon treatment Acute rupture repair Chronic reconstruction Foot arthrodesis Osteoarthritis Rheumatoid arthritis Deformity Other reasons Flat foot or cavus foot correction Big toe arthrodesis Osteoarthritis Rheumatoid arthritis Deformity Other reasons Cheilectomy Bunion correction Hammertoe correction Bunion and hammertoe correction Fracture treatment Tibia or fibula Ankle Foot or toes Amputation Below knee Foot Toes Excision of leg or ankle tumor Excision of foot or toe tumor Other treatment Arthroscopic Surgery Osteochondritis dissecans lesion repair Other treatment Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge Orthopaedic & Rheumatologic Institute 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 15

18 Orthopaedics Overview Pediatric Shoulder and Hand/Upper Extremity Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Shoulder Surgery Capsulorrhaphy /28 1/ Treatment of shoulder fracture /16 88/ Other treatment Arthroscopic Shoulder Surgery Capsulorrhaphy /23 68/ SLAP repair /19 79/ Other treatment Open Hand/UE Surgery Trigger finger release /53 47/ Fracture treatment /34 66/ Humeral shaft /48 5/ Distal humerus Radial head Proximal ulna Radial or ulnar shaft /33 63/ Distal radius /28 67/ Scaphoid /11 91/ Hand or finger /27 79/ Mass excision /57 3/ Other treatment /39 68/ Arthroscopic Hand/UE Surgery 5 1 Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior, UE = upper extremity Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care 16 Outcomes 214

19 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Shoulder Surgery Capsulorrhaphy Treatment of shoulder fracture Other treatment Arthroscopic Shoulder Surgery Capsulorrhaphy SLAP repair Other treatment Open Hand/UE Surgery Trigger finger release Fracture treatment Humeral shaft Distal humerus Radial head Proximal ulna Radial or ulnar shaft Distal radius Scaphoid Hand or finger Mass excision Other treatment Arthroscopic Hand/UE Surgery Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior, UE = upper extremity Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) Orthopaedic & Rheumatologic Institute 17

20 Orthopaedics Overview Pediatric Hip, Knee, and Foot/Ankle Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Length of Stay, Days Discharged Home, % Open Hip Surgery 69 6 Treatment of hip or pelvis fracture Other treatment /53 41/ Arthroscopic Hip Surgery Open Knee Surgery Treatment of periarticular knee fracture /2 82/ Other treatment /5 44/ Arthroscopic Knee Surgery ACL reconstruction /51 44/ Meniscectomy /36 67/ Meniscus repair Chondroplasty /42 42/ Other treatment /52 41/ Open Foot/Ankle Surgery Flat foot or cavus foot correction /49 45/ Fracture treatment /3 71/ Tibia or fibula /29 81/ Ankle Foot or toes /32 77/ Excision of leg or ankle tumor /48 58/ Excision of foot or toe tumor Other treatment /51 55/ Arthroscopic Foot/Ankle Surgery 5 3 Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament Column descriptions: Procedure: type of surgical procedure performed Yearly Volume: number of surgeries performed per year Average Age, Years: average patient age Males/Females, %: males-to-females ratio Length of Stay, Days: average length of stay in days for inpatient surgeries Discharged Home, %: percentage of patients who were discharged home or to home care 18 Outcomes 214

21 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % 9-Day Infection Rate, % Preop Function 9-Day Postop Function Open Hip Surgery Treatment of hip or pelvis fracture Other treatment Arthroscopic Hip Surgery Open Knee Surgery Treatment of periarticular knee fracture Other treatment Arthroscopic Knee Surgery ACL reconstruction Meniscectomy Meniscus repair Chondroplasty Other treatment Open Foot/Ankle Surgery Flat foot or cavus foot correction Fracture treatment Tibia or fibula Ankle Foot or toes Excision of leg or ankle tumor Excision of foot or toe tumor Other treatment Arthroscopic Foot/Ankle Surgery Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida. Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament Column descriptions: Procedure: type of surgical procedure performed In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred 3-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 3 days of discharge 3-Day Reoperation Rate, %: rate of reoperation on the same joint within 3 days of discharge 9-Day Infection Rate, %: rate of infection within 9 days of surgery Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems prior to surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) 9-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems 9 days after surgery; scores range from (extreme limitations, low function) to 1 (no limitations, high function) Orthopaedic & Rheumatologic Institute 19

22 Adult Total Shoulder Arthroplasty for Osteoarthritis Shoulder-Related Pain 1 Year After Surgery Shoulder-Related Function 1 Year After Surgery Patients (%) 1 8 > 3 MCID a 1 3 MCID Patients (%) 1 8 > 3 MCID a 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 91% of patients reported a clinically important improvement in shoulder-related pain after 1 year, while 1% reported worsening (8% showed no detectable change in shoulder-related pain). On average, 92% of patients reported a clinically important improvement in shoulder-related function after 1 year, while 1% reported worsening (7% showed no detectable change in shoulder-related function). Shoulder-related pain and function are measured using a modified Penn Shoulder Score (PSS) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years. ªMCID refers to the minimal clinically important difference and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For shoulder-related pain, the MCID is 12.3 (N = 336) on a scale from (extreme pain) to 1 (no pain). For shoulder-related function, the MCID is 13.5 (N = 316) on a scale from (extreme limitations) to 1 (no limitations). 2 Outcomes 214

23 Arm-Related Physical Function 1 Year After Surgery Whole-Body Physical Function 1 Year After Surgery Patients (%) 1 8 > 3 MCID a 1 3 MCID Patients (%) 1 8 > 3 MCID a 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 87% of patients reported a clinically important improvement in arm-related physical function after 1 year, while 4% reported worsening (9% showed no detectable change in arm-related physical function). On average, 53% of patients reported a clinically important improvement in whole-body physical function after 1 year, while 9% reported worsening (38% showed no detectable change in whole-body physical function). Arm-related physical function is measured using the Review of Musculoskeletal System (ROMS) questionnaire. Wholebody physical function is measured using the Veterans RAND 12 (VR-12) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years. ªMCID refers to the minimal clinically important difference and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For arm-related physical function, the MCID is 1.6 (N = 465) on a scale from (extreme limitations) to 1 (no limitations). For whole-body physical function, the MCID is 5.1 (N = 391) on a norm-based scale where 5 represents the mean score of a nonpatient control group and every 1 units represents 1 SD from the mean. Orthopaedic & Rheumatologic Institute 21

24 Adult Total Hip Arthroplasty for Osteoarthritis Hip-Related Pain 1 Year After Surgery Patients (%) 1 Hip-Related Function 1 Year After Surgery Patients (%) > 3 MCID a 1 3 MCID 8 6 > 3 MCID a 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 93% of patients reported a clinically important improvement in hip-related pain after 1 year, while 1% reported worsening (6% showed no detectable change in hip-related pain). On average, 91% of patients reported a clinically important improvement in hip-related function after 1 year, while 2% reported worsening (7% showed no detectable change in hip-related function). Hip-related pain and function are measured using a modified Hip dysfunction and Osteoarthritis Outcome Score (HOOS) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years. ªMCID refers to the minimal clinically important difference and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For hip-related pain, the MCID is 11.6 (N = 951) on a scale from (extreme pain) to 1 (no pain). For hip-related function, the MCID is 12.8 (N = 935) on a scale from (extreme limitations) to 1 (no limitations). 22 Outcomes 214

25 Leg-Related Physical Function 1 Year After Surgery Patients (%) 1 Whole-Body Physical Function 1 Year After Surgery Patients (%) > 3 MCID a 1 3 MCID 8 6 > 3 MCID a 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 78% of patients reported a clinically important improvement in leg-related physical function after 1 year, while 7% reported worsening (15% showed no detectable change in leg-related physical function). On average, 67% of patients reported a clinically important improvement in whole-body physical function after 1 year, while 7% reported worsening (26% showed no detectable change in whole-body physical function). Leg-related physical function is measured using the Review of Musculoskeletal System (ROMS) questionnaire. Wholebody physical function is measured using the Veterans RAND 12 (VR-12) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years. ªMCID refers to the minimal clinically important difference and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For leg-related physical function, the MCID is 2. (N = 1859) on a scale from (extreme limitations) to 1 (no limitations). For whole-body physical function, the MCID is 5.8 (N = 1784) on a norm-based scale where 5 represents the mean score of a nonpatient control group and every 1 units represents 1 SD from the mean. Orthopaedic & Rheumatologic Institute 23

26 Adult Unilateral Total Knee Arthroplasty for Osteoarthritis Knee-Related Pain 1 Year After Surgery Knee-Related Function 1 Year After Surgery Patients (%) 1 8 > 3 MCID a 1 3 MCID Patients (%) 1 8 > 3 MCID a 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 88% of patients reported a clinically important improvement in knee-related pain after 1 year, while 2% reported worsening (1% showed no detectable change in knee-related pain). On average, 82% of patients reported a clinically important improvement in knee-related function after 1 year, while 2% reported worsening (16% showed no detectable change in knee-related function). Knee-related pain and function are measured using a modified Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years. ªMCID refers to the minimal clinically important difference and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For knee-related pain, the MCID is 12. (N = 1614) on a scale from (extreme pain) to 1 (no pain). For knee-related function, the MCID is 12.9 (N = 155) on a scale from (extreme limitations) to 1 (no limitations). 24 Outcomes 214

27 Leg-Related Physical Function 1 Year After Surgery Whole-Body Physical Function 1 Year After Surgery Patients (%) 1 8 > 3 MCID a 1 3 MCID Patients (%) 1 8 > 3 MCID a 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 74% of patients reported a clinically important improvement in leg-related physical function after 1 year, while 7% reported worsening (19% showed no detectable change in leg-related physical function). On average, 58% of patients reported a clinically important improvement in whole-body physical function after 1 year, while 11% reported worsening (31% showed no detectable change in whole-body physical function). Leg-related physical function is measured using the Review of Musculoskeletal System (ROMS) questionnaire. Whole-body physical function is measured using the Veterans RAND 12 (VR-12) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years. ªMCID refers to the minimal clinically important difference and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For leg-related physical function, the MCID is 1.8 (N = 334) on a scale from (extreme limitations) to 1 (no limitations). For whole-body physical function, the MCID is 5.5 (N = 2443) on a norm-based scale where 5 represents the mean score of a nonpatient control group and every 1 units represents 1 SD from the mean. Orthopaedic & Rheumatologic Institute 25

28 Orthopaedic Surgical Quality Improvement American College of Surgeons National Surgical Quality Improvement Program The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP ) objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. These outcomes data reflect Cleveland Clinic s orthopaedic surgery ACS NSQIP performance benchmarked against 362 participating sites. Orthopaedic Surgery Outcomes July 213 June 214 Outcome N Observed Rate (%) Expected Rate (%) 3-day mortality day morbidity Pneumonia a.49 Deep vein thrombosis/pulmonary embolism a 1. Urinary tract infection Surgical site infection Return to operating room a Identified as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model In addition to overall orthopaedic surgery ACS NSQIP outcomes data, data specific to total knee arthroplasty (TKA) and total hip arthroplasty (THA) are provided. TKA performance is benchmarked against 74 participating sites; THA surgery performance is benchmarked against 76 sites. Total Knee Arthroplasty Outcomes July 213 June 214 Outcome N Observed Rate (%) Expected Rate (%) 3-day morbidity Surgical site infection Total Hip Arthroplasty Outcomes July 213 June 214 Outcome N Observed Rate (%) Expected Rate (%) 3-day mortality day morbidity Surgical site infection Outcomes 214

29 Elective Primary Total Hip Arthroplasy and/or Total Knee Arthroplasty Complications April 211 March 214 All-Cause 3-Day Readmissions July 211 June 214 Percent 6 5 Cleveland Clinic National rate a Complications Readmissions N = a Source: medicare.gov/hospitalcompare The Centers for Medicare and Medicaid Services (CMS) calculates 2 elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) outcomes measures based on Medicare claims and enrollment information. The most recent risk-adjusted data available from CMS are shown. Although Cleveland Clinic s THA/TKA complications and readmissions rates are both slightly lower than the US national rates, CMS ranks Cleveland Clinic s performance on each as no different than the respective US national rates. To further reduce avoidable readmissions, Cleveland Clinic is focused on optimizing transitions from hospital to home or postacute facility. Specific initiatives have been implemented to ensure effective communication, education, and follow-up. Orthopaedic & Rheumatologic Institute 27

30 Spinal Disease The Center for Spine Health provides comprehensive care for a continuum of spinal disorders. Comprehensive care includes medical management, physical therapy, surgical interventions, minimally invasive injection procedures, specialized exercise programs, acupuncture, osteopathic manipulation, and referral to an in-house functional restoration program, all intended to maximize return to participation in vocational, family, and recreational activities. The Center for Spine Health consists of surgeons, all board-certified in either neurosurgery or orthopedic surgery, and medical specialists board-certified in various fields that include rheumatology, physical medicine and rehabilitation, neurology, internal medicine, sports medicine, pain medicine, psychiatry, and psychology. Cervical Myelopathy Change in Functional Status Following Cervical Decompression With Fusion for Myelopathy Surgical Dates: Jan. 6, 212 July 1, 214 Patients (%) N = EQ-5D Score 159 PDQ Score 127 PHQ-9 Score 9 Improved Stable Worsened In patients undergoing cervical decompression for myelopathy, among those with EuroQol (EQ-5D ) scores < 1 (N = 159), 36% noted improvement and 1% worsened in health-related quality of life. In those with baseline impairment of physical function, defined as Pain Disability Questionnaire (PDQ) score > 16, 39% noted improvement after surgery and 15% worsened. In those with at least moderate depressive symptoms, defined as a score 1 on the Patient Health Questionnaire (PHQ- 9) prior to treatment, 14% noted improvement in depressive symptoms. Median duration of follow-up after surgery was 125 days (range, ). In this and subsequent graphs, clinically meaningful change was defined as a change of half a standard deviation, 1 or a total point change of.11, based on 212 Neurological Institute data, for the EQ-5D, a total point change of > 16 for the PDQ, and a change of 5 points for the PHQ-9. 2 References 1. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 23 May;41(5): Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 24 Dec;42(12): Outcomes 214

31 Change in Functional Status Following Single-Level Cervical Decompression Without Fusion for Myelopathy Surgical Dates: Feb. 16, 212 June 5, 214 Patients (%) N = EQ-5D Score 45 PDQ Score 38 PHQ-9 Score 31 Improved Stable Worsened Among patients undergoing single-level decompression without fusion for cervical myelopathy, 96% (N = 45) had EQ-5D < 1; 44% noted improvement and 9% worsened in health-related quality of life. In those with baseline impairment of physical function (N = 38), defined as PDQ > 16, 42% noted improvement after surgery and 15% worsened. Among patients undergoing single-level decompression without fusion for cervical myelopathy, 75% (N = 31) had at least moderate depressive symptoms (PHQ-9 1) prior to treatment; 6.5% noted improvement and 1% worsened in depressive symptoms. Median duration of follow-up after surgery was 161 days (range, ). Change in Functional Status Following Multilevel Cervical Decompression Without Fusion for Myelopathy Surgical Dates: Jan. 4, 212 Aug. 1, 214 Patients (%) N = EQ-5D Score 17 PDQ Score 1 PHQ-9 Score 13 Improved Stable Worsened Among patients undergoing multilevel decompression without fusion for cervical myelopathy, 95% (N = 17) had EQ-5D < 1; 18% noted improvement, 71% remained stable, and 12% worsened in health-related quality of life. Among patients with baseline impairment of physical function (PDQ > 16), 7% noted improvement after surgery and 1% worsened. Among patients who had at least moderate depressive symptoms (PHQ-9 1) prior to surgery, 77% remained stable and 23% worsened in depressive symptoms. Median duration of follow-up after surgery was 161 days (range, ). Orthopaedic & Rheumatologic Institute 29

32 Spinal Disease Cervical Disc Herniation Change in Functional Status Following Cervical Decompression With Fusion for Cervical Disc Herniation Surgical Dates: Nov. 22, 211 July 1, 214 Patients (%) Improved Stable Worsened 4 2 N = EQ-5D Score 95 PDQ Score 74 PHQ-9 Score 38 In patients who underwent surgery for symptoms of cervical disc herniation, 39% of those with EQ-5D < 1 (N = 95) noted improvement and 9.5% noted worsening in health-related quality of life. In those with baseline impairment of physical function, as measured by the PDQ, 51% noted improvement after surgery and 9.5% worsened. In those with at least moderate depressive symptoms (PHQ- 9 1) prior to treatment, 21% noted improvement in depressive symptoms and the rest remained stable. Median duration of follow-up after surgery was 127 days (range, ). 3 Outcomes 214

33 Cost-Effectiveness in Cervical Spine Surgery Cleveland Clinic s Center for Spine Health recognizes the drive to document value and has engaged in a program to measure, compare, and intervene to improve value. The center recently published a comparison of 2 surgeries commonly performed in the cervical spine: anterior cervical discectomy and fusion with plating (ACDFP) and posterior cervical foraminotomy (PCF). 1 Both surgeries produced meaningful postoperative improvement in physical function and health-related quality of life, but PCF costs about 23% less than ACDFP. Further work is needed to determine appropriate indications for each surgery and predictors of cost variance. Change in Physical Function and Quality of Life Following Cervical Spine Surgeries Surgical Dates: Mean PDQ Score 1 8 Before surgery One year after surgery N = Anterior Cervical Discectomy and Fusion 71 Posterior Cervical Foraminotomy 19 Mean EQ-5D Score 1..8 Before surgery One year after surgery N = Anterior Cervical Discectomy and Fusion 71 Posterior Cervical Foraminotomy 19 Reference 1. Alvin MD, Lubelski D, Abdullah KG, Whitmore RG, Benzel EC, Mroz TE. Cost-utility analysis of anterior cervical discectomy and fusion with plating (ACDFP) versus posterior cervical foraminotomy (PCF) for patients with single-level cervical radiculopathy at 1-year follow-up. J Spinal Disord Tech. 214 Mar 27. [Epub ahead of print] Orthopaedic & Rheumatologic Institute 31

34 Spinal Disease Lumbar Spinal Stenosis Surgical Treatment Spinal stenosis results in narrowing of the spinal canal, which often causes leg pain that can impair walking, standing, and many aspects of daily function. For symptomatic patients, the goal of surgery is to decompress the spinal canal to eliminate neural compression and relieve leg pain; this may or may not require instrumented fusion of the operated levels. Change in Functional Status Following Lumbar Decompression With Fusion for Spinal Stenosis Surgical Dates: Dec. 3, 211 Jan. 2, 214 Patients (%) Improved Stable Worsened 4 2 N = EQ-5D Score 91 PDQ Score 82 PHQ-9 Score 54 Among 91 patients undergoing lumbar decompression with fusion, all had EQ-5D < 1; 59% noted improvement and 8% worsened in health-related quality of life after surgery. Clinically meaningful change was defined as half a standard deviation, 1 or a total point change of.11. Of the patients who had baseline impairment of physical function (PDQ > 16), 57% noted improvement after surgery and 1% worsened. Clinically meaningful change was defined as a total point change of > 16. Among patients reporting at least moderate depressive symptoms (PHQ-9 1) prior to surgery, 2% noted improvement and 6% worsened in depressive symptoms. Clinically meaningful change was defined as a total point change of 5. 2 Median duration of follow-up was 15 days after surgery (range, ). References 1. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 23 May;41(5): Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 24 Dec;42(12): Outcomes 214

35 Intramedullary Spinal Cord Tumors Change in Functional Status Following Surgery for Intramedullary Spinal Cord Tumors (N = 98) Patients (%) N = Ependymoma 53 Glioma 13 Schwannoma 4 Angioma 23 Lipoma 5 Improved Stable Worsened Intramedullary spinal cord tumors are uncommon, but potentially catastrophic. Among 98 consecutive patients operated on over 15 years, 54% to 75% achieved functional improvement after surgery and 13% to 4% of patients had worsening of functional status after surgery, as measured with the Modified McCormick Scale, which grades neurological function in spinal cord disorders. Mean duration of follow-up was 65 months. Readmissions and Mortality 3-Day Unplanned Readmission Rate Among Spine Center Patients (N = 375) Readmission Rate (%) N = Q1 272 Q2 Q Q4 39 Q1 29 Q2 Q Q4 278 Q1 254 Q2 Q Q4 274 New protocols were initiated in 212 in an effort to reduce unplanned 3-day readmissions. These new protocols included a Discharge Call Program to contact patients 48 hours after discharge to review disease symptoms, medications, and follow-up plans and to address any questions the patient may have about the plan of care. Patients readmitted for planned surgery or other planned procedures were excluded. N = total number of patients discharged per quarter. Orthopaedic & Rheumatologic Institute 33

36 Spinal Disease 3-Day Postoperative Mortality Rate Following Spinal Surgery (N = 3468) 214 Mortality Rate (%) Cleveland Clinic NSQIP 1 Medicare 2 The 3-day postoperative mortality rate following spinal surgery in 214 was.14%, compared with a rate of.3% for the National Surgical Quality Improvement Program (NSQIP) 1 database and a rate of.4% for the Medicare database. 2 Surgical Site Infections Surgical Site Infection Rates for Spinal Surgery (N = 2861) Infections per 1 Clean Cases N = Q1 366 Q2 Q Q4 38 Q1 377 Q2 Q New protocols introduced in 212 to reduce surgical site infections include nasal staphylococcus surveillance and decolonization protocols, an updated perioperative scrub protocol, new rules restricting operating room traffic and updating operating room table preparation, and new wound closure recommendations. The most recent overall postoperative infection rates in the Spine Center of 1.5% for 213 and 1.9% for 214 compare favorably with available published data ranging from 1.4% to 11%. 1, 2 N = spinal surgeries with available infection surveillance data. Q4 363 Q1 344 Q2 Q Q4 345 References 1. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ. Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program (NSQIP). J Bone Joint Surg Am. 211 Sep 7; 93(17): Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 21 Apr 7; 33(13): References 1. Smith JS, Shaffrey CI, Sansur CA, Berven SH, Fu KM, Broadstone PA, Choma TJ, Goytan MJ, Noordeen HH, Knapp DR Jr, Hart RA, Donaldson WF 3rd, Polly DW Jr, Perra JH, Boachie-Adjei O; Scoliosis Research Society Morbidity and Mortality Committee. Rates of infection after spine surgery based on 18,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine. 211 Apr 1; 36(7): Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J. 21 Oct; 19(1): Outcomes 214

37 Cost Reduction With Implementation of Surgical Site Infection Prevention Initiative (N = 1839) Surgical Dates: April 212 December 213 Percent of Total Cost 1 8 Before initiative (N = 993) After initiative (N = 846) Days Presurgery Day of Surgery 9 Days Postsurgery Average direct internal cost per patient (as a percentage of total direct internal cost before the initiative) was compared for similar cohorts of patients before (April December 212) and after (April December 213) implementation of the surgical site infection reduction initiative. Overall, comparing nearly 1 matched patients in each cohort, there was a 14% reduction in average total cost per patient postinitiative. Use of nasal swabs and preoperative antiseptic wash solutions added minimally to the preoperative cost, defined as health system related cost 3 days prior to surgery. Average intraoperative costs decreased minimally by 3%. The main cost savings occurred in the 9 days after surgery, presumably related to a reduction in emergency department visits and readmissions related to surgical site infections. Orthopaedic & Rheumatologic Institute 35

38 Sports Medicine Concussion is a type of mild traumatic brain injury caused by a bump, blow, or jolt to the head that can present with a variety of symptoms. Cleveland Clinic s Concussion Center is a leader in the evaluation and management of patients with concussion. In an effort to optimize community-based sports concussion care, the Concussion Center developed and implemented standardized methods of reporting, evaluating, and managing concussion injury in youth and high school athletes. The following outcomes highlight sports concussion care using the Concussion Center s highly integrated, multidisciplinary approach. Incident Reporting The collection and reporting of head injury details (eg, symptoms, date, time, location of injury, and action taken) facilitates the collaboration of care between athletic trainers on the sideline and physicians in the hospital or office. The development and deployment of the Concussion Incident Report module to a mobile device, ipad, or iphone allows athletic trainers, who are typically the first medical personnel to evaluate an injured athlete, to track head injury details. Additional assessment modules are utilized to objectively characterize aspects of cognitive and motor status. 36 Outcomes 214

39 Incident Reporting Over Time June 213 December 214 Assessments 3, 2, Baseline Follow-up Incident reports Incident Reports 3 2 1, 1 Q3 213 Q4 Q1 Q2 Q3 Q4 214 The graph illustrates the historical use of the Cleveland Clinic Concussion (C3) Application and the Incident Report (IR) after the pilot phase. Collectively, both the preseason baseline and in-season follow-up assessments increased dramatically from 213 to the beginning of the fall 214 sports season. The Concussion Center is currently analyzing both baseline and postinjury data for this data set. As shown by the red line, the number of IRs dramatically increased starting in July 214, after all Cleveland Clinic athletic trainers received education on its use. The remainder of the reported outcomes will focus on the IR as it provides data that will guide process improvement, facilitate patient hand-offs, and allow calculation of injury rates for communication to community partners. Orthopaedic & Rheumatologic Institute 37

40 Sports Medicine Concussion Incidence Across Various Sports (N = 57) July 214 January 215 Number of Concussions Football Girls Soccer Boys Soccer Girls Basketball Boys Wrestling Girls Volleyball Boys Basketball Boys Ice Hockey Cheerleading Girls Swim/Dive Boys Swim/Dive Girls Gymnastics Between July 214 and January 215, football, girls and boys soccer, girls basketball, and boys wrestling had the highest reported incidence of sports-related concussion. The frequency of these data is similar to those reported throughout the US. 1 Reference 1. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 2 sports. Am J Sports Med. 212 Apr;4(4): Outcomes 214

41 Concussion Rates by Sport and Venue for High School Athletes (N = 57) July 214 January 215 Cleveland Clinic National 1 Sport Game/Event (%) Practice (%) Total (%) Game/Event (%) Practice (%) Total (%) Football Boys ice hockey Boys soccer Boys wrestling Boys basketball Boys swimming/diving Girls soccer Girls basketball Girls gymnastics Cheerleading Girls volleyball Girls swimming/diving The rates of concussion IR were higher in competition than in practice for all sports, except wrestling, cheerleading, and swimming/diving, in the Cleveland Clinic patient population, and the overall rates of observed concussions among girls volleyball and both boys and girls soccer were higher compared with a national sample. 1 The presence of Cleveland Clinic high school athletic trainers at soccer and volleyball practices and competitions likely improved detection. Increased popularity of soccer, as well as community education and awareness of concussion signs and symptoms, may contribute to greater incidence among these athletes. Reference 1. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 2 sports. Am J Sports Med. 212 Apr;4(4): Orthopaedic & Rheumatologic Institute 39

42 Sports Medicine Distribution of Football-Associated Concussions by Age and Position (N = 26) July 214 January 215 Frequency 5 Age < Frequency Frequency Age Quarterback Offensive Line Defensive Line Linebacker Running Back Cornerback Offensive Line Defensive Line Fullback Wide Receiver Safety Linebacker Tight End Running Back Other Other Cornerback Offensive Line Special Teams Wide Receiver Quarterback Defensive Line Safety Linebacker Kick Returner Special Teams Tight End Cornerback Fullback Running Back Safety Tight End Quarterback Fullback Punt Returner Age 18 To better understand how age and position played in football may affect concussion rates, patients with concussion were evaluated in 3 age groups. High school athletes reported 183 concussions while playing football, which is consistent with prior reports of the associated increased incidence of concussion in football players. 1 Within the 14- to 17-yearold age group, 47% of football-related concussions occurred on offense, while 37% occurred while playing defense. Offensive and defensive linemen accounted for 32%, 31.1%, and 3.7% of concussions across the < 14, 14 17, and 18 age groups, respectively. Linemen account for nearly half of football positions on the field. Wide receivers accounted for 12% of all concussions, despite making up approximately 9.1% of the positions on the field. Reference 1. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 2 sports. Am J Sports Med. 212 Apr;4(4): Outcomes 214

43 Same-Day Incident Reports: Action Taken After Concussion (N = 163) July 214 January 215 Frequency Sent to Locker Room Remained on Sideline Sent Home Sent to ED Returned to Play; No Concussion No Action Taken; Injury Not Reported ED = emergency department The immediate action following the identification of or evaluation for a concussion is critical in terms of preventing a more serious injury as a result of an immediate subsequent blow to the head. As shown in the graph, most athletes were sent to the locker room or remained on the sideline. Unfortunately, 6.1% exhibited more concerning signs and symptoms and were sent to a local emergency department for a more thorough evaluation. Among athletes who were removed from play and evaluated at the time of injury, 4.3% (N = 7) were returned to play after it was determined that they did not suffer a concussion. The incident reports show a disturbing 6.1% of athletes (N = 1) who did not report their injury during the athletic event and continued to play, putting them at higher risk for further injury and a more prolonged recovery. N = number of same day incident reports. Orthopaedic & Rheumatologic Institute 41

44 Rheumatology Overview Patient Visit Volumes Since the beginning of the BIOLOGIC SUMMITS in 25, this local Total Visits (in Thousands) Cleveland Clinic regional practices Cleveland Clinic main campus meeting has grown into an international event. In 215, more than attendees will gather in Cleveland. More N = 21 52, , , , ,556 impressively, each SUMMIT has been repurposed and Volume of New Rheumatoid Arthritis Patient Visits posted at ccfcme.org/ rheumcme and is available free to all. As of 214, the Number of Patients R. J. Fasenmyer Center for 1 Clinical Immunology has issued more than 36, hours of continuing medical education credit for this remarkable meeting. N = Outcomes 214

45 Most Common Conditions Treated in 214 a Condition Volume Rheumatoid arthritis 5367 Osteoporosis 5192 Connective tissue diseases 3645 Osteoarthritis 3451 Soft tissue rheumatism 2629 Vasculitis 2267 Fibromyalgia 2163 Chronic pain syndromes 17 Immunodeficiency diseases 941 Unspecified arthritis 749 Psoriatic arthritis 75 Gout 667 Spinal diseases 632 Polymyalgia rheumatica 57 Sprains 53 Ankylosing spondylitis 41 Diseases of the eye 371 Volume of Visits of Patients With Rare Disorders in 214 Diagnosis Volume Giant cell arteritis 258 Sarcoidosis 154 Familial Mediterranean fever 134 Common variable immunodeficiency 122 Takayasu disease 99 Behcet syndrome 8 Hypermobility syndrome 41 Ehlers-Danlos syndrome 27 Cerebral arteritis 19 Erythema nodosum 12 Inclusion body myositis 6 Mononeuritis multiplex 3 ªExcludes Cleveland Clinic family health centers Volume of New Granulomatosis With Polyangiitis (Wegener s) Patient Visits Number of Patients N = Orthopaedic & Rheumatologic Institute 43

46 Rheumatology Overview Volume of Medication Infusions Cleveland Clinic Main Campus Outpatient Medication Intravenous immunoglobulin (Gammagard ) Infliximab (Remicade ) Rituximab (Rituxan ) Abatacept (Orencia ) Zoledronic acid (Reclast ) Tocilizumab (Actemra ) Belimumab (Benlysta ) Pegloticase (Krystexxa ) Cyclophosphamide (Cytoxan ) Methylprednisolone (Solu-Medrol ) Ibandronate (Boniva ) Basiliximab (Simulect ) 1 1 Pamidronate (Aredia ) Volume of New Psoriatic Arthritis Patient Visits Number of Patients N = Outcomes 214

47 Transplant Percentage of Cardiac Transplant Patients Who Had a DXA Scan Percentage of Lung Transplant Patients Who Had a DXA Scan Percent 1 Percent N = N = DXA = dual energy x-ray absorptiometry DXA = dual energy x-ray absorptiometry Glucocorticoid use is associated with bone loss and fractures. The 21 American College of Rheumatology guidelines on glucocorticoid-induced osteoporosis recommend a DXA scan for patients on glucocorticoid therapy for 3 months or more. Cardiac transplant recipients receive glucocorticoids for more than 3 months after surgery to prevent organ rejection. Fewer than 15% of transplant patients had DXA scans before or within 6 months after transplant in 21. Collaboration between the Transplant and Osteoporosis centers since 21 has significantly improved the frequency of DXA scans in cardiac transplant patients before or within 6 months after transplant surgery. Lung transplant recipients receive glucocorticoids for more than 3 months after surgery to prevent organ rejection. Collaboration between the Transplant and Osteoporosis centers since 21 has resulted in a continued high frequency of DXA scans in lung transplant patients before or within 6 months after transplant surgery. Orthopaedic & Rheumatologic Institute 45

48 Osteoporosis Percentage of Osteoporosis Patients Started on Denosumab Who Received Continued Therapy at Specified Intervals Percent months ± 3 days 6 months ± 6 days 6 months ± 9 days 2 N = Second Dose 62 Third Dose 389 Fourth Dose 242 Fifth Dose 14 Sixth Dose 73 Seventh Dose 32 Eighth Dose 11 Denosumab (Prolia ) is a medication for patients with low bone mass who are at high risk for fracture. Once treatment is started, current guidelines recommend treatment at 6-month intervals. Delays in treatment result in loss of effect. After initiation of therapy with denosumab, a second dose was administered to 68.9% of patients at 6 months ± 3 days, to 78.1% within 6 months ± 6 days, and to 82.4% within 6 months ± 9 days. Of those who received a second dose, a third dose was administered to 72.8% of patients at 6 months ± 3 days, to 81.2% within 6 months ± 6 days, and to 86.1% within 6 months ± 9 days. For those who received continued treatment, the rate of subsequent injections increased over time through the eighth dose. Systematic methods to monitor drug dosing at recommended intervals are needed to improve compliance with established guidelines. Percentage of Osteoporosis Patients Started on Denosumab Who Continued Osteoporosis Therapy (N = 62) Percent Second Dose Denosumab Adherence to an oral bisphosphonate regimen is poor, with < 5% of patients on therapy at 1 year. Adherence to an injectable medication regimen is a function of patient acceptance and systems measures in practice to ensure patient scheduling. Of 62 patients receiving their first dose of denosumab, 496 (82.4%) received a second dose of medication. Of the 16 patients not receiving a second dose of denosumab, approximately 2% received another osteoporosis medication. 46 Outcomes 214

49 Percentage of Patients Treated With Denosumab Who Had Vitamin D and Calcium Testing Prior to Treatment (N = 2475) Percent Days Prior to Infusion Serum calcium Vitamin D Denosumab (Prolia) is a treatment for osteoporosis given as an injection every 6 months. It has been associated with hypocalcemia, which is more common in patients with preinjection hypocalcemia and vitamin D deficiency. A serum calcium and vitamin D test is suggested within the preceding year to reduce the risk of hypocalcemia: 8.9% and 92.2% of patients had serum calcium testing in the preceding 18 and 365 days, respectively, while 87.9% and 91.2% of patients had vitamin D testing in the preceding 18 and 365 days, respectively. Percentage of Osteoporosis Patients Started on Zoledronic Acid Who Received Continued Therapy at Specified Intervals Percent year ± 3 days 1 year ± 6 days 1 year ± 9 days 2 N = Second Dose 1113 Third Dose 542 Fourth Dose 14 Zoledronic acid (Reclast ) is a medication for patients with low bone mass who are at high risk for fracture. Once treatment is started, current guidelines recommend treatment at 1-year intervals. Delays in treatment may result in loss of effect. After initiation of therapy with zoledronic acid, a second dose was administered to 61.7% of patients at 1 year ± 3 days, to 74.5% within 1 year ± 6 days, and to 8.8% within 1 year ± 9 days. Of those who received a second dose, a third dose was administered to 74.5% of patients at 1 year ± 3 days, to 8.4% within 1 year ± 6 days, and to 86.7% within 1 year ± 9 days. Of those who received a third dose, a fourth dose was administered to 8.8% of patients at 1 year ± 3 days, to 86.7% within 1 year ± 6 days, and to 95.7% within 1 year ± 9 days. Systematic methods to monitor drug dosing at recommended intervals are needed to improve compliance with established guidelines. Orthopaedic & Rheumatologic Institute 47

50 Osteoporosis Percentage of Osteoporosis Patients Started on Zoledronic Acid Who Continued Osteoporosis Therapy (N = 1113) Percent Second Dose Zoledronic Acid Adherence to oral bisphosphonate medication is poor, with < 5% of patients on therapy at 1 year. Adherence with an infusible medication is a function of patient acceptance and systems measures in practice to ensure patient scheduling. Of 1113 patients receiving their first dose of zoledronic acid, 9 (8.9%) received a second dose of medication. Of the 213 patients not receiving a second dose of zoledronic acid, approximately 25% were changed to another osteoporosis medication. Percentage of Patients Treated With Zoledronic Acid Who Had Renal Function Testing Prior to Infusion (N = 1517) Percent Days Prior to Infusion Zoledronic acid (Reclast) infusion for osteoporosis is not recommended for patients with a glomerular filtration rate 35 ml/min. During the period , 96.4% of patients had renal function testing with a creatinine and estimated glomerular filtration rate within 365 days prior to infusion. A chart survey of 2 patients who did not have an estimated glomerular filtration rate in the electronic medical record revealed that all 2 had labs done outside Cleveland Clinic, which were documented in the chart prior to zoledronic acid infusion. 48 Outcomes 214

51 Percentage of Patients Treated With Zoledronic Acid Who Had Vitamin D Testing Prior to Infusion (N = 3811) Percent Days Prior to Infusion Zoledronic acid (Reclast) infusion for osteoporosis may be associated with hypocalcemia after infusion. Patients with hypovitaminosis D are at high risk for hypocalcemia. Obtaining a vitamin D level is considered standard of care for patients prior to infusion. More than 91% of patients undergoing infusion had a vitamin D level measured within 365 days before infusion. Percentage of Patients on Glucocorticoids Treated With Osteoporosis Medications (N = 18) Percent FRAX < 1% FRAX 1% 2% FRAX > 2% Days Post DXA DXA = dual energy x-ray absorptiometry, FRAX = World Health Organization Fracture Risk Assessment Tool American College of Rheumatology guidelines for glucocorticoid-induced osteoporosis (GIO) recommend treatment based on duration and dose of steroid therapy and absolute fracture risk for major osteoporotic fractures using the FRAX tool (World Health Organization Fracture Risk Assessment Tool). Treatment is recommended for most patients with a 1-year absolute fracture risk of major osteoporotic fractures 1%. National Osteoporosis Foundation guidelines in the US recommend treatment if the FRAX 1-year risk is 2%. Patients on glucocorticoids for > 9 days were examined by absolute fracture risk categories for major osteoporotic fractures. In patients with a 1-year risk for fracture 2%, 59.1%, 65.5%, and 7.9% were on therapy for GIO at 9, 18, and 365 days, respectively. Orthopaedic & Rheumatologic Institute 49

52 Osteoporosis Percentage of Patients With Low Bone Mass (T-Score 2.5) and High Fracture Risk by FRAX Who Were Treated With Osteoporosis Medications Percent (N = 317) (N = 424) (N = 436) Days Post DXA DXA = dual energy x-ray absorptiometry, FRAX = World Health Organization Fracture Risk Assessment Tool Current guidelines recommend treatment of patients with low bone mass, with a T-score 2.5 at the hip or lumbar spine, or patients who have a 1-year absolute fracture risk as calculated by FRAX of 2% for major osteoporotic fracture or 3% for hip fracture. Patients were reviewed who were not on treatment at the time of a bone density scan and had low bone mass or high fracture risk, who were then placed on therapy for osteoporosis with medications (bisphosphonates, denosumab, raloxifene, and teriparatide). For the period , more than 8% of patients were placed on medication within 9 days, with small increases in treatment after that time up to 365 days. For the periods and , treatment rates have trended higher. Cleveland Clinic s dual energy x-ray absorptiometry (DXA) registry enrolled its first patient in 29. The ability to combine bone density registry data with the World Health Organization s FRAX 1-year absolute fracture risk, osteoporosis medications, and glucocorticoid use has created a powerful tool for quality improvement and outcomes. A collaboration with the University of Alabama will combine DXA registries and allow linkage of patients with Medicare claims data. Enrollment in Cleveland Clinic s DXA registry through 214 totals more than 55, patients. 5 Outcomes 214

53 Gout Percentage of Gout Patients Treated With Urate-Lowering Therapy Who Reached Target Uric Acid Level (N = 2143) Percent mg/dl mg/dl Uric Acid Level > 7. mg/dl % 12.6% 13.6% % 12.7% 13.4% % 13.3% 13.5% % 13.5% 14.9% Patients in this cohort had a diagnosis of gout, had at least 2 visits with a Cleveland Clinic rheumatologist, and were prescribed a uric acid-lowering agent (allopurinol or febuxostat). The recommended target uric acid level was 6. mg/dl. Between 71.6% and 73.9% of patients had a uric acid level of 6. mg/dl between 21 and 214, demonstrating successful treatment to reach the target level. Additionally, 12.6% to 13.5% of patients had a uric acid level between 6.1 mg/dl and 7. mg/dl, demonstrating acceptable levels. Between 13.4% and 14.9% of patients did not achieve target levels, with uric acid levels > 7. mg/dl. The percentage of patients who achieved target plus acceptable uric acid levels remains stable; however, substantial numbers of patients are undertreated with urate-lowering therapy. Orthopaedic & Rheumatologic Institute 51

54 Gout Percentage of Tophaceous Gout Patients Treated With Urate- Lowering Therapy Who Reached Target Uric Acid Level (N = 131) Percent mg/dl mg/dl Uric Acid Level > 7. mg/dl % 9.4% 15.3% % 9.5% 13.3% % 8.6% 12.% % 9.5% 13.% Patients in this cohort had a diagnosis of tophaceous gout, had at least 2 visits with a Cleveland Clinic rheumatologist, and were prescribed a uric acid-lowering agent (allopurinol or febuxostat). The recommended target uric acid level was 6. mg/dl. Between 75.3% and 79.5% of patients had a uric acid level of 6. mg/dl between 21 and 214, demonstrating successful treatment to reach the target level. Additionally, 8.6% to 9.5% of patients had a uric acid level between 6.1 mg/dl and 7. mg/dl, demonstrating acceptable levels. Between 12.% and 15.3% of patients did not achieve target levels, with uric acid levels > 7. mg/dl. The percentage of patients with tophaceous gout who reached uric acid levels < 7. mg/dl was similar to the percentage of patients in the entire gout cohort; however, substantial numbers of patients are undertreated with urate-lowering therapy. 52 Outcomes 214

55 Number of Gout Patients Treated With Pegloticase Who Reached Target Uric Acid Level Number of Infusions (N = 34) 214 (N = 7) Infusions Serum Uric Acid Checked Serum Uric Acid < 6 mg/dl Pegloticase (Krystexxa ) is a pegylated uricase indicated for the treatment of chronic gout in adult patients resistant to conventional therapy. It is given as an IV infusion every 2 weeks. Anaphylaxis and immune reactions can occur and are based on formation of antibodies. The antibodies result in a loss of effect of the drug, which has been shown to precede the reactions in 91% of cases. Typically, uric acid levels fall below 1 mg/dl; with loss of effect, uric acid levels are higher. This has led to the recommendation that a uric acid level be checked before each infusion. Treatment should be discontinued if uric acid rises to 6 mg/dl or greater on 2 consecutive tests. In 213, 34 pegloticase infusions were performed in 5 patients; serum uric acid was checked prior to infusion in all cases and was < 6 mg/dl in all tests. No infusion reactions occurred. In 214, 7 pegloticase infusions were performed in 7 patients; 68 had a uric acid level checked, and 66 were < 6 mg/dl. In the 2 with uric acid levels > 6 mg/dl, pegloticase was discontinued. Orthopaedic & Rheumatologic Institute 53

56 Rheumatoid Arthritis Percentage of Rheumatoid Arthritis Patients Taking Disease-Modifying Antirheumatic Drug Therapy (N = 17,715) Percent N = American College of Rheumatology guidelines recommend that rheumatoid arthritis patients be treated with disease-modifying antirheumatic drug (DMARD) therapy. More than 99% of rheumatoid arthritis patients who were seen in the Department of Rheumatology at least 2 times during the years 21, 211, 212, 213, and 214 were treated with DMARD therapy. Reasons for not prescribing DMARD therapy for the small percentage of patients not on DMARDs included disease remission, refusal of treatment, and contraindications to DMARD therapy. In any given year, 93% to 95% of patients were on a DMARD. 54 Outcomes 214

57 Percentage of Newly Diagnosed Patients With Rheumatoid Arthritis Starting Biologic DMARDs Who Had Tuberculosis Testing Percent N = DMARDs = disease-modifying antirheumatic drugs The 212 Update of the 28 American College of Rheumatology (ACR) Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis 1 recommends tuberculosis (TB) screening before using biologic agents to identify latent TB infection (LTBI). The ACR recommends the tuberculin skin test or interferon-γ release assays as the initial test in all rheumatoid arthritis patients starting biologic agents, regardless of risk factors for LTBI. In 213, 91% (73 of 81) and in 214, 93% (12 of 19) of patients had TB testing. Reference 1. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, Moreland LW, O Dell J, Winthrop KL, Beukelman T, Bridges SL Jr, Chatham WW, Paulus HE, Suarez-Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG. 212 update of the 28 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 212 May;64(5): Percentage of Rheumatoid Arthritis Patients Treated With Methotrexate Who Were Prescribed Folic Acid (N = 8644) Percent N = Methotrexate is an effective and frequently used medication for the treatment of rheumatoid arthritis. Long-term therapy is usually required for effective treatment. Methotrexate side effects are a common reason for discontinuation. A Cochrane Review 1 of 6 randomized controlled trials demonstrated that concomitant use of folic acid reduced gastrointestinal toxicity, abnormal transaminase elevation, and patient withdrawal symptoms from methotrexate with no reduction in efficacy. Use of folic acid should be considered in all patients with rheumatoid arthritis. More than 88% of patients were prescribed folic acid; a chart review of a subset of patients who did not receive a folic acid prescription showed frequent use of over the counter preparations. Reference 1. Shea B, Swinden MV, Tanjong Ghogomu E, Ortiz Z, Katchamart W, Rader T, Bombardier C, Wells GA, Tugwell P. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev. 213 May 31;5:CD951. Orthopaedic & Rheumatologic Institute 55

58 Immunodeficiency Percentage of Patients With HIV/AIDS Who Obtained Lab Tests per Recommended Guidelines (N = 85) Patients (%) Rapid Plasma Reagin Yearly Hepatitis B/C Screen at Baseline Patients with HIV/AIDS should have a rapid plasma reagin for syphilis yearly and screening for hepatitis B and C at the baseline visit. All patients had hepatitis screening at baseline, and 85% to 1% had screening for syphilis during These outcomes are based on guidelines prepared by the National Committee for Quality Assurance, HIV Medicine Association, Infectious Diseases Society of America, and HIV/AIDS Workgroup, and are the standard of care for HIV patients. Percentage of Patients With HIV/AIDS Who Obtained Lab Tests per Recommended Guidelines (N = 85) Patients (%) Viral Load < 4 Copies/mL Viral Load < 4 Copies/mL All Tests Tuberculosis Testing Patients with HIV/AIDS should have testing for tuberculosis at the baseline visit; 74% of patients in the cohort had tuberculosis testing in 213 and 88% in 214. The goal of treatment is viral suppression to a level < 4 copies/ml: 94% of patients had a documented viral load < 4 copies/ml in 213, and 99% in 214; 68% of patients had a viral load < 4 copies/ml on every test in 213, and 91% in 214. These outcomes are based on guidelines prepared by the National Committee for Quality Assurance, HIV Medicine Association, Infectious Diseases Society of America, and HIV/AIDS Workgroup, and are the standard of care for HIV patients. 56 Outcomes 214

59 Percentage of CVID Patients Who Meet Diagnostic, Evaluation, and Treatment Guidelines Patients (%) (N = 26) 214 (N = 5) 4 2 Low IgG and Low IgA or IgM B-Cell Subset Vaccination Testing PFT or CT LFT and Creatinine Immunoglobulin Treatment Trough IgG > 5 mg/dl CVID = common variable immunodeficiency, CT = computed tomography, LFT = liver function tests, PFT = pulmonary function testing The diagnosis of common variable immunodeficiency (CVID) requires low levels of IgG, low IgA or IgM, and poor response to vaccines. Replacement immunoglobulin therapy is recommended regardless of infectious history, and expert consensus suggests that trough levels be > 5 mg/dl to prevent infections. Pulmonary function testing (PFT) or a computed tomography (CT) scan of the chest, liver function tests (LFT), and creatinine levels are recommended as yearly follow-up testing. B-cell subsets are recommended at the time of diagnosis because of their value in predicting future clinical course. These current guidelines are based on expert panel recommendations formulated through the Immune Deficiency Foundation as well as published recommendations of experts in the field. Orthopaedic & Rheumatologic Institute 57

60 Psoriatic Arthritis Cardiovascular Risk in Psoriatic Arthritis Using Serum Paraoxonase and Arylesterase Activities (N =134) Arylesterase Activity (µmol/min/ml) 15 Paraoxonase Activity (nmol/min/ml) Healthy Controls < 1% 1% to 2% > 2% Healthy Controls < 1% 1% to 2% > 2% Framingham Risk Score Framingham Risk Score Psoriatic diseases are chronic inflammatory illnesses that affect both the skin and joints and are associated with increased cardiovascular (CV) morbidity and mortality not fully explained by known traditional CV risk factors. Inflammatory biomarkers such as C-reactive protein and erythrocyte sedimentation rate, which are traditionally used as measures of atherosclerotic burden, are confounded by systemic inflammatory disease. Research has shown that decreasing enzymatic activity of the paraoxonase-1 (PON- 1) family of high-density lipoprotein (HDL) associated antioxidant enzymes may be used as a measure of oxidative stress and serve as a surrogate for increased CV disease burden in patients with psoriatic disease. PON-1 enzymes promote the antiatherogenic and antiinflammatory properties of HDL. The PON-1 assays from 134 patients in the Cardiometabolic Outcome Measures in Psoriatic Arthritis Study (COMPASS) demonstrated decreasing antioxidant associated enzymatic activity with increased Framingham risk scores stratified into low (< 1%), intermediate (1% to 2%), and high (> 2%) risk for cardiovascular disease. This study will increase understanding of the accelerated pathogenesis of atherosclerosis in psoriatic disease and provide biomarkers to improve CV risk stratification and identify therapeutic targets for CV disease prevention. 58 Outcomes 214

61 Percentage of Psoriatic Arthritis Patients Taking Disease- Modifying Antirheumatic Drug Therapy (N = 2427) Percent N = American College of Rheumatology guidelines recommend that psoriatic arthritis patients be treated with diseasemodifying antirheumatic drug (DMARD) therapy. More than 99% of psoriatic arthritis patients who were seen in the Department of Rheumatology at least 2 times during the years 21, 211, 212, 213, and 214 were treated with DMARD therapy. Reasons for not prescribing DMARD therapy for the small percentage of patients not on DMARDs included disease remission, refusal of treatment, and contraindications to DMARD therapy. In any given year, between 88% and 95% of patients were on a DMARD. Treatment Patterns in Psoriatic and Rheumatoid Arthritis: Use of Biologic DMARDs Percent Biologic Only Nonbiologic Only Rheumatoid arthritis (N = 18,729) Psoriatic arthritis (N = 2427) Both DMARDs = disease-modifying antirheumatic drugs Neither A comparison was made of DMARD treatment patterns for rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Nonbiologic DMARDs are oral agents (methotrexate, leflunomide, azathioprine, sulfasalazine), while biologic DMARDs are subcutaneous or intravenous medications and are monoclonal antibodies targeting inflammatory cytokines or cells (tumor necrosis factors, IL-1, B-cell). A majority of RA and PsA patients received DMARD therapy (93% RA; 91% PsA). More patients with PsA received biologic plus nonbiologic DMARD combination therapy (2% RA; 3% PsA). Treatment patterns differed with nonbiologic DMARD monotherapy used in 68% of RA patients vs 37% of PsA patients. RA patients rarely (5%) received biologic DMARD monotherapy, which was provided to 25% of PsA patients. These outcomes represent DMARD therapy utilization in patients with RA and PsA seen at an academic health center, but may not be representative of general treatment patterns across the US because of clinical factors resulting in selection bias. These outcomes may provide valuable data on practice patterns that may inform clinical trials, decision-making in biologic choice, and differences in response to agents commonly used in RA and PsA treatment. Orthopaedic & Rheumatologic Institute 59

62 Psoriatic Arthritis Percentage of Newly Diagnosed Patients With Psoriatic Arthritis Starting Biologic DMARDs Who Had Tuberculosis Testing (N = 57) Percent Patients With Tuberculosis Testing DMARDs = disease-modifying antirheumatic drugs The 212 Update of the 28 American College of Rheumatology (ACR) Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents 1 recommends tuberculosis (TB) screening before using biologic agents to identify latent TB infection (LTBI). The ACR recommends the tuberculin skin test or interferon-γ release assays as the initial test in all patients starting biologic agents, regardless of risk factors for LTBI. One hundred percent (57 of 57) of newly diagnosed psoriatic arthritis patients in 213 and 214 had TB testing. Reference 1. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, Moreland LW, O Dell J, Winthrop KL, Beukelman T, Bridges SL Jr, Chatham WW, Paulus HE, Suarez- Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG. 212 update of the 28 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 212 May;64(5): Outcomes 214

63 Percentage of Psoriatic Arthritis Patients Treated With Methotrexate Who Were Prescribed Folic Acid (N = 763) Percent N = Methotrexate is an effective and frequently used medication for the treatment of psoriatic arthritis. Long-term therapy is usually required for effective treatment. Methotrexate side effects are a common reason for discontinuation. A Cochrane Review 1 of 6 randomized controlled trials in rheumatoid arthritis demonstrated that concomitant use of folic acid reduced gastrointestinal toxicity, abnormal transaminase elevation, and patient withdrawal symptoms from methotrexate with no reduction in efficacy. This recommendation is likely to apply to methotrexate use in other conditions such as psoriatic arthritis. More than 87% of patients were prescribed folic acid; a chart review of a subset of patients who did not receive a folic acid prescription showed frequent use of over the counter preparations. Reference 1. Shea B, Swinden MV, Tanjong Ghogomu E, Ortiz Z, Katchamart W, Rader T, Bombardier C, Wells GA, Tugwell P. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev. 213 May 31;5:CD951. Orthopaedic & Rheumatologic Institute 61

64 Vasculitis Idiopathic Aortitis (N = 196) Number of Patients N = Aortitis Biopsy Proven 196 Focal Isolated Aortitis 129 Giant Cell Arteritis 42 Takayasu Arteritis 14 Other 11 Idiopathic aortitis is a rare diagnosis that may occur in the context of a primary systemic vasculitis, as part of a systemic autoimmune disease, or in isolation. In patients with focal isolated aortitis (FIA), surgery alone may be curative. Although new vascular lesions may develop, the risk of progression to systemic disease is uncertain. Of 7551 patients who underwent thoracic aortic surgery between 1996 and 212, 196 had biopsy-proven aortitis: 129 had FIA, and the remainder had giant cell arteritis, Takayasu arteritis, and other systemic diseases. 62 Outcomes 214

65 Focal Isolated Aortitis (N = 73) Number of Patients N = Focal Isolated Aortitis 73 Progressed to Systemic Disease 23 Giant Cell Arteritis 21 Takayasu Arteritis 1 Other 1 For 73 patients with focal isolated aortitis (FIA), a minimum of 6 months of follow-up was available (median 45 months; range, 6 21 months). Twenty-three patients (31.5%) developed a systemic disease: giant cell arteritis in 21; Takayasu arteritis in 1; and other in 1. When compared with patients with known systemic disease at surgery, patients with FIA were less likely to develop symptoms (P =.1), but were no different with respect to development of inflammatory markers, new vascular lesions determined by imaging, need for further vascular surgery, aortic dissection, or likelihood of death. Orthopaedic & Rheumatologic Institute 63

66 Fibromyalgia Depression in Fibromyalgia Cohort (N = 35) Percent Mild (PHQ-9 5 9) Moderate (PHQ ) Moderate/Severe (PHQ ) Severe (PHQ-9 2) PHQ-9 = Patient Health Questionnaire Fibromyalgia (FM) is a biopsychosocial disorder with a prevalence of 2% to 4% in the general population. Both depression and bipolar disorder are reported to be increased in FM patients. Of 35 FM patients seen between 28 and 214, > 88% were diagnosed with depression (a score 5) based on the Patient Health Questionnaire (PHQ-9), with 59.7% having a moderate or greater level (PHQ-9 1). Bipolar Disorder in Fibromyalgia Cohort (N = 35) Percent Mood Disorder Questionnaire 7 Bipolar disorder, as measured with the Mood Disorder Questionnaire (MDQ 7), occurred with a 4-fold higher rate in FM patients than in the general population (16.4% vs 3.7%). 5 Fibromyalgia Cohort General Population 64 Outcomes 214

67 Effect of Depression on Bipolar Disorder in Fibromyalgia Cohort (N = 35) Percent None Bipolar disorder MDQ > 7 Mild (PHQ-9 5 9) Moderate Moderate/Severe (PHQ ) (PHQ ) Severe (PHQ-9 2) MDQ = Mood Disorder Questionnaire, PHQ-9 = Patient Health Questionnaire Patients with increasing severity of depression based on PHQ-9 scores had an increased frequency of bipolar disorder (MDQ > 7). Effect of Depression on Pain and Fatigue in Fibromyalgia Cohort (N = 35) Score FIQ pain FIQ fatigue 4 2 None Mild (PHQ-9 5 9) Moderate Moderate/Severe (PHQ ) (PHQ ) Severe (PHQ-9 2) FIQ = Fibromyalgia Impact Questionnaire, PHQ-9 = Patient Health Questionnaire Increasing levels of depression were associated with increasing prevalence of FM symptoms, including pain and fatigue, as measured with the Fibromyalgia Impact Questionnaire (FIQ). Orthopaedic & Rheumatologic Institute 65

68 Progressive Systemic Sclerosis Percentage of Patients With Progressive Systemic Sclerosis Who Obtained Yearly Pulmonary Function Testing and Echocardiograms (N = 867) Pulmonary Function Testing (%) Echocardiogram (%) Reference 1. Khanna D, Gladue H, Channick R, Chung L, Distler O, Furst DE, Hachulla E, Humbert M, Langleben D, Mathai SC, Saggar R, Visovatti S, Altorok N, Townsend W, FitzGerald J, McLaughlin VV; Scleroderma Foundation and Pulmonary Hypertension Association. Recommendations for screening and detection of connective tissue disease-associated pulmonary arterial hypertension. Arthritis Rheum. 213 Dec;65(12): The American College of Rheumatology provided guidelines for detection of pulmonary hypertension (PH) in connective tissue diseases, including progressive systemic sclerosis (PSS). 1 The key recommendation stated that all patients with PSS should be screened for PH with pulmonary function tests (PFTs), including single-breath diffusing capacity for carbon monoxide; transthoracic echocardiogram (echo); and measurement of N-terminal protein natriuretic peptide (NT-proBNP), performed annually. The percentage of patients having PFTs and echos ranged from 24% to 33% between 21 and 214. A chart review of 2 patients who did not obtain a PFT every year (5 PFTs years ) showed that 1 patient had morphea, 1 patient had PFTs performed outside Cleveland Clinic, 16 patients had 1 to 4 PFTs, and only 2 patients (1%) had no PFTs performed. A chart review of 2 patients who did not obtain an echo every year (5 echos years ) showed that 18 patients had 1 to 4 echos, 1 patient had systemic lupus erythematosus, and only 1 patient (5%) had no echo. It appears that most patients had a PFT or echo performed during the 5-year period; only a quarter had yearly testing. 66 Outcomes 214

69 Percentage of Scleroderma Patients With Gastroesophageal Reflux Disease Treated With Antisecretory Medications (N = 327) Percent Antisecretory Agent The American Gastroenterological Association Institute Medical Position Panel 1 recommends antisecretory drugs for the treatment of patients with gastroesophageal reflux disease syndromes, based on their ability to heal esophagitis and provide symptomatic relief. In these uses, proton pump inhibitors are more effective than histamine 2 receptor antagonists, which are more effective than placebo. This recommendation is graded A, strongly recommended based on good evidence that it improves important health outcomes. During 213 and 214, between 97.5% and 98.5% of patients were on antisecretory medications. Reference 1. Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM, Johnson SP, Allen J, Brill JV. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 28 Oct;135(4): Interstitial Lung Disease in Patients With Anti-PM-Scl Antibody (N = 42) Number of Patients N = PM-Scl Cohort 42 ILD 27 No ILD 15 ILD = interstitial lung disease, PM-Scl = anti-pm-scl antibody Patients with anti-pm-scl antibody (PM-Scl) can present with several phenotypes including polymyositis, dermatomyositis, progressive systemic sclerosis (PSS), scleromyositis, or sclera-dermatomyositis. Pulmonary artery hypertension (PAH) occurs in PSS but the incidence in patients with PM-Scl has not been rigorously examined. All patients with PAH were diagnosed by right-heart catheterization (RHC). Forty-two patients with PM-Scl were reviewed. Five (11.9%) had RHC-confirmed PAH. The incidence of PAH in PSS is 7.8% and in the general population is.15%. Of the 5 patients with PAH, 3 were mild (pulmonary artery pressure 25 4 mm Hg) and 2 were moderate (41 55 mm Hg). Of the 42 patients, 27 had interstitial lung disease and 4 had PAH. Patients with anti-pm-scl antibodies frequently have PAH and should be screened for its presence. Orthopaedic & Rheumatologic Institute 67

70 Progressive Systemic Sclerosis Pulmonary Artery Hypertension in Patients With Anti-PM-Scl Antibody (N = 42) Number of Patients PM-Scl PAH Mild PAH Moderate PAH Cohort (25 4 mm Hg) (41 55 mm Hg) N = PAH = pulmonary artery hypertension, PM-Scl = anti-pm-scl antibody 68 Outcomes 214

71 Reversible Cerebral Vasoconstriction Syndrome Long-Term Outcomes After Reversible Cerebral Vasoconstriction Syndrome Impact of Persistent Headache in a Cohort of Patients With Reversible Cerebral Vasoconstriction Syndrome (N = 35) 214 Number of Patients Headache Impact Test-6 Score < 55 Some/little/none Substantial 6 Severe Reversible cerebral vasoconstriction syndrome (RCVS) comprises a group of diverse conditions characterized by reversible multifocal narrowing of the cerebral arteries with no evidence of vasculitic brain pathology. RCVS is associated at presentation with acute-onset, severe, recurrent headaches, often termed thunderclap. Thunderclap headaches do not recur, but many patients develop persistent headaches. Of the RCVS cohort, 35 patients were evaluated for headaches after initial presentation using the Headache Impact Test (HIT-6 ), which measures the patient s ability to function in multiple situations. More than 5% of patients had persistent headaches that impacted their ability to function. Effect of Persistent Headache on Pain Using the European Quality of Life Questionnaire in Patients With Reversible Cerebral Vasoconstriction Syndrome (N = 4) 214 Percent Persistent headache No headache No Pain Slight Pain Moderate Pain Severe Pain Orthopaedic & Rheumatologic Institute 69

72 Reversible Cerebral Vasoconstriction Syndrome European Quality of Life Questionnaire in Patients With Reversible Cerebral Vasoconstriction Syndrome (N = 4) 214 Number of Patients Mobility Self-Care Leisure Pain Anxiety No problem Slight Mild Moderate Severe The European Quality of Life Questionnaire (EQ-5D ) is a standardized measure of health status and provides a simple measure of health for clinical appraisal. The EQ-5D is composed of 5 dimensions: mobility, self-care, leisure, pain, and anxiety. Each dimension has 5 levels. The majority of patients rated their health status as no problem although significant decline in quality of life occurred in some patients. Patients with persistent headache had significantly higher levels of generalized pain as measured with the EQ-5D. 7 Outcomes 214

73 Blood-Brain Barrier Disruption as Measured With Astrocyte Protein S1B in Reversible Cerebral Vasoconstriction Syndrome (N = 1) 214 ng/ml Control All RCVS Ischemic RCVS Hemorrhagic RCVS RCVS = reversible cerebral vasoconstriction syndrome The blood-brain barrier disruption has been linked to a variety of neurologic disorders. Astrocyte protein S1B is considered an important peripheral blood marker of disruption of the blood-brain barrier. S1B protein levels are elevated in patients with reversible cerebral vasoconstriction syndrome (RCVS) during the ictal phase vs controls. The lack of elevated levels with hemorrhagic vs ischemic RCVS may suggest a different mechanism of brain injury in the subsets of RCVS. Orthopaedic & Rheumatologic Institute 71

74 Osteoarthritis Quality of Life in Patients With Osteoarthritis and Obesity After Bariatric Surgery and Nonsurgical Weight Loss (N = 67) SF-36 Differences (Surgical vs Nonsurgical Patients) Physical Functioning (P =.3) General Health (P <.1) Physical Health Summary (P =.4) SF-36 = Short Form Health Survey Obesity is a strong risk factor for development and progression of knee osteoarthritis (OA). The potential benefits of massive weight loss, as seen after bariatric surgery, have not been well studied. The study objective was to examine whether massive weight loss after bariatric surgery is associated with improved OA symptoms and quality of life (QOL), compared with medical management alone in obese patients. A total of 15 patients were screened for clinical and radiographic evidence of OA within the Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial (27 211). The STAMPEDE trial examined the effects of bariatric surgery vs medical management alone in obese patients with diabetes: 1 patients received bariatric surgery (5 received sleeve gastrectomy and 5 received Roux-en-Y gastric bypass), and 5 patients were medically managed. QOL scores were collected before and 12 months after intervention. OA was defined by physician diagnosis at an office visit and/or radiographic evidence of OA (joint space narrowing and osteophytes) of the hip, knee, ankle, or foot. The change in 12-month postintervention Short Form Health Survey (SF-36) scores between the surgical group and the medically managed group were compared. Sixty-seven patients with OA had baseline and follow-up data available for review; 49 patients were in the surgery group and 18 patients were in the medical group. There was a statistically significant difference in body mass index (BMI) change, during 12 months, between the surgical group and the medical group (BMI 9.12 and 2.24, respectively). There was a significantly greater improvement in the surgical group compared with the medical group in SF-36 domains of physical functioning, general health, and overall physical health scores. There was no significant difference between the groups in pain or role physical scores. 72 Outcomes 214

75 Autoinflammatory Disease Outcomes in Patients With Phenotypes Suggestive of NOD2-Associated Autoinflammatory Disease (N = 143) Number of Patients Inflammatory Phenotype NOD2 + Genotype NAID Diagnosis N = NAID = NOD2-associated autoinflammatory disease, NOD2 = nucleotide-binding oligomerization domain containing 2 Percent Cutaneous Organ Involvement Fever Sicca Headache Arthritis Oral Ulcers Lymphadenopathy Autoinflammatory diseases are characterized by episodes of inflammation, without high titers of autoantibodies, and derive from genetic variants of the innate immune system. Nucleotide oligomerization domain containing 2 (NOD2) is the coding region for a family of intracellular proteins that play an essential role in apoptosis, necrosis, and inflammation. NOD2 sequence variants are associated with Crohn s disease, Blau syndrome, and NOD2 autoinflammatory disease (NAID). The cohort of patients had clinical phenotypes suggestive of NAID, based on periodic disease occurrence and recurrent fever of unknown origin and/or dermatitis (N = 143). Sixty-seven patients (47%) were found to have 1 or more NOD2 variants, and 54 of 67 patients (81%) had NAID. The clinical manifestations included cutaneous erythematous patches and plaques; oligoarthritis/polyarthritis/arthralgia; recurrent fever; organ involvement, most often gastrointestinal; and sicca-like symptoms. NOD2-associated autoinflammatory disease is an emerging entity that is a genetically multisystem disease frequently associated with NOD2 genetic variants and may be more common than previously thought. Orthopaedic & Rheumatologic Institute 73

76 Infusion Center Infusion Reactions in Patients Treated With Biologic and Nonbiologic Therapies in a Rheumatology Infusion Center Percent (N = 2826) 214 (N = 2835).4.2. N = Mild Moderate Severe The Rheumatology Infusion Center administered 2826 infusions in 213 and 2835 infusions in 214. Both biologic and nonbiologic medications were used to treat a large number of rheumatic diseases. Infusion reactions can be serious complications and require established protocols to guarantee appropriate premedication, infusion rates, and treatment for drug reactions to ensure patient safety. In 213, reactions occurred in 48 of 2826 infusions (1.7%), and were mild in 19, moderate in 28, and severe in 1 infusion. In 214, reactions occurred in 5 of 2835 infusions (1.8%), and were mild in 5, moderate in 43, and severe in 2 infusions. Only 1 patient was not able to complete his infusion (.35%) in both 213 and Outcomes 214

77 Patient Experience in a Rheumatology Infusion Center (N = 1) 214 Likert Scale ( 5) Infusion Staff Preinfusion Visit Infusion Center Process Infusions for patients with rheumatic diseases are performed in an 8-bed Rheumatology Infusion Center. In 214, there were > 28 infusions. A patient questionnaire was given to 1 consecutive patients using a 1 5 scale (1 = poor, 5 = outstanding), requesting their experience in 4 domains: infusion staff (helpful, communication, coordinated care, expertise, responsiveness), preinfusion visit (provider explanation of infusion, education, waiting room, wait-time, provider visit, transition to infusion center), infusion center (comfort, amenities, privacy, design, experience), and process (ease of check-in, scheduling, parking). Infusion staff scored 4.99, preinfusion visit scored 4.93, infusion center scored 4.9, and process scored Most negative comments related to the process (especially parking). Patient questionnaires are important tools to assess and improve the experience for patients who often have serious and sometimes life-threatening rheumatic diseases. Orthopaedic & Rheumatologic Institute 75

78 Patient Experience Orthopaedic & Rheumatologic Institute Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care. Outpatient Office Visit Survey Orthopaedic & Rheumatologic Institute CG-CAHPS Assessment a Percent Best Response (N = 5161) 214 (N = 1,253) CG-CAHPS 213 database average (all practices) b 2 Appointment Access (% Always) c Doctor Communication (% Yes, Definitely) d a In 213, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the CG-CAHPS database from 2172 medical practices in 213. c Response options: Always, Usually, Sometimes, Never d Response options: Yes, definitely; Yes, somewhat; No e Response options: Yes, No Source: Press Ganey, a national hospital survey vendor Doctor Rating (% 9 or 1) 1 Scale Clerical Staff (% Yes, Definitely) d Test Results Communication (% Yes) e 76 Outcomes 214

79 Inpatient Survey Orthopaedic & Rheumatologic Institute HCAHPS Overall Assessment Best Response (%) Hospital Rating (% 9 or 1) 1 Scale Recommend Hospital (% Definitely Yes) b a Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare b Response options: Definitely yes, Probably yes, Probably no, Definitely no Source: Press Ganey, a national hospital survey vendor 213 (N = 535) 214 (N = 63) National average all patients a The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/ hospitalcompare. HCAHPS Domains of Care a Best Response (%) (N = 535) 214 (N = 63) National average all patients b Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Quiet at Night Source: Press Ganey, a national hospital survey vendor b Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare Orthopaedic & Rheumatologic Institute 77

80 Cleveland Clinic Implementing Value-Based Care Overview Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing 3 goals: improving the patient experience of care (including quality and satisfaction), improving population health, and reducing the cost of healthcare. The following measures are examples of 214 focus areas in pursuit of this 3-part aim. Throughout this section, Cleveland Clinic refers to the academic medical center or main campus, and those results are shown. Real-time dashboard data are leveraged in each Cleveland Clinic location to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels and support improved care in all clinical locations. Improve the Patient Experience of Care Cleveland Clinic Overall Mortality Observed/Expected Ratio O/E Ratio Cleveland Clinic Central Line-Associated Bloodstream Infection ICU Rate per 1 Line Days Rate per 1 Line Days 2.5 Cleveland Clinic Cleveland Clinic target Cleveland Clinic Cleveland Clinic target Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Data from the UHC Clinical Data Base/Resource Manager TM used by permission of UHC. All rights reserved. Cleveland Clinic s observed/expected (O/E) mortality ratio outperformed its internal target derived from the University HealthSystem Consortium (UHC) 214 risk model. Ratios less than 1. indicate mortality performance better than expected in UHC s risk adjustment model.. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSI), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews of every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population. 78 Outcomes 214

81 Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1 Eligible Patients Rate per 1 Patients Q1 Cleveland Clinic Cleveland Clinic target Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Data from the UHC Clinical Data Base/Resource Manager TM used by permission of UHC. All rights reserved. Improved screening, risk adjustment, and prevention strategies have supported Cleveland Clinic s continued improvement with respect to perioperative pulmonary embolism and deep vein thrombosis (AHRQ Patient Safety Indicator 12). Embolism/thrombosis prevention remains a safety priority for Cleveland Clinic in 215. Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult) Percent Q1 Cleveland Clinic NDNQI 5 th percentile (academic medical centers) Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Data reported from the National Database for Nursing Quality Indicators (NDNQI) with permission from Press Ganey. A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing position on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning help while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur. Orthopaedic & Rheumatologic Institute 79

82 Cleveland Clinic Implementing Value-Based Care Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care. Outpatient Office Visit Survey Cleveland Clinic CG-CAHPS Assessment a Best Response (%) (N = 64,792) 214 (N = 124,521) CG-CAHPS 213 database average (all practices) b Appointment Access (% Always) c a In 213, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 213 c Response options: Always, Usually, Sometimes, Never d Response options: Yes, definitely; Yes, somewhat; No e Response options: Yes, No Source: Press Ganey, a national hospital survey vendor Primary Care Specialty Care Doctor Communication (% Always) c (% Yes, Definitely) d Doctor Rating (% 9 or 1) 1 Scale Clerical Staff (% Yes, Definitely) d Test Results Communication (% Yes) e 8

83 Inpatient Survey Cleveland Clinic HCAHPS Overall Assessment Best Response (%) Hospital Rating (% 9 or 1) 1 Scale Recommend Hospital (% Definitely Yes) b a Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare b Response options: Definitely yes, Probably yes, Probably no, Definitely no Source: Press Ganey, a national hospital survey vendor 213 (N = 1,73) 214 (N = 1,369) National average all patients a The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/ hospitalcompare. HCAHPS Domains of Care a Best Response (%) (N = 1,73) 214 (N = 1,369) National average all patients b Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Quiet at Night Source: Press Ganey, a national hospital survey vendor b Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare 81

84 Cleveland Clinic Implementing Value-Based Care Focus on Value Cleveland Clinic is developing and implementing new models of care that focus on Patients First and aim to deliver on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new models of Value-Based Care is a strategic priority for Cleveland Clinic. As care delivery shifts from fee-for-service to a population health and bundled payment delivery system, Cleveland Clinic is focused on concurrently improving patient safety, outcomes, and experience. What does this new model of care look like? Integrated Care Model Retail Venues Home Community-Based Organizations Care System Outpatient Clinics Post-Acute (other) Emergency Independent Physician Offices Skilled Nursing Facilities MyChart Rehabilitation Facilities Ambulatory Diagnosis & Treatment Hospitals The Cleveland Clinic Integrated Care Model (CCICM) is a value-based model of care, designed to improve outcomes while reducing cost. It is designed to deliver value in both population health and specialty care. The patient remains at the heart of the CCICM. The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in different settings. The care system represents integration of care across the continuum. Critical competencies are required to build this new care system. Cleveland Clinic is creating disease- and condition-specific care paths for a variety of procedures and chronic diseases. Another facet is implementing comprehensive care coordination for high-risk patients to prevent unnecessary hospitalizations and emergency department visits. Efforts include managing transitions in care, optimizing access and flow for patients through the CCICM, and developing novel tactics to engage patients and caregivers in this work. Measuring performance around quality, safety, utilization, cost, appropriateness of care, and patient and caregiver experience is an essential component of this work. 82

85 Improve Population Health Select Accountable Care Organization Performance Measures Measure a 215 ACO 9 th percentile b Lower is better Cleveland Clinic 214 Cleveland Clinic Performance (%) Goal a (%) Pneumococcal vaccination Colorectal cancer screening Mammography screening Hemoglobin b A1c > 9% Hypertension control As part of Cleveland Clinic s commitment to population health and in support of its newly certified Accountable Care Organization (ACO), these primary care ACO measures have been prioritized for monitoring and improvement. Cleveland Clinic is improving performance in these measures through enhanced care coordination, optimizing technology and information systems, and engaging primary care physicians and specialists directly in the improvement work. These pursuits are part of Cleveland Clinic s overall strategy to transform care in order to improve health and make care more affordable. Reduce the Cost of Care Cleveland Clinic All-Cause 3-Day Readmission Rate to Any Cleveland Clinic Hospital Percent of Discharges N a = Q1 CMI = case mix index a Total discharges Cleveland Clinic rate Cleveland Clinic CMI UHC academic medical centers CMI Case Mix Index 3. Q2 Q3 Q4 Q1 Q2 Q3 Q , ,755 Source: Data from the UHC Clinical Data Base/Resource Manager TM used by permission of UHC. All rights reserved. Cleveland Clinic monitors 3-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Strategies associated with communication, education, and follow-up have been implemented for several high-risk conditions, including heart failure and pneumonia. These practices are being expanded and enhanced to reduce overall avoidable readmissions. Sicker, more complex patients are more susceptible to readmission. Case mix index (CMI) reflects patient severity of illness and resource utilization. Cleveland Clinic s CMI remains one of the highest among American academic medical centers

86 Innovations Abatacept (CTLA4-Ig) for the Treatment of Relapsing, Nonsevere, Granulomatosis With Polyangiitis (Wegener s) (ABROGATE) Relapses occur in over 5% of patients with granulomatosis with polyangiitis (Wegener s) (GPA), which can result in organ damage and require long-term glucocorticoid therapy. There is an unmet need to identify treatment options for nonsevere relapsing GPA. An open-label trial of abatacept funded by the National Institutes of Health was conducted by the Vasculitis Clinical Research Consortium (VCRC). In this study of 2 patients with nonsevere relapsing GPA, abatacept was well tolerated and led to disease remission and reduction in glucocorticoids in a large percentage of patients. Based on these results, an international multicenter, randomized, double-blind, placebo-controlled trial to evaluate the efficacy of abatacept in patients with relapsing nonsevere GPA will start in 215. This trial will be conducted collaboratively by the VCRC and the European Vasculitis Society (EUVAS). Screening for Eligibility Randomized Treatment Period Prednisone + Continued maintenance + Abatacept or Placebo Remissioni Nonsevere ere relapse Nonsevere worsening No remission Month 6 Severe relapse Open Label Extension Period Prednisone + Continued maintenance + Abatacept Early Termination or Common Close 84 Outcomes 214

87 Managing Comorbidities of Psoriatic Arthritis: New Guidelines Provide First Expert Recommendations To provide comprehensive care to patients with psoriatic arthritis (PsA), clinicians must be aware of pertinent multiple comorbidities and extraarticular/cutaneous manifestations. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) updated its 29 treatment guidelines with a section on managing comorbidities and extraarticular manifestations in patients with PsA. 1 Evidence-based recommendations from systematic literature reviews focused on the more common comorbidities and their impact on treatment of PsA. 2 These include: Cardiovascular disease 3 Obesity, metabolic syndrome, and diabetes 3 Inflammatory bowel disease Autoimmune ophthalmic disease Osteoporosis (increased prevalence in PsA patients) Liver disease (particularly nonalcoholic fatty liver disease) Kidney disease Concomitant circumstances common in PsA include chronic viral infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus) and vaccinations. References 1. Ogdie A, Schwartzman S, Eder L, Maharaj AB, Zisman D, Raychaudhuri SP, Reddy SM, Husni E. Comprehensive treatment of psoriatic arthritis: managing comorbidities and extraarticular manifestations. J Rheumatol. 214 Nov;41(11): Ogdie A, Schwartzman S, Husni ME. Recognizing and managing comorbidities in psoriatic arthritis. Curr Opin Rheumatol. 215 Mar;27(2): Lin YC, Dalal D, Churton S, Brennan DM, Korman NJ, Kim ES, Husni ME. Relationship between metabolic syndrome and carotid intima-media thickness: cross-sectional comparison between psoriasis and psoriatic arthritis. Arthritis Care Res (Hoboken). 214 Jan;66(1): Orthopaedic & Rheumatologic Institute 85

88 Innovations Analysis of Cytokine Profiles in the Diagnosis of Periprosthetic Joint Infections of the Shoulder Improved diagnosis of shoulder periprosthetic joint infection (PJI) will lead to better decision-making regarding treatment in revision surgery. This study evaluated the efficacy of synovial fluid cytokine analysis in the diagnosis of shoulder PJI. Nine proinflammatory cytokines were measured in synovial fluid obtained from 37 patients undergoing revision shoulder arthroplasty, using an immunoassay technique. All cytokines showed increasing levels as the likelihood of infection increased. GM-CSF and IL-1ß demonstrated the strongest correlations; IL-6 and IL-8 showed the largest magnitude of elevations. Synovial fluid cytokine profile analysis may improve the diagnostic accuracy of shoulder PJI and may help guide treatment decision-making. This work has been selected for the 215 Charles S. Neer Award in Basic Science Research. Synovial Fluid Cytokine Levels by Infection Category Mean Level Log Scale (ng/ml) 1, 1, No infection Probable infection Definite infection GM-CSF IFN- TNF- IL-1 IL-2 IL-6 IL-8 IL-1 IL-12 Mean synovial fluid cytokine levels (ng/ml) based on infection category. The white numeric ratios represent the Kendall tau rank correlation for the association between infection category and each cytokine. 86 Outcomes 214

89 NOD2-Associated Autoinflammatory Disease (NAID) an Emerging Disorder: Insights From the Largest Published Cohort Study NAID Essentials NOD2 refers to the nucleotide-binding oligomerization domain containing a member of a gene family that encodes intracellular proteins with N-terminal caspase recruitment domains (CARDs) involved in the inflammatory response and apoptosis. NOD2 genetic variants are associated with Crohn s disease, Blau syndrome, and NAID. A new category of autoinflammatory disease associated with NOD2 gene mutations, designated as NAID, was previously reported that is characterized by periodic fever, dermatitis, polyarthritis, and sicca-like and gastrointestinal symptoms. A large cohort study 1 has recently underscored the association between the new entity and certain NOD2 genetic mutations (IVS and/or R72W). NAID is a new disorder, and its clinical phenotype and genotypic profile are distinct from Crohn s disease and Blau syndrome. Reference 1. Yao Q, Myles J, Shen B, McDonald C. NOD2-associated autoinflammatory disease: an exploratory study of its pathogenesis. Rheumatology (Oxford). 214 May;53(5): Schematic representation of the NOD2 gene and protein structures. Coding exons are represented by blocks connected with lines representing introns. (See text for abbreviation expansions.) Orthopaedic & Rheumatologic Institute 87

90 Contact Information Orthopaedic & Rheumatologic Institute Appointments or , ext Orthopaedic & Rheumatologic Institute Referrals 855.REFER.123 ( ) On the Web at clevelandclinic.org/orthorheum Staff Listing For a complete listing of Cleveland Clinic s Orthopaedic & Rheumatologic Institute staff, please visit clevelandclinic.org/staff. Publications Orthopaedic & Rheumatologic Institute staff authored 214 publications in 214. For a complete list, go to clevelandclinic.org/outcomes. Locations For a complete listing of Orthopaedic & Rheumatologic Institute locations, please visit clevelandclinic.org/orthorheum. 88 Outcomes 214

91 Institute Overview Additional Contact Information General Patient Referral 24/7 hospital transfers or physician consults General Information Hospital Patient Information General Patient Appointments or Referring Physician Center and Hotline 855.REFER.123 ( ) Or or visit clevelandclinic.org/refer123 Request for Medical Records or , ext Same-Day Appointments CARE (2273) Global Patient Services/ International Center Complimentary assistance for international patients and families or visit clevelandclinic.org/gps Medical Concierge Complimentary assistance for out-of-state patients and families , ext. 5558, or Cleveland Clinic Abu Dhabi clevelandclinicabudhabi.ae Cleveland Clinic Canada Cleveland Clinic Florida Cleveland Clinic Nevada For address corrections or changes, please call Orthopaedic & Rheumatologic Institute 89

92 About Cleveland Clinic 9 Overview Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 32 Cleveland Clinic staff physicians and scientists in 13 medical specialties and subspecialties care for more than 5.9 million patients across the system, performing more than 192, surgeries and conducting more than 497, emergency department visits. Patients come to Cleveland Clinic from all 5 states and more than 147 nations. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 14- bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 42 buildings on 165 acres. Cleveland Clinic s CMS case-mix index is the second highest in the nation. Cleveland Clinic encompasses more than 9 northern Ohio outpatient locations, including 18 full-service family health centers, 8 regional hospitals, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida; Cleveland Clinic Nevada, which includes the Lou Ruvo Center for Brain Health in Las Vegas, and urology and nephrology services; Cleveland Clinic Canada; and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu Dhabi is a full-service hospital and outpatient center in the United Arab Emirates (UAE), which began offering services in spring 215. Cleveland Clinic is the second-largest employer in Ohio, with more than 42,5 employees. It generates $12.6 billion of economic activity a year. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Canada, China, the Dominican Republic, El Salvador, Guatemala, Honduras, Panama, Peru, Saudi Arabia, Turkey, UAE, and the United Kingdom. The Cleveland Clinic Model Cleveland Clinic was founded in 1921 by 4 physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education. The Cleveland Clinic health system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 199s with the development of 18 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and 6 other regional hospitals have joined Cleveland Clinic over the past 2 decades, offering Cleveland Clinic institute services in heart and neurological care, physical rehabilitation, and more. Clinical and support services were reorganized into 27 patient-centered institutes beginning in 27. Institutes combine medical and surgical specialists for specific diseases or organ systems under unified leadership and in a shared location to provide optimal team care for every patient. Institutes work with the Office of Patient Experience to give every patient the best outcome and experience. A Clinically Integrated Network Cleveland Clinic is committed to providing value-based care, and it has grown the Cleveland Clinic Quality Alliance into the nation s second-largest and Northeast Ohio s largest clinically integrated network. The network comprises more than 54 physician members, both employed and independent physicians from the community. Led by its physician members, the Quality Alliance strives to improve quality and consistency of care; reduce costs and increase efficiency; and provide access to expertise, data, and experience. Outcomes 214

93 Cleveland Clinic Lerner College of Medicine Lerner College of Medicine is known for its small class sizes, unique curriculum, and full-tuition scholarships for all students. Each new class accepts 32 students who are preparing to be physician investigators. Cleveland Clinic is building a multidisciplinary Health Education Campus as the new home of the Case Western Reserve University (CWRU) School of Medicine and Cleveland Clinic s Lerner College of Medicine, as well as the CWRU School of Dental Medicine, the Frances Payne Bolton School of Nursing, and physician assistant and allied health training programs. Graduate Medical Education In 214, nearly 18 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, which is part of a continuing upward trend. U.S. News & World Report Ranking Cleveland Clinic is consistently ranked among the top hospitals in America by U.S. News & World Report. It is ranked No. 1 in urology and has ranked No. 1 in heart care and heart surgery since In 214, 4 of its programs were ranked No. 2 in the nation: diabetes and endocrinology, gastroenterology and GI surgery, nephrology, and rheumatology. For more information about Cleveland Clinic, please visit clevelandclinic.org. Cleveland Clinic Physician Ratings At Cleveland Clinic, we believe in transparency. We also believe in the positive influence of the physician-patient relationship on healthcare outcomes. To continue to meet the highest standards of patient satisfaction, we now publish Cleveland Clinic physician ratings, based on nationally recognized Press Ganey patient satisfaction surveys, online at clevelandclinic.org/staff. Orthopaedic & Rheumatologic Institute 91

94 Resources Referring Physician Center and Hotline Call 24/7 for access to medical services or to schedule patient appointments: 855.REFER.123 ( ), or go to clevelandclinic.org/refer123. The free Cleveland Clinic Physician Referral App, available for mobile devices, gives you 1-click access. Available at the App Store or Google Play. Remote Consults Anybody anywhere can get an online second opinion from a Cleveland Clinic specialist through our MyConsult service. For more information, go to clevelandclinic. org/myconsult, eclevelandclinic.org, or call , ext Request Medical Records or , ext Track Your Patients Care Online Cleveland Clinic offers an array of secure online services that allow referring physicians to monitor their patients treatment while under Cleveland Clinic care, as well as access test results, medications, and treatment plans. my.clevelandclinic.org/online-services DrConnect (online access to patients treatment progress while under referred care): ; drconnect@ ccf.org MyPractice Community (affordable electronic medical records system for physicians in private practice): eradiology (teleradiology consultation provided nationwide by board-certified radiologists with specialty training, within 24 hours or stat): ; starimaging@ccf.org Medical Records Online Patients can view portions of their medical record, receive diagnostic images and test results, make appointments, and renew prescriptions through MyChart, a secure online portal. All new Cleveland Clinic patients are automatically registered for MyChart. clevelandclinic.org/mychart Critical Care Transport Worldwide Cleveland Clinic s fleet of ground and air transport vehicles is ready to transfer patients at any level of acuity anywhere on earth. Specially trained crews provide Cleveland Clinic care protocols from first contact. To arrange a transfer for STEMI (ST-elevation myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call CODE (2633). For all other critical care transfers, call or CME Opportunities: Live and Online Cleveland Clinic s Center for Continuing Education operates the largest CME program in the country. Live courses are offered in Cleveland and cities around the nation and the world. The center s website (ccfcme.org) is an educational resource for healthcare providers and the public. It has a calendar of upcoming courses, online programs on topics in 3 areas, and the award-winning virtual textbook of medicine, The Disease Management Project. Clinical Trials Cleveland Clinic is running more than 21 clinical trials at any given time for conditions including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. Cancer Clinical Trials is a mobile app that provides information on the more than 1 active clinical trials available to cancer patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp. 92 Outcomes 214

95 Healthcare Executive Education Cleveland Clinic has programs to teach people from outside the organization how it operates a major medical center. The Executive Visitors Program is an intensive 3-day behind-the-scenes es view of the Cleveland Clinic organization for the busy executive. The Samson Global Leadership Academy is a 2-week immersion in challenges of leadership, management, and innovation taught by Cleveland Clinic leaders, administrators, and clinicians. Curriculum includes coaching and a personalized 3-year leadership development plan. Learn more at clevelandclinic.org/executiveeducation. Consult QD Physician Blog A singular blog for physicians and healthcare professionals from Cleveland Clinic. Discover the latest research insights, innovations, treatment t trends, and more for all specialties. Join the conversation: consultqd.clevelandclinic.org. Social Media Cleveland Clinic uses social media to help caregivers everywhere provide better patient care. Millions of people currently like, friend, or link to Cleveland Clinic social media including ng leaders in medicine. Facebook for Medical Professionals facebook.com/cmeclevelandclinic Follow us on Connect with us on LinkedIn Clevelandclinic.org/Mdlinkedin Orthopaedic & Rheumatologic Institute 93