Orthopaedic & Rheumatologic Institute Outcomes

Transcription

1 Orthopaedic & Rheumatologic Institute 213 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 data on patient volumes and outcomes 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) Ohio Department of Health (ohiohospitalcompare.ohio.gov) 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 our Outcomes books, please visit Cleveland Clinic s Quality and Patient Safety Institute website at clevelandclinic.org/outcomes.

4 Dear Colleague: Welcome to this 213 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 a summary 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 around 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 reports has received favorable notice from colleagues and healthcare observers. 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 Orthopaedic Surgery 2 Rheumatology Overview 32 Surgical Quality Improvement 72 Institute Patient Experience 74 Cleveland Clinic Implementing Value-Based Care 76 Innovations 82 Contact Information 92 About Cleveland Clinic 94 Resources 96 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.

6 Chairman s Letter Dear Colleagues, I am pleased to share 213 Outcomes for Cleveland Clinic s Orthopaedic & Rheumatologic Institute. This book provides an overview of our ongoing work in measuring our patients health and functional outcomes following the full spectrum of surgical procedures and nonsurgical treatments. We are committed to the best outcomes for patients and continually strive to do things in new and better ways. The year 213 was an exciting year for research and innovation for the institute. Some of our major advancements include: Orthopaedic Surgery has 65 active externally funded research projects underway. Collectively, they represent nearly $5 million in total research support. More than $24 million to support musculoskeletal and connective tissue research comes from the National Institutes of Health funding, which is spread across 23 active extramural NIH studies. We have launched the National Orthopaedic & Spine Alliance LLC. This national network of bone, joint and spine specialists will contract directly with large employers to provide surgical care for their workers. We are developing an interactive visual health record (ivhr) to extrapolate data from the EMR so that physicians can work more efficiently with patient data. Euclid Hospital, a Cleveland Clinic community hospital, is collaborating with the Centers for Medicare & Medicaid Services to deliver innovative care in the Bundled Payments for Joint Replacement project. We welcome your feedback, questions and ideas for collaboration. Please contact me via at OutcomesBooksFeedback@ccf.org and reference the Orthopaedic & Rheumatologic Institute book in your message. Sincerely, Joseph Iannotti, MD, PhD Chair, Orthopaedic & Rheumatologic Institute 4 Outcomes 213

7 Institute Overview This year s Outcomes book profiles the clinical outcomes of patients treated by the institute s caregivers in 213. Patients with the most complex clinical problems from around the nation and the world come to us for care and expert opinions. We are proud that these outcomes contributed to Cleveland Clinic s ranking among the nation s top two rheumatology programs and top three orthopaedics programs in U.S. News & World Report s America s Best Hospitals survey for cultivation of new knowledge and innovation through basic science and clinical research. Its clinical research center includes 32 faculty and 14 full-time and nine part-time support staff. Some of these individuals are responsible for the collection, management, and analysis of the data in this book. The institute is composed of Orthopaedic Surgery, Rheumatic and Immunologic Diseases, Musculoskeletal Physical Medicine and Rehabilitation, and Orthotics and Prosthetics. Current full-time faculty include 6 orthopaedic surgeons (54 orthopaedic; six spine), 32 rheumatologists, 12 musculoskeletal radiologists, nine podiatrists, 1 sports and exercise medicine physicians, five medical orthopaedists, and three physiatrists (PM&R physicians). The institute also is dedicated to educating and training residents and fellows as well as colleagues at Cleveland Clinic and beyond. Its goal is to select and train individuals committed to contributing to the fields of orthopaedics and rheumatology through teaching and research. Similarly, the institute is dedicated to the Total clinic visits 485,362 Total surgeries 21, 213 clinical research funding level $2,652,865 Orthopaedic & Rheumatologic Institute 5

8 Orthopaedics Overview Adult Shoulder Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Inpatients, % Length of Stay, Days Discharged Home, % Open Surgery Total shoulder arthroplasty /49 51/ osteoarthritis /46 51/ other reasons /75 48/ Reverse total shoulder arthroplasty /62 38/ Hemiarthroplasty /47 65/ Revision of total shoulder arthroplasty /48 47/ Rotator cuff repair /43 61/ Capsulorrhaphy /29 79/ Biceps tenodesis /27 89/ Fracture treatment /5 52/ proximal humerus /7 33/ clavicle /26 83/ Other treatment /42 54/ Arthroscopic Surgery Rotator cuff repair /38 62/ Capsulorrhaphy /26 71/ Biceps tenodesis /39 7/ SLAP a repair /18 77/ Subacromial decompression /41 5/ Debridement /36 63/ Other treatment /36 52/ Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. a 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 Inpatients, %: percentage of inpatient surgeries 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 213

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 a repair Subacromial decompression Debridement Other treatment Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. a 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, % Inpatients, % Length of Stay, Days Discharged Home, % Open Surgery Total elbow arthroplasty /77 2/ Ulnar nerve neuroplasty at elbow /43 55/ Elbow tenotomy /52 47/ Distal bicep repair /5 97/ Carpal tunnel release /63 37/ without distal radial fracture /63 37/ with distal radial fracture /73 25/ Wrist arthrodesis /39 7/ Hand arthroplasty /78 17/ Palmar fasciectomy /26 88/ De Quervain's release /83 23/ Trigger finger release /65 38/ Finger arthrodesis /66 41/ Finger amputation /31 71/ Fracture treatment /54 45/ humeral shaft /67 42/ distal humerus /68 43/ radial head proximal ulna /55 28/ radial or ulnar shaft /52 46/ distal radius /73 27/ scaphoid /42 69/ hand or finger /3 62/ Mass excision /63 41/ Other treatment /42 62/ Arthroscopic Surgery Elbow treatment /2 96/ Wrist treatment /51 35/ Other treatment 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 Inpatients, %: percentage of inpatient surgeries 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 213

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 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, % Inpatients, % Length of Stay, Days Discharged Home, % Open Surgery Hip resurfacing /29 74/ Total hip arthroplasty /55 46/ osteoarthritis /55 44/ rheumatoid arthritis /79 18/ avascular necrosis /42 59/ other reasons (eg, fracture) /66 56/ Conversion to total hip arthroplasty /51 6/ Hemiarthroplasty /66 47/ Revision of total hip arthroplasty /52 41/ infection /42 55/ other reasons /54 37/ Treatment of hip or pelvis fracture /69 31/ Other treatment /56 49/ Arthroscopic Surgery Treatment of labral tear /65 26/ without osteoarthritis /66 26/ with osteoarthritis /6 33/ Other treatment /63 47/ 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 Inpatients, %: percentage of inpatient surgeries 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 213

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 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) Orthopaedic & Rheumatologic Institute 11

14 Orthopaedics Overview Adult Knee Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Inpatients, % Length of Stay, Days Discharged Home, % Open Surgery Unilateral total knee arthroplasty /63 39/ osteoarthritis /62 39/ rheumatoid arthritis /8 31/ avascular necrosis /81 3/ other reasons /46 29/ Bilateral total knee arthroplasty /6 44/ Partial knee arthroplasty /53 4/ Revision of total knee arthroplasty /57 4/ infection /47 44/ other reasons /6 39/ Treatment of periarticular knee fracture /65 41/ Other treatment /49 57/ Arthroscopic Surgery ACL reconstruction /38 67/ Meniscectomy /45 52/ meniscus injury without osteoarthritis /42 57/ meniscus injury with osteoarthritis /48 49/ other reasons /53 26/ Meniscus repair /35 59/ Chondroplasty /54 39/ Other treatment /55 47/ 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 Inpatients, %: percentage of inpatient surgeries 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 213

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 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) Orthopaedic & Rheumatologic Institute 13

16 Orthopaedics Overview Adult Foot and Ankle Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Inpatients, % Length of Stay, Days Discharged Home, % Open Surgery Total ankle arthroplasty /48 73/ Ankle arthrodesis /46 55/ osteoarthritis /48 55/ rheumatoid arthritis traumatic injury /42 47/ other reasons /35 61/ Achilles tendon treatment /29 63/ acute rupture repair /22 72/ chronic reconstruction /55 29/ Foot arthrodesis /64 36/ osteoarthritis /67 45/ rheumatoid arthritis deformity /65 31/ other reasons /57 31/ Flat foot or cavus foot correction /82 19/ Big toe arthrodesis /8 23/ osteoarthritis /78 23/ rheumatoid arthritis /94 9/ deformity /8 25/ other reasons Cheilectomy /67 3/ Bunion correction /88 7/ Hammertoe correction /78 17/ Bunion and hammertoe correction /93 16/ Fracture treatment /54 48/ tibia or fibula /45 54/ ankle /65 4/ foot or toes /48 51/ Amputation /4 68/ below knee /37 65/ foot /38 7/ toes /43 68/ Excision of leg or ankle tumor /59 55/ Excision of foot or toe tumor /7 34/ Other treatment /6 39/ Arthroscopic Surgery Osteochondritis dissecans lesion repair /49 52/ Other treatment /56 42/ 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 Inpatients, %: percentage of inpatient surgeries 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 14 Outcomes 213

17 Procedure In-Hospital Mortality, % 3-Day Readmission Rate, % 3-Day Reoperation Rate, % Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. 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 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) 15

18 Orthopaedics Overview Pediatric Shoulder and Hand/Upper Extremity Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Inpatients, % Length of Stay, Days Discharged Home, % Open Shoulder Surgery Capsulorrhaphy Treatment of shoulder fracture Other treatment Arthroscopic Shoulder Surgery Capsulorrhaphy /22 75/ SLAP a repair /22 1/ Other treatment Open Hand/U.E. Surgery Trigger finger release Fracture treatment /34 65/ humeral shaft /48 53/ distal humerus radial head proximal ulna radial or ulnar shaft /34 72/ distal radius /29 77/ scaphoid hand or finger /28 73/ Mass excision Other treatment /39 57/ Arthroscopic Hand/U.E. Surgery 6 2 Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. a 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 Inpatients, %: percentage of inpatient surgeries 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 213

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 a repair Other treatment Open Hand/U.E. 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/U.E. Surgery Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. a 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 17

20 Orthopaedics Overview Pediatric Hip, Knee, and Foot/Ankle Surgery, Procedure Yearly Volume Average Age, Years Males/ Females, % Inpatients, % Length of Stay, Days Discharged Home, % Open Hip Surgery 7 64 Treatment of hip or pelvis fracture Other treatment /49 33/ Arthroscopic Hip Surgery Open Knee Surgery Treatment of periarticular knee fracture /17 65/ Other treatment /49 47/ Arthroscopic Knee Surgery ACL reconstruction /5 47/ Meniscectomy /35 57/ Meniscus repair /32 62/ Chondroplasty /41 58/ Other treatment /51 39/ Open Foot/Ankle Surgery Flat foot or cavus foot correction /49 54/ Fracture treatment /32 8/ tibia or fibula /3 77/ ankle foot or toes Excision of leg or ankle tumor Excision of foot or toe tumor Other treatment /51 49/ Arthroscopic Foot/Ankle Surgery 6 4 Pediatric patients are younger than 18 years. 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 Inpatients, %: percentage of inpatient surgeries 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 213

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 Pediatric patients are younger than 18 years. 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) 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 (%) MCID a 1 3 MCID Patients (%) MCID 1 3 MCID N = Improving Worsening N = 9 58 Improving Worsening On average, 87% of patients reported a clinically important improvement in shoulder-related pain after 1 year, while 3% reported worsening (1% showed no detectable change in shoulder-related pain). On average, 89% of patients reported a clinically important improvement in shoulder-related function after 1 year, while 2% reported worsening (9% showed no detectable change in shoulder-related function). 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 12.9 (N = 37) on a scale from (extreme pain) to 1 (no pain). For shoulder-related function, the MCID is 14. (N = 353) on a scale from (extreme limitations) to 1 (no limitations). 2 Outcomes 213

23 Arm-Related Physical Limitations 1 Year After Surgery Whole-Body Physical Limitations 1 Year After Surgery Patients (%) MCID a 1 3 MCID Patients (%) MCID 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 87% of patients reported a clinically important improvement in arm-related physical limitations after 1 year, while 2% reported worsening (11% showed no detectable change in arm-related physical limitations). On average, 55% of patients reported a clinically important improvement in whole-body physical limitations after 1 year, while 11% reported worsening (34% showed no detectable change in whole-body physical limitations). 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 limitations, the MCID is 1.5 (N = 449) on a scale from (extreme limitations) to 1 (no limitations). For whole-body physical limitations, the MCID is 5.2 (N = 47) 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 (%) MCID a 1 3 MCID MCID 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, 9% of patients reported a clinically important improvement in hip-related function after 1 year, while 2% reported worsening (8% showed no detectable change in hip-related function). 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 11.8 (N = 813) on a scale from (extreme pain) to 1 (no pain). For hip-related function, the MCID is 13.1 (N = 826) on a scale from (extreme limitations) to 1 (no limitations) days: Average length of stay for hip replacement patients in the rapid recovery program 22 Outcomes 213

25 Leg-Related Physical Limitations 1 Year After Surgery Patients (%) 1 Whole-Body Physical Limitations 1 Year After Surgery Patients (%) MCID a 1 3 MCID MCID 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 78% of patients reported a clinically important improvement in leg-related physical limitations after 1 year, while 6% reported worsening (16% showed no detectable change in leg-related physical limitations). On average, 68% of patients reported a clinically important improvement in whole-body physical limitations after 1 year, while 7% reported worsening (25% showed no detectable change in whole-body physical limitations). 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 limitations, the MCID is 1.9 (N = 1617) on a scale from (extreme limitations) to 1 (no limitations). For whole-body physical limitations, the MCID is 5.8 (N = 1614) 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 (%) MCID a 1 3 MCID Patients (%) MCID 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 86% of patients reported a clinically important improvement in knee-related pain after 1 year, while 3% reported worsening (11% showed no detectable change in knee-related pain). On average, 8% of patients reported a clinically important improvement in knee-related function after 1 year, while 4% reported worsening (16% showed no detectable change in knee-related function). 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 12.2 (N = 142) on a scale from (extreme pain) to 1 (no pain). For knee-related function, the MCID is 13. (N = 141) on a scale from (extreme limitations) to 1 (no limitations) days: Average length of stay for knee replacement patients in the rapid recovery program 24 Outcomes 213

27 Leg-Related Physical Limitations 1 Year After Surgery Whole-Body Physical Limitations 1 Year After Surgery Patients (%) MCID a 1 3 MCID Patients (%) MCID 1 3 MCID N = Improving Worsening N = Improving Worsening On average, 73% of patients reported a clinically important improvement in leg-related physical limitations after 1 year, while 7% reported worsening (2% showed no detectable change in leg-related physical limitations). On average, 58% of patients reported a clinically important improvement in whole-body physical limitations after 1 year, while 1% reported worsening (32% showed no detectable change in whole-body physical limitations). 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 limitations, the MCID is 1.8 (N = 2897) on a scale from (extreme limitations) to 1 (no limitations). For whole-body physical limitations, the MCID is 5.5 (N = 2176) 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 Spinal Disease Change in Functional Status Following Lumbar Spinal Injections for Disc Herniation Treatment Dates: Sept. 1, 212 Jan. 15, 214 Patients (%) N = EQ-5D Score 52 PDQ Score 51 PHQ-9 Score 22 Improved Stable Worsened In patients undergoing spinal injections for symptomatic lumbar disc herniation, 5% noted improvement in health-related quality of life, as measured by the EQ-5D (mean duration of follow-up = 197 days); 4% noted improvement in functional status as measured by the PDQ (mean duration of follow-up = 192 days). In those with at least moderate depressive symptoms (PHQ-9 > 9) prior to treatment, 64% noted improvement in depressive symptoms (mean duration of follow-up = 23 days). 26 Outcomes 213

29 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 Without Fusion for Spinal Stenosis Surgical Dates: Oct. 1, 212 Oct. 13, 213 Patients (%) N = EQ-5D Score 127 PDQ Score 129 PHQ-9 Score 46 Improved Stable Worsened In patients who failed to respond to conservative care and underwent lumbar decompression without fusion for symptoms of lumbar spinal stenosis, 57% noted improvement in health-related quality of life, as measured by the EQ-5D (mean duration of follow-up = 15 days); 57% noted improvement in their functional status after surgery, as measured by the PDQ (mean duration of follow-up = 152 days). In those with at least moderate depressive symptoms (PHQ-9 > 9) prior to treatment, 65% noted improvement in depressive symptoms (mean duration of follow-up = 147 days). Change in Functional Status Following Lumbar Decompression With Fusion for Spinal Stenosis Surgical Dates: Oct. 1, 212 Oct. 13, 213 Patients (%) N = EQ-5D Score 144 PDQ Score 146 PHQ-9 Score 42 Improved Stable Worsened In patients who failed to respond to conservative care and underwent lumbar decompression surgery with fusion for symptoms of lumbar spinal stenosis, 57% noted improvement in health-related quality of life, as measured by the EQ-5D (mean duration of follow-up = 155 days); 51% noted improvement in their functional status after surgery, as measured by the PDQ (mean duration of follow-up = 156 days). In those with at least moderate depressive symptoms (PHQ-9 > 9) prior to treatment, 71% noted improvement in depressive symptoms (mean duration of follow-up = 138 days). Orthopaedic & Rheumatologic Institute 27

30 Spinal Disease Cervical Disc Herniation Change in Functional Status Following Surgery for Cervical Disc Herniation in Patients Without Medical Comorbidities Surgical Dates: Oct. 1, 212 Oct. 13, 213 Patients (%) N = EQ-5D Score 45 PDQ Score 43 PHQ-9 Score 22 Improved Stable Worsened In patients who underwent surgery for cervical disc herniation causing arm pain, 53% noted improvement in health-related quality of life, as measured by the EQ-5D (mean duration of followup = 128 days); 56% noted improvement in their functional status after surgery, as measured by the PDQ (mean duration of follow-up = 126 days). In those with at least moderate depressive symptoms (PHQ-9 > 9) prior to treatment, 45% noted improvement in depressive symptoms (mean duration of follow-up = 143 days). Change in Functional Status Following Surgery for Cervical Disc Herniation in Patients With Medical Comorbidities Surgical Dates: Oct. 1, 212 Oct. 13, 213 Patients (%) N = EQ-5D Score 8 PDQ Score 8 Improved Stable Worsened In patients with medical comorbidities who underwent surgery for cervical disc herniation causing arm pain, 63% noted improvement in quality of life, as measured by the EQ-5D (mean duration of follow-up = 128 days); 38% noted improvement in functional status, as measured by the PDQ (mean duration of follow-up = 126 days). 28 Outcomes 213

31 Cervical Myelopathy Change in Functional Status Following Spinal Decompression for Cervical Myelopathy Surgical Dates: Oct. 1, 212 Oct. 13, 213 Patients (%) N = EQ-5D Score 75 PDQ Score 72 PHQ-9 Score 27 Improved Stable Worsened In patients who underwent spinal decompression surgery for symptoms of cervical myelopathy, 48% noted improvement in health-related quality of life, as measured by the EQ-5D (mean duration of follow-up = 135 days); 5% noted improvement in their functional status after surgery, as measured by the PDQ (mean duration of follow-up = 136 days). In those with at least moderate depressive symptoms (PHQ-9 > 9) prior to treatment, 52% noted improvement in depressive symptoms (mean duration of follow-up = 137 days). Complex Spinal Deformity Change in Functional Status Following Surgery for Complex Spinal Deformity Surgical Dates: Oct. 1, 212 Oct. 13, 213 Patients (%) N = EQ-5D Score 88 PDQ Score 87 PHQ-9 Score 37 Improved Stable Worsened In patients who underwent multilevel fusion surgery for complex spinal deformities, 48% noted improvement in health-related quality of life, as measured by the EQ-5D (mean duration of followup = 161 days); 51% noted improvement in their functional status after surgery, as measured by the PDQ (mean duration of follow-up = 162 days). In those with at least moderate depressive symptoms (PHQ-9 > 9) prior to treatment, 65% noted improvement in depressive symptoms (mean duration of follow-up = 163 days). Orthopaedic & Rheumatologic Institute 29

32 Spinal Disease Readmissions and Mortality 3-Day Unplanned Readmission Rate Among Spine Center Patients Readmission Rate (%) Q1 Q2 Q3 211 N = Q4 311 Q1 272 Q2 Q Q4 39 Q1 29 Q2 Q Q4 278 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. 3-Day Postoperative Mortality Rate Following Spinal Surgery (N = 2114) 213 Mortality Rate (%) Cleveland Clinic NSQIP Medicare The 3-day postoperative mortality rate following spinal surgery in 213 was.9%, compared with a rate of.3% for the National Surgical Quality Improvement Program (NSQIP) Database 1 and a rate of.4% for the Medicare database. 2 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): Outcomes 213

33 Surgical Site Infections Surgical Site Infection Rates for Spinal Surgery Surgical Site Infection Rate (%) N = Q1 366 Q2 Q Q4 38 Q1 377 Q2 Q Q4 363 An ongoing effort to reduce infection includes nasal staphylococcus surveillance and decolonization protocols, an updated perioperative scrub protocol, new rules restricting operating room traffic and updating operating table preparation, and new wound closure recommendations. The overall postoperative infection rates in the Spine Center of 3.7% for 212 and 1.5% for 213 compare favorably with available Level I data ranging from 1.4% to 11%. 1,2 N = spinal surgeries with available infection surveillance data. 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): Orthopaedic & Rheumatologic Institute 31

34 Rheumatology Overview Patient Visit Volumes Total Visits (in Thousands) 7 FHC 6 a Main campus b N = 42,669 47,321 a Cleveland Clinic family health centers 29 5, , ,11 b Cleveland Clinic main campus , ,312 Cleveland Clinic Main Campus Multidisciplinary Arthritis Center Volumes Total Visits (in Thousands) N = Volume of New Rheumatoid Arthritis Patient Visits Number of Patients N = Outcomes 213

35 Volume of New Granulomatosis With Polyangiitis (Wegener s) Patient Visits Number of Patients N = Volume of New Psoriatic Arthritis Patient Visits Number of Patients N = Volume of New Gout Patient Visits Number of Patients N = Orthopaedic & Rheumatologic Institute 33

36 Rheumatology Overview Most Common Conditions Treated in 213 Condition Total Visit Volume Unique Patients Osteoporosis 18, Rheumatoid arthritis 18, 4124 Fibromyalgia 13, Joint pain Osteoarthritis Wegener's granulomatosis Systemic lupus erythematosus Polymyalgia rheumatica Gout Inflammatory polyarthropathy Back pain ,543 32,879 Volume of Visits of Patients With Rare Disorders in 213 Diagnosis Volume Giant cell arteritis 324 Common variable immunodeficiency 163 Polyarteritis nodosa 143 Takayasu disease 15 Behcet syndrome 11 Hypermobility syndrome 56 Familial Mediterranean fever 46 Osteitis deformans (Paget disease of bone) 34 Ehlers-Danlos syndrome 3 Cerebral arteritis 29 Primary hypercoagulable state 25 Erythema nodosum 21 Osteogenesis imperfecta 1 Inclusion body myositis 9 Mononeuritis multiplex 4 Rheumatology Infusion Center Treatment Volume: Cleveland Clinic Main Campus Number of Infusions N = Rheumatology Infusion Center Treatment Volume: Cleveland Clinic Main Campus and Family Health Centers 213 Number of Infusions Main Campus Family Health Centers N = Outcomes 213

37 Volume of Medication Infusions Cleveland Clinic Main Campus Outpatient Medication Infliximab (Remicade ) Intravenous immunoglobulin (Gammagard ) Abatacept (Orencia ) Zoledronic acid (Reclast ) Rituximab (Rituxan ) Tocilizumab (Actemra ) Belimumab (Benlysta ) Ibandronate (Boniva ) Cyclophosphamide (Cytoxan ) Methylprednisolone (Solu-Medrol ) Basiliximab (Simulect ) 1 1 Pegloticase (Krystexxa ) Pamidronate (Aredia ) Group Practice Site Growth Growth in Number of Rheumatology Physicians Number of Sites N = Number of Physicians N = Orthopaedic & Rheumatologic Institute 35

38 Rheumatology Overview DXA a Scan Volume Number of Scans (in Thousands) N = a dual energy X-ray absorptiometry 26 16, ,975 Cleveland Clinic s R.J. Fasenmyer Center for Clinical Immunology: Continuing Medical Education (CME) Growth of Web-Based Educational Programming Total of CME Certificates Issued (in Thousands) DXA a Registry Enrollment N = , , , Total Scans (in Thousands) Yearly Cumulative 18 9 N = , , , ,134 a dual energy X-ray absorptiometry 36 Outcomes 213

39 Transplant Percentage of Cardiac Transplant Patients Who Had a DXA a Scan Percent Percentage of Lung Transplant Patients Who Had a DXA Scan Percent N = N = a 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 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 37

40 Osteoporosis Percentage of Osteoporosis Patients Started on Denosumab Who Received Continued Therapy at Specified Intervals Percent ± 3 days ± 6 days ± 9 days 2 N = Second Dose 324 Third Dose 176 Fourth Dose 55 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 74.4% of patients at ± 3 days, to 84.9% within ± 6 days, and to 88.9% within ± 9 days. A third dose was administered to 8.1% of patients at ± 3 days, to 89.2% within ± 6 days, and to 94.3% within ± 9 days. A fourth dose was administered to 9.9% of patients at ± 3 days, to 1% within ± 6 days, and to 1% within ± 9 days. 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 = 34) Adherence with oral bisphosphonate medication is poor, with Percent < 5% of patients on therapy at 1 year. Adherence with an 1 injectable medication is a function of patient acceptance and systems measures in practice to ensure patient scheduling. 8 Of 34 patients receiving their first dose of denosumab, (81.6%) received a second dose of medication. Of the 4 56 patients not receiving a second dose of denosumab, 11 2 (19.6%) received another osteoporosis medication. Of 34 patients initially treated with denosumab, 259 (85.2%) Second Dose Denosumab continued on an osteoporosis medication. 38 Outcomes 213

41 Percentage of Patients Treated With Denosumab Who Had Vitamin D and Calcium Testing Prior to Treatment (N = 57) 213 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: 84.7% and 93% of patients had serum calcium testing in the preceding 18 and 365 days, respectively, while 88% and 94.2% 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 89 Third Dose 453 Fourth Dose 128 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 62.3% of patients at 1 year ± 3 days, to 75.3% within 1 year ± 6 days, and to 82.5% within 1 year ± 9 days. A third dose was administered to 69.5% of patients at 1 year ± 3 days, to 8.8% within 1 year ± 6 days, and to 86.8% within 1 year ± 9 days. A fourth dose was administered to 78.1% of patients at 1 year ± 3 days, to 9.6% within 1 year ± 6 days, and to 96.9% 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 39

42 Osteoporosis Percentage of Osteoporosis Patients Started on Zoledronic Acid Who Continued Osteoporosis Therapy (N = 1245) Adherence with oral bisphosphonate medication is poor, with Percent < 5% of patients on therapy at 1 year. Adherence with an infusible medication is a function of patient acceptance and 1 systems measures in practice to ensure patient scheduling. 8 Of 1245 patients receiving their first dose of zoledronic acid, (68.4%) received a second dose of medication. Of 4 the 394 patients not receiving a second dose of zoledronic 2 acid, 13 (26.1%) were changed to another osteoporosis medication, for a total of 954 patients (76.6%) who Second Dose Zoledronic Acid continued on 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 , 96.1% of patients had renal function testing with a creatinine and estimated glomerular filtration rate within 365 days prior to infusion. During the period , 97.4% had renal function testing. 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. 4 Outcomes 213

43 Percentage of Patients Treated With Zoledronic Acid Who Had Vitamin D Testing Prior to Infusion (N = 1411) 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 99% of patients undergoing infusion had a vitamin D level when measured at 9, 18, or 365 days before infusion. Percentage of Patients on Glucocorticoids Treated With Osteoporosis Medications (N = 113) Percent FRAX a < 1% FRAX 1 2% FRAX > 2% Days Post DXA b a World Health Organization Fracture Risk Assessment Tool 1-year absolute fracture risk of major osteoporotic fracture b dual energy X-ray absorptiometry 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%, 7.1%, 73.5%, and 75.2% were on therapy for GIO at 9, 18, and 365 days, respectively. Orthopaedic & Rheumatologic Institute 41

44 Osteoporosis Percentage of Patients With Low Bone Mass (T-Score 2.5) and High Fracture Risk by FRAX a Who Were Treated With Osteoporosis Medications Percent Days Post DXA b (N = 816) (N = 969) a World Health Organization Fracture Risk Assessment Tool b dual energy X-ray absorptiometry 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 69% of patients were placed on medication within 9 days, 77% by 18 days, and more than 81% were placed on medication within 365 days. For the period , treatment rate improved; more than 77% of patients were placed on medication within 9 days, 81% by 18 days, and more than 84% were placed on medication within 365 days. 42 Outcomes 213

45 Percentage of Patients With Hip Fracture and Vertebral Fracture Treated With Osteoporosis Medication a Percent Hip Fracture Vertebral Fracture N = a osteoporosis medication = bisphosphonate, denosumab, teriparatide, estrogen, raloxifene Current national osteoporosis guidelines recommend treatment with an approved osteoporosis medication after hip and vertebral fracture. Nationwide, only 2% of patients receive treatment after hip fracture; no data are available for vertebral fracture. Only 18.2% of patients who had a hip fracture requiring surgery received medication for osteoporosis in the next 365 days. For patients with a vertebral fracture who had vertebral augmentation (kyphoplasty or vertebroplasty), 48.3% received an osteoporosis medication. For both types of fracture, a care gap exists. Likelihood of Treatment After Hip or Vertebral Fracture Based on Fracture Type and Gender Odds Ratio Odds Ratio Treatment Odds Ratio Treatment Vertebral vs Hip Fracture Women vs Men N = Current national osteoporosis guidelines recommend treatment with an approved osteoporosis medication after hip and vertebral fracture. The likelihood of treatment was greater for patients with a vertebral fracture undergoing vertebral augmentation than for hip fracture (odds ratio [OR] 4.1; confidence interval [CI] ) and greater for women vs men (OR 2.6; CI ). Orthopaedic & Rheumatologic Institute 43

46 Gout Percentage of Gout Patients Treated With Urate-Lowering Therapy Who Reached Target Uric Acid Level (N = 2875) Percent mg/dl mg/dl > 7. mg/dl Uric Acid Level % 14.54% 16.39% % 14.29% 17.5% % 14.89% 17.6% Patients in this cohort had a diagnosis of gout, had at least two 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. Sixty-seven percent of patients had a uric acid level of 6. mg/dl, demonstrating successful treatment to reach the target level. Additionally, 15% of patients had a uric acid level between 6.1 mg/dl and 7. mg/dl, demonstrating acceptable levels. Eighteen percent of patients did not achieve target levels. The percentage of patients who achieved target uric acid levels remains stable; however, substantial numbers of patients are undertreated with urate-lowering therapy. 44 Outcomes 213

47 Percentage of Tophaceous Gout Patients Treated With Urate- Lowering Therapy Who Reached Target Uric Acid Level (N = 194) Percent mg/dl mg/dl Uric Acid Level > 7. mg/dl % 11.11% 18.75% % 1.86% 21.14% % 11.86% 2.1% Patients in this cohort had a diagnosis of tophaceous gout, had at least two 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. Sixty-seven percent of patients had a uric acid level of 6. mg/dl, demonstrating successful treatment to reach the target level. Additionally, 15% of patients had a uric acid level between 6.1 mg/dl and 7. mg/dl, demonstrating acceptable levels. Eighteen percent of patients did not achieve target levels. 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. Number of Gout Patients Treated With Pegloticase Who Reached Target Uric Acid Level 213 Number of Infusions (N = 34) a sua = serum uric acid Infusions sua a Checked sua < 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; the loss of effect 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 obtained before each infusion. Treatment should be discontinued if uric acid rises to 6. mg/dl or greater on two consecutive tests. In 213, 34 pegloticase infusions were performed in five patients; serum uric acid was checked prior to infusion in all cases and was < 6 mg/dl in all tests. No infusion reactions occurred. Orthopaedic & Rheumatologic Institute 45

48 Rheumatoid Arthritis Percentage of Rheumatoid Arthritis Patients Taking Disease- Modifying Antirheumatic Drug Therapy (N = 13,878) Percent N = American College of Rheumatology guidelines recommend that rheumatoid arthritis patients be treated with diseasemodifying antirheumatic drug (DMARD) therapy. More than 99% of rheumatoid arthritis patients who were seen in the Department of Rheumatology at least two times during the years 21, 211, 212, and 213 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. Percentage of Newly Diagnosed Patients With Rheumatoid Arthritis Starting Biologic DMARDs a Who Had Tuberculosis Testing (N = 92) 213 Percent Patients With Tuberculosis Testing a 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. Ninetytwo percent (85 of 92) 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): Outcomes 213

49 Percentage of Rheumatoid Arthritis Patients Treated With Methotrexate Who Were Prescribed Folic Acid 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 six 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 8% 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. Infusion Reactions in Patients Treated With Biologic and Nonbiologic Therapies in a Rheumatology Infusion Center (N = 2826) 213 Percent Mild Moderate Severe The rheumatology infusion center administered 2826 infusions in 731 patients in 213. 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. Reactions occurred in 48 of 2826 infusions (1.7%), and were mild in 19, moderate in 28, and severe in one infusion. Only one patient was not able to complete his infusion (.35%). 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 47

50 Psoriatic Arthritis Optimizing the Identification of Psoriatic Arthritis Patients in Need of Early and Aggressive Cardiac Interventions (N = 87) Percent Plaque No plaque BP a > 14/9 Diabetes History CV b Disease Smoker a blood pressure b cardiovascular It is critical to identify psoriatic arthritis patients at the highest risk for cardiovascular disease. Psoriatic arthritis is independently associated with premature atherosclerosis and increased prevalence of cardiovascular disease. Carotid ultrasonography is used to detect increased carotid artery intima-media wall thickness as a prognostic indicator of future cardiovascular events. There is now increasing evidence that carotid plaque burden may be an additional predictor of cardiovascular disease. The Cardiometabolic Outcome Measures in Psoriatic Arthritis Study (COMPASS) is a longitudinal observation of patients with a focus on cardiovascular health. Between 211 and 213, 87 patients had carotid ultrasound. Detailed analysis of patients with carotid plaque also showed increased prevalence of diabetes, history of cardiovascular disease, and smoking compared with those without plaque. Psoriatic arthritis patients with carotid plaque and these traditional cardiovascular risk factors may benefit from earlier and more aggressive cardiac intervention. 48 Outcomes 213

51 Patterns of Cardiovascular Disease in Rheumatoid Arthritis and Psoriatic Arthritis Identifying Carotid Plaque Burden in Patients With Psoriatic Arthritis (N = 87) Percent Ischemic Heart Disease Psoriatic arthritis (N = 187) Rheumatoid arthritis (N = 1429) Congestive Heart Failure Stroke Percent N = Plaque 34 No Plaque 53 General Population 2669 Cardiovascular disease is the leading cause of death in the US. Psoriatic arthritis (PsA) is a chronic, inflammatory, immune-mediated, systemic disease that not only affects joints, skin, and nails but has also been associated with an increased risk of developing cardiovascular disease. The association of accelerated risk for cardiovascular disease in rheumatoid arthritis (RA) is also well accepted. The pattern of cardiovascular diagnoses was compared in patients with PsA and RA. The association between PsA and cardiovascular events has important implications for therapy because current treatments may either increase or decrease the risks of myocardial infarction and stroke, which can have a significant impact on patient morbidity and mortality. Patients with PsA have a similar prevalence of ischemic heart disease and stroke compared with RA patients. Aggressive cardiac risk factor screening and management is critical for both RA and PsA patients in order to ameliorate this at-risk patient population. There is a well known association of accelerated cardiovascular disease in patients with inflammatory arthritis such as psoriatic arthritis (PsA) leading to excess mortality. Much research has focused on identifying PsA patients at highest risk for cardiovascular disease who may benefit from earlier and more aggressive cardiac management to ameliorate this risk. Carotid ultrasonography to measure intima-media thickness (IMT) is well accepted in the general population and has been used as a prognostic indicator of future cardiovascular events. Carotid plaque burden has also been used to help further identify higher risk patients. The Cardiometabolic Outcome Measures in Psoriatic Arthritis Study (COMPASS) is a longitudinal observation of patients with psoriatic diseases. A subset of 87 patients had carotid ultrasound performed. In addition to carotid IMT measurements, carotid plaque was noted to be present in 39% of patients (34 of 87) compared with a prevalence of 28% in the general population. The additional evaluation of plaque burden allows for early identification of asymptomatic patients who are at high risk of cardiovascular disease and who may benefit from further cardiology assessment and risk factor management. Orthopaedic & Rheumatologic Institute 49

52 Psoriatic Arthritis Relationship Between Metabolic Syndrome and Carotid Intima-Media Thickness in Patients With Psoriatic Arthritis (PsA) and Psoriasis (PsO) Overall Maximum CIMT a (Median) N = PsA Patients 98 PsO Patients 117 MetSyn b No MetSyn Relative Risk of Metabolic Syndrome, PsA vs PsO (N = 343) Relative Risk Metabolic Syndrome, PsA vs PsO a carotid artery intima-media thickness b metabolic syndrome Cardiovascular disease risk has been found to be elevated in patients with inflammatory arthropathies such as psoriatic arthritis, with an increased incidence of subclinical atherosclerosis compared with the general population. Metabolic syndrome is a cluster of several additional known cardiovascular risk factors, including insulin resistance, obesity, atherogenic dyslipidemia, and hypertension. The additive effect of metabolic syndrome on carotid artery intima-media thickness (CIMT) as a prognostic indicator of future cardiovascular events was evaluated using carotid ultrasound in patients with psoriatic arthritis (PsA) and psoriasis (PsO). Patients with psoriatic disease (N = 343) were evaluated (PsA, 57.72%; PsO, 42.28%) in the Cardiometabolic Outcome Measures in Psoriatic Arthritis Study (COMPASS). PsA patients were almost twice as likely to be associated with metabolic syndrome compared with PsO patients (univariate overall risk 1.78 [95% confidence interval ]; P =.25). Carotid artery imaging was performed in a subgroup of this population (PsA, N = 98; PsO, N = 117) to compare CIMT measurement in psoriatic disease patients with and without metabolic syndrome. Both PsA and PsO patients with metabolic syndrome had thicker CIMT values compared with patients without metabolic syndrome. Patients with PsA also had thicker maximum CIMT values compared with PsO patients (P =.1). 5 Outcomes 213

53 Comparison of Physical and Mental Health Status in Psoriatic Arthritis and Rheumatoid Arthritis Patients Evaluated for Joint Replacement Surgery Health Status Prior to Joint Replacement: PsA a (N = 26); RA b (N = 48) 8 Psoriatic arthritis Rheumatoid arthritis Health Status Without Joint Replacement: PsA (N = 97); RA (N = 984) Psoriatic arthritis Rheumatoid arthritis PCS c MCS d PCS MCS a psoriatic arthritis b rheumatoid arthritis c physical component score d mental component score General health status was compared in patients with psoriatic and rheumatoid arthritis who were evaluated in an orthopaedic clinic. The cohort was divided into those who had joint replacement surgery [PsA (N = 26); RA (N = 48)] and those who did not [PsA (N = 97); RA (N = 984)]. General health was assessed by the Short Form (36) Health Survey, a patient-reported measure of health status that includes physical component score (PCS) and mental component score (MCS) norm-based scales where 5 represents the mean score of a nonpatient control group and every 1 units represents 1 SD from the mean. Mental health scores regardless of the type of arthritis or the severity of disease reflected in the surgery vs nonsurgery groups were all in the normal range (5). Both the psoriatic and rheumatoid arthritis group PCS scores decreased to similar levels based on disease severity. Physical function decreased 2 SD from normal in the surgery groups (PsA = 3.5; RA = 28.4) and 1.5 SD from normal in the nonsurgery groups (PsA and RA = 36). While psoriatic arthritis has been generally considered the more benign inflammatory joint disease compared with rheumatoid arthritis, both mental and physical health domains were very similar in the cohort regardless of the severity of disease. These data suggest that psoriatic arthritis impacts patient mental health and physical functioning to degrees equal to those seen in rheumatoid arthritis patients. Orthopaedic & Rheumatologic Institute 51

54 Psoriatic Arthritis Percentage of Psoriatic Arthritis Patients Taking Disease-Modifying Antirheumatic Drug Therapy (N = 236) Percent N = American College of Rheumatology guidelines recommend that psoriatic arthritis patients be treated with disease-modifying antirheumatic drug (DMARD) therapy. More than 99% of psoriatic arthritis patients who were seen in the Department of Rheumatology at least two times during the years 21, 211, 212, and 213 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. 52 Outcomes 213

55 Treatment Patterns in Psoriatic and Rheumatoid Arthritis: Use of Biologic DMARDs Percent Rheumatoid arthritis (N = 14,566) Psoriatic arthritis (N = 2116) 2 Biologic Only Nonbiologic Only Both Neither A comparison was made of disease-modifying antirheumatic drug (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). Treatment patterns are similar, with a majority of RA and PsA patients receiving DMARD therapy (96% RA; 95% PsA) and a similar percentage receiving biologic plus nonbiologic DMARD combination therapy (25% RA; 33% PsA). These outcomes represent DMARD therapy utilization in patients with RA and PsA seen in 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. Treatment patterns differed with nonbiologic DMARD monotherapy used in two-thirds (65%) of RA patients while PsA patients were distributed evenly between combination (33%), biologic monotherapy (32%), and nonbiologic monotherapy (3%). This difference is largely a result of RA patients rarely (6%) receiving biologic DMARD monotherapy, which is provided to 32% of PsA patients. Orthopaedic & Rheumatologic Institute 53

56 Psoriatic Arthritis Percentage of Newly Diagnosed Patients With Psoriatic Arthritis Starting Biologic DMARDs a Who Had Tuberculosis Testing (N = 26) 213 Percent Patients With Tuberculosis Testing a 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 (26 of 26) of newly diagnosed psoriatic arthritis 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): Outcomes 213

57 Percentage of Psoriatic Arthritis Patients Treated With Methotrexate Who Were Prescribed Folic Acid 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 six 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 75% 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 Vasculitis Evaluating Disease Activity in Patients With Inflammatory Thoracic Aortic Aneurysms (N = 9) Number of Patients Active disease: histology Active disease: clinical 4 2 At Surgery 1 Year Prior to Surgery Large vessel vasculitis (LVV) can cause thoracic aortic aneurysms. LVV may be multifocal, resulting from a systemic disease (eg, giant cell arteritis or Takayasu arteritis), or may be a focal process restricted to just the aortic arch (focal isolated aortitis). Ongoing inflammation is usually estimated indirectly by clinical features, inflammatory markers, and imaging characteristics. Histologic exams in 126 patients who had repair of a thoracic aortic aneurysm revealed 14 patients (11%) with aortitis: 1 with multifocal LVV and four with focal aortitis. Of the 1 patients with multifocal LVV, nine had features of active vasculitis (aortitis) on biopsy, and one had burned out aortitis. At the time of surgery, of the nine patients with multifocal LVV and inflammatory infiltrates within the aorta, only two had active disease based on NIH clinical and laboratory criteria. When assessed during the year prior to surgery, five of nine had active disease. None of the four patients with focal aortitis had clinically active disease. Conclusion: Indirect assessment of disease activity was insensitive in patients with thoracic aortic aneurysms who had histologic confirmation of inflammatory lesions. Improved markers are needed for assessing disease activity in patients with LVV. 56 Outcomes 213

59 B-Cell Subset Phenotypes in Patients With Granulomatosis With Polyangiitis (Wegener s) Percent B-Cells GPA active (N = 4) GPA remission (N = 13) GPA RTX (N = 7) GPA no RTX (N = 6) Controls (N = 5).3 Immature Transitional B-Cells Percent Total Lymphocytes GPA active (N = 4) GPA remission (N = 13) GPA RTX (N = 7) GPA no RTX (N = 6) Controls (N = 5) Naïve B-Cells B-cells are pathogenic in granulomatosis with polyangiitis (GPA). Rituximab (RTX), an anti-cd2 monoclonal antibody, is effective therapy in GPA. B-cell subsets were evaluated in active GPA (N = 4), remission GPA (N = 13), and controls (N = 5). Total lymphocytes were decreased in all GPA patients compared with controls. B-cells were high in active GPA; patients who had received RTX had decreased naïve B-cells. GPA patients with active disease had an increase in the proportion of immature transitional (IT) B-cells; these cells were not detected in GPA in remission nor in those treated with RTX. Preliminary results show that patients with GPA have altered lymphocyte cell profiles compared with healthy controls and those with active disease have increased IT B-cells, while all GPA patients have reduced total lymphocytes. Orthopaedic & Rheumatologic Institute 57

60 Vasculitis Immunoglobulin Deposition in Patients With Leukocytoclastic Vasculitis: Clinical Significance (N = 88) Number of Patients One Organ Involved a direct immunofluorescence Percent b immunoglobulin A Gastrointestinal Involvement Two Organs Involved DIF IgA b positive DIF IgA negative Renal Involvement Three Organs Involved DIF a positive DIF negative Four Organs Involved Joint Involvement Leukocytoclastic vasculitis (LCV) is a vasculitis of small vessels, with neutrophils a predominant cell type in biopsy. The conditions associated with LCV include infections, drug reactions, malignancies, autoimmune diseases, and primary vasculitides. Direct immunofluorescence (DIF) from skin biopsies is used to identify immunoglobulins, complement, and/ or fibrinogen in the vessel wall. Immunoglobulin A (IgA) deposition has been associated with Henoch Schönlein purpura, renamed IgA vasculitis. A retrospective analysis of consecutive LCV cases identified from Cleveland Clinic s pathology database, seen within the span of 5 years (N = 218), investigated the clinical utility of DIF (N = 88). Patients who were IgA DIF positive had more internal organs affected by vasculitis compared with patients who were IgA DIF negative. IgA (not IgG or IgM) was associated with internal organ involvement by vasculitis. Patients with IgA deposition had more renal and gastrointestinal involvement (P =.4), as well as joint involvement. Patients with DIF + IgA LCV should be monitored for renal and gastrointestinal involvement by vasculitis. 58 Outcomes 213

61 Serum S1 Proteins as a Marker of Disease Activity in Giant Cell Arteritis (N = 59) 213 Sensitivity All (AUC a =.79) CRP b + ESR c (AUC =.73) S1A8/9 + S1A12 (AUC =.61) Specificity a area under the curve b c-reactive protein c erythrocyte sedimentation rate Calgranulins including S1A8/9 and S1A12 are calcium binding proteins expressed during myeloid differentiation and are linked with the innate immune response. Upon release by myeloid cells, they serve as damage-associated molecular pattern molecules. In giant cell arteritis (GCA), the S1A8/9 complex has been identified in abundance in the adventitia and media of affected temporal arteries, whereas S1A12 expression is found around the vasa vasorum of the adventitia. The association was assessed of S1 proteins with disease activity in forms of large vessel vasculitis and their value in predicting disease activity compared with standard inflammatory markers, c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in 59 patients with GCA (samples = 16: active disease = 5; inactive = 56). Results show that S1A8/9 and S1A12 are significantly higher during active disease in GCA. When compared with standard biomarkers (ESR and CRP), the S1 proteins did not perform as well as markers of disease activity. A model combining these S1 proteins with the standard disease activity markers showed a trend toward this model outperforming models using either alone (P =.13). Orthopaedic & Rheumatologic Institute 59

62 Inflammatory Diseases Indeterminate QuantiFERON -TB Gold In-Tube Assay (QFT-GIT) in Patients With Chronic Inflammatory Diseases Relative Risk for Indeterminate QFT-GIT in Patients Using Glucocorticoids and Nonbiologic DMARDs a Percent Chronic Inflammatory Diseases General Hospital Healthy Reference Relative Risk Glucocorticoid Use N = 929 Nonbiologic DMARD Use 983 N = ,592 25,672 a nonbiologic DMARDs = disease-modifying antirheumatic drugs such as methotrexate and excluding biologic agents such as tumor necrosis factor inhibitors Mycobacterium tuberculosis-specific interferon-γ release assays (IGRAs) are widely used as screening tools for the detection of tuberculosis infection. Indeterminate tests often lead to repeat testing, use of an alternative IGRA, or skin testing. Indeterminate tests can be seen in immunosuppressed patients, including those with HIV. The frequency of indeterminate QFT-GIT was evaluated in patients (N = 2868) with chronic inflammatory diseases (rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis, systemic vasculitis, systemic lupus erythematosus, and inflammatory spondyloarthropathy). These patients were compared with general hospital patients (N = 26,592) and healthy reference patients (N = 25,672). Patients with inflammatory diseases were significantly more likely to have an indeterminate QFT-GIT than other groups (relative risk [RR] 3.6, 95% confidence interval [CI] ). Glucocorticoid use increased the likelihood of an indeterminate test (RR 1.43, 95% CI ). Nonbiologic DMARD use reduced the risk of an indeterminate QFT-GIT (RR.67, 95% CI.46.97). 6 Outcomes 213

63 Fibromyalgia Effect of a 1-Day Educational Intervention on Disease Management (N = 17) Symptom Management Before Intervention After Intervention Number of Patients (%) Extremely Helpful Very Helpful Moderately Helpful Minimally Helpful A 1-day educational intervention was performed with a group of 17 patients with fibromyalgia. The patients were asked if the course was helpful in managing their symptoms: = I do not know how to manage my symptoms to 5 = I know very well how to manage my symptoms. Patients who took the course increased symptom management from an average of 2.71 before the course to 3.76 after the course (P =.13). Many patients (58.8%) found the course to be extremely helpful, while 17.6% found the course to be very helpful. Orthopaedic & Rheumatologic Institute 61

64 Fibromyalgia Body Mass Index in Patients With Fibromyalgia (N = 224) Percent Normal Overweight Obese Obese Fibromyalgia Cohort U.S. Census Bureau Normal = < 25 Overweight = 25 3 Obese = > 3 Epidemiologic data have suggested that fibromyalgia patients have a higher prevalence of obesity. More than 73% of fibromyalgia patients in Cleveland Clinic s cohort were overweight or obese. U.S. Census Bureau data (29 21) showed that the percentage of people with a body mass index (BMI) > 3 was 35.7%, while 43.8% of fibromyalgia patients were obese. This relationship is important because obesity may impair physical activity and predispose patients to sleep disturbances as well as depression. Some studies have suggested that weight loss may lessen fibromyalgia severity. Correlation of BMI a With Clinical Parameters in Fibromyalgia Patients (N = 224) Percent Stress P = a BMI = body mass index Aerobic Exercise > 3 min BMI normal BMI overweight BMI obese Hypothyroidism History of Abuse Narcotics A higher BMI was correlated with increased stress, number of medications used for fibromyalgia, hypothyroidism, and narcotic use. Obese fibromyalgia patients were less likely to engage in aerobic activity on a regular basis. These associations are also found in obese patients without fibromyalgia. 62 Outcomes 213

65 Comparison of Depression and Medication Use Based on BMI a (N = 224) Score P = a BMI = body mass index b PHQ-9 = Patient Health Questionnaire BMI normal BMI overweight BMI obese PHQ-9 b Number of Medications for Fibromyalgia.3.1 Comparison of Medical Comorbidities and Functional Status Based on BMI (N = 224) Score 2 1 P = a HAQ = Health Assessment Questionnaire BMI normal BMI overweight BMI obese Comorbidities HAQ a.1.1 Higher BMI was found to be correlated with increased risk for depression (PHQ-9) and an increase in number of medications used for fibromyalgia. Obese patients had a greater number of other medical diagnoses (medical comorbidities). Assessment of functional status (HAQ) was higher, indicating lower functional capacity. Orthopaedic & Rheumatologic Institute 63

66 Progressive Systemic Sclerosis Percentage of Patients With Progressive Systemic Sclerosis Who Obtained Yearly Echocardiograms and Pulmonary Function Testing Percent N = 467 a pulmonary function testing Percent N = PFT a Echo b 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; and measurement of N-terminal protein natriuretic peptide (NT-proBNP), performed annually. The percentage of patients having PFTs and echos increased from 4 to 6 between 21 and 213. A chart review of 2 patients missing PFTs showed that one patient had morphea, one patient had PFTs outside Cleveland Clinic, 16 had one to three PFTs, and only two (1%) had no PFTs performed. A chart review of 2 patients missing echos showed that 18 had one to three echos, one had systemic lupus erythematosus, and only one (5%) had no echo. b 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): Outcomes 213

67 Percentage of Patients With Progressive Systemic Sclerosis and Interstitial Lung Disease Who Obtained Yearly Echocardiograms and Pulmonary Function Testing Percent N = 189 a pulmonary function testing Percent N = 195 b echocardiogram PFT a Echo b 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 and transthoracic echocardiogram, performed annually. Patients with abnormal PFTs were more likely to receive a computed tomography scan and, if they had interstitial lung disease (ILD), were more likely to have an echo than were PSS patients without a diagnosis of ILD. The percentage of patients having PFTs and echos has increased from about 5 in 21 to 7 by 212. A chart review of 2 patients missing PFTs showed that one patient had morphea, one patient had PFTs outside Cleveland Clinic, 16 had one to three PFTs, and only two (1%) had no PFTs performed. A chart review of 2 patients missing echos showed that 18 had one to three echos, one had systemic lupus erythematosus, and only one (5%) had no echo. 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): Orthopaedic & Rheumatologic Institute 65

68 Progressive Systemic Sclerosis Percentage of Scleroderma Patients With Gastroesophageal Reflux Disease Treated With Antisecretory Medications (N = 48) 213 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 ability to heal esophagitis and provide symptomatic relief. In these uses, proton pump inhibitors are more effective than histamine2 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. Of 48 patients, 42 (98.5%) 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): Diastolic Dysfunction in Progressive Systemic Sclerosis by Autoantibody Subgroup Percent N = Scl-7 a Positive 18 a scleroderma-7 antibodies b antibodies to RNA polymerase III Pol-III b Positive 24 Diastolic dysfunction has been reported to occur in 23% of progressive systemic sclerosis (PSS) patients with both limited and diffuse disease. Diastolic heart failure and diastolic dysfunction refer to the decline in performance of one ventricle (usually the left) or both ventricles (left and right) during diastole. Diastolic dysfunction has four basic echocardiographic patterns, which are graded I to IV; all have an abnormal relaxation pattern. At least seven autoantibodies have been described in PSS. Patients (N = 42) with RNA polymerase III (Pol-III) antibodies were identified, of whom 18 had diffuse disease (proximal extremity or truncal skin involvement). Patients (N = 54) with scleroderma (Scl-7) antibodies were identified, of whom 24 had diffuse disease. Diastolic dysfunction had a significantly higher prevalence in PSS patients with Scl-7 antibodies (74%), compared with those with Pol-III antibodies (26%) (relative risk = 4.2, P =.52). 66 Outcomes 213

69 Reversible Cerebral Vasoconstriction Syndrome Vessel Wall Characteristics Using High Resolution Magnetic Resonance Imaging in Reversible Cerebral Vasoconstriction Syndrome and Central Nervous System Vasculitis (N = 26) 213 Number of Patients (%) Vessel Wall Thickening Initial Scan Marked Vessel Wall Enhancement Initial Scan CNS a vasculitis RCVS b Resolution Vessel Wall Enhancement/Narrowing a central nervous system b reversible cerebral vasoconstriction syndrome 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 with acute-onset, severe, recurrent headaches. It is important to distinguish this condition from central nervous system (CNS) vasculitis because RCVS patients do not require immunosuppressive agents. The utility of 3Tesla high resolution magnetic resonance imaging (3T-HRMRI) in characterizing intracranial vessel wall patterns was evaluated in cerebrovascular diseases. Vessel wall characteristics of thickening, gadolinium enhancement, and resolution of enhancement at baseline and follow-up were examined using 3T-HRMRI with gadolinium enhancement. While both CNS vasculitis and RCVS patients had vessel wall thickening (92% and 77%, respectively), no patients with RCVS had marked vessel wall enhancement while 92% with CNS vasculitis had marked enhancement on MRI. Of patients with RCVS, 3% had negligible to mild enhancement. Follow-up MRIs showed that resolution of enhancement/luminal narrowing occurred in only 33% of CNS vasculitis patients and in 89% of RCVS patients. This study showed distinguishable HRMRI wall patterns for CNS vasculitis and RCVS which are clinically useful for differentiating between these two conditions. Orthopaedic & Rheumatologic Institute 67

70 Reversible Cerebral Vasoconstriction Syndrome Evidence for Noncerebral Vasomotor Abnormalities in Reversible Cerebral Vasoconstriction Syndrome by Transthoracic Echocardiogram (N = 18) 213 Number of Patients RCVS a TTE b Performed TTE Abnormal TTE Resolved a reversible cerebral vasoconstriction syndrome b transthoracic echocardiogram Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache, with or without neurologic deficits, and cerebral vasoconstriction that is reversible on serial testing. Systemic hemodynamic abnormalities have not been described in RCVS. Sixty-eight patients with RCVS were reviewed: 18 patients had neurologic or cardiac symptoms that resulted in a transthoracic echocardiogram (TTE). Three patients had global wall motion abnormalities, and two patients improved on repeat TTE. None of the patients had a history of cardiac disease. The resolution of cardiac wall motion abnormalities suggests that the systemic circulation, in addition to the cerebral circulation, may be affected in some patients with RCVS. 68 Outcomes 213

71 Common Variable Immunodeficiency Percentage of CVID a Patients Who Meet Diagnostic, Evaluation, and Treatment Guidelines (N = 26) 213 Patients (%) Low IgG and Low IgA or IgM B-Cell Subset Vaccination Testing PFT b or CT c LFT d and Creatinine Immunoglobulin Treatment Trough IgG > 5 mg/dl a common variable immunodeficiency b pulmonary function testing c computed tomography d liver function tests 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 69

72 Immunodeficiency HIV 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 slightly more than 85% to 93% had screening for syphilis. 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) 213 Patients (%) Viral Load < 4 Copies Viral Load < 4 Copies All Tests Tuberculosis Testing Patients with HIV/AIDS should have testing for tuberculosis at the baseline visit; 74% of patients in the cohort have had tuberculosis testing. The goal of treatment is viral suppression to a level < 4 copies/ ml; 94% of patients had a documented viral load < 4 copies/ml at least once in 213, and 68% had a viral load < 4 copies/ml on every test in 213. 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. 7 Outcomes 213

73 Myositis Pulmonary Hypertension and Interstitial Lung Disease in Patients With Myositis Who Have Antibodies to Jo-1 (N = 116) Percent Interstitial Lung Disease Pulmonary Hypertension Number PAP a 25 4 mm Hg PAP mm Hg PAP > 55 mm Hg 2 Mild PH b Moderate PH Severe PH a pulmonary artery pressure b pulmonary hypertension Antisynthetase syndrome represents a subset of patients with myositis who have a constellation of findings that include interstitial lung disease (ILD), mechanic s hands, Raynaud phenomenon, and arthritis. The most common autoantibody is anti-jo-1. Pulmonary hypertension (PH) occurs in autoimmune rheumatic diseases including systemic sclerosis and can occur with or without ILD. Patients with poly/dermatomyositis were identified (N = 1823); 116 (6.4%) had anti-jo-1 antibody, 13 had ILD, and 12 had PH by right heart catheterization (RHC). The severity of ILD was graded based on high resolution computed tomography scans. There was no relationship between ILD severity score and mean pulmonary artery pressure on RHC, which suggests that vascular damage and not ILD severity plays a significant role in PH. Routine screening for PH should be considered in patients with myositis and antibodies to Jo-1. Orthopaedic & Rheumatologic Institute 71

74 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 ACS NSQIP performance benchmarked against more than 4 participating hospitals. Cleveland Clinic Overall Multispecialty 3-Day Mortality and 3-Day Morbidity (N = 4682) July 212 June 213 Percent Observed Expected Overall mortality was lower than expected; overall morbidity was higher than expected and identified as a statistical outlier by the ACS NSQIP hierarchical model. 3-Day Mortality 3-Day Morbidity Orthopaedic Surgery Outcomes July 212 June 213 Percent Observed Expected N = 3-Day Mortality Day Morbidity 763 Pneumonia 763 Deep Vein Thrombosis (DVT) 763 Urinary Tract Infection 762 Surgical Site Infection 761 Return to Operating Room 763 In addition to overall surgical performance, ACS NSQIP data specific to orthopaedic surgery are provided. Pneumonia and DVT were higher than expected and identified as statistical outliers by the ACS NSQIP hierarchical model. 72 Outcomes 213

75 National Hospital Quality Measures Cleveland Clinic Surgical Appropriateness of Care Percent N = Source: medicare.gov/hospitalcompare Cleveland Clinic target This composite metric, based on a group of hospital surgical quality process measures developed by the Centers for Medicare & Medicaid Services, shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic s goal is for all patients to receive all the recommended care that is appropriate. An aggregated all or nothing measurement approach to monitoring multiple publicly reported surgical measures trended positively in 213. Total Knee Replacement (TKR) and Total Hip Replacement (THR) Complications and All-Cause 3-Day Readmissions July 29 June 212 Percent Complications Readmissions N b = Cleveland Clinic National Rate a CMS calculates two TKR/THR outcomes measures based on Medicare claims and enrollment information. The most recent risk-adjusted data available from CMS are shown. Although Cleveland Clinic s TKR/THR complications rate and readmissions rate are slightly higher than the US national rates, CMS ranks Cleveland Clinic s performance on both as no different than the US national rate. To further reduce avoidable readmissions, Cleveland Clinic is focused on improving transitions from hospital to home or postacute facility. Specific initiatives have been implemented in each of these focus areas: communication, education, and follow-up. a Source: medicare.gov/hospitalcompare b N = eligible discharges Orthopaedic & Rheumatologic Institute 73

76 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 educational opportunities and training programs designed to help them provide the best possible experience in every patient encounter. Outpatient Office Visit Survey Orthopaedic & Rheumatologic Institute CG-CAHPS Assessment a (N = 5161) 213 Percent Best Response 1 8 CAHPS Database Average (All Practices b ) Appointment Access Doctor Communication Doctor Rating Clerical Staff Test Results Communication 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 CAHPS database from 2399 medical practices in 212. Source: Press Ganey, a national hospital survey vendor 74 Outcomes 213

77 Inpatient Survey Orthopaedic & Rheumatologic Institute HCAHPS Overall Assessment Percent Best Response Hospital Rating (% 9 or 1) 1 Scale 77 a Response options: Definitely Yes, Probably Yes, Probably No, Definitely No Source: Press Ganey, a national hospital survey vendor 84 Recommend Hospital (% Definitely Yes) a 212 (N = 549) 213 (N = 535) National Average All Patients b 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 Percent Best Response a (N = 549) 213 (N = 535) 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, April 212 March 213, from 3938 US hospitals. medicare.gov/hospitalcompare Orthopaedic & Rheumatologic Institute 75

78 Cleveland Clinic Implementing Value-Based Care Overview Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing three 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 213 focus areas in pursuit of this three-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 1..8 Cleveland Clinic Central Line-Associated Bloodstream Infection ICU Rate per 1 Line Days Rate per 1 Line Days Cleveland Clinic UHC a Academic Medical Center 5 th Percentile (213) 1..5 Cleveland Clinic Performance Cleveland Clinic Target. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q a These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Cleveland Clinic s observed/expected (O/E) mortality ratio outperformed the University HealthSystem Consortium (UHC) academic medical center 5th percentile throughout 213 based on the UHC 213 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 (CLABSIs), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews for every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population. 76 Outcomes 213

79 Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1 Eligible Patients Rate per 1 Patients Cleveland Clinic UHC a Academic Medical Center 5 th Percentile Q3 Q4 Q1 Q2 Q3 Q a These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Improved screening and prevention strategies have supported Cleveland Clinic s continued improvement with respect to postoperative pulmonary embolism and deep vein thrombosis (AHRQ Patient Safety Indicator 12). Embolism/thrombosis prevention remains a safety priority for Cleveland Clinic in 214. Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult) Percent Q1 Cleveland Clinic NDNQI 5 th Percentile (academic medical centers) a Q2 Q3 Q4 Q1 Q2 Q3 Q a Data reported from the National Database for Nursing Quality Indicators (NDNQI ) with permission of the American Nurses Association A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. Cleveland Clinic caregivers have been trained to provide appropriate skin care preventive measures, which include patient repositioning and the use of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively identify hospital-acquired pressure ulcers through daily nursing assessments and, in collaboration with the multidisciplinary team, implement early treatment recommendations. Orthopaedic & Rheumatologic Institute 77

80 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 educational opportunities and training programs designed to help them provide the best possible experience in every patient encounter. Outpatient Office Visit Survey Cleveland Clinic CG-CAHPS Assessment a (N = 64,463) 213 Percent Best Response 1 8 CAHPS Database Average (All Practices b ) Appointment Access Primary Care Specialty Care Doctor Communication Doctor Rating Clerical Staff Test Results Communication 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 CAHPS database from 2399 medical practices in 212. Source: Press Ganey, a national hospital survey vendor 78 Outcomes 213

81 Inpatient Survey Cleveland Clinic HCAHPS Overall Assessment Percent Best Response Hospital Rating (% 9 or 1) 1 Scale a Response options: Definitely Yes, Probably Yes, Probably No, Definitely No Source: Press Ganey, a national hospital survey vendor HCAHPS Domains of Care Percent Best Response a Recommend Hospital (% Definitely Yes) a 212 (N = 11,254) 213 (N = 1,671) National Average All Patients b 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. 212 (N = 11,254) 213 (N = 1,671) 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, April 212 March 213, from 3938 US hospitals. medicare.gov/hospitalcompare Orthopaedic & Rheumatologic Institute 79

82 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 top strategic priority for Cleveland Clinic as healthcare reform moves care delivery from fee-for-service to a population health and bundled payment delivery system, while concurrently improving patient safety, outcomes, and experience. What will our 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 is a value-based model of care, designed to improve outcomes while reducing cost. The patient remains at the heart of the Cleveland Clinic Integrated Care Model. The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in the different settings listed. The care system represents integration of care across the continuum. To build this new care system, critical competencies are care paths and care coordination. We have therefore begun to build disease and condition-specific care paths, and are implementing comprehensive care coordination. Care paths guide patient care both within a venue (e.g., a hospital) as well as along the care system (blue band) to appropriate care venues. Care paths will improve value by employing evidence and/or experience-based practice to reduce unnecessary variation in care, with the goal of achieving optimal outcomes at the lowest possible cost. Measurement of use and outcomes is integral to care paths. Care coordination identifies high-risk patients and risk points in transitions of care, and enhances communication and handoffs between providers and locations. 8 Outcomes 213

83 Improve Population Health In the future, value will be increasingly focused on measures such as the patient s functional status, rather than on traditional outcomes measures. The stroke care path measure below is an example. Improved Health-Related Quality of Life with Implementation of Stroke Care Path (N = 48) Mean Difference in EQ-5D a N b = Stroke Care Path A positive score indicates stable status or improvement a As measured between first and last visit in the same year and adjusted for age, gender, race, marital status, and socioeconomic status. b Patients with perfect self-reported health-related quality of life (EQ-5D index = 1.) were excluded from the analysis. The Ischemic Stroke Care Path, spanning the in-hospital and ambulatory settings, was implemented in 21. Health-related quality of life, defined by the EQ-5D and measured in the ambulatory setting, has shown greater improvements since implementation of the care path. Reduce the Cost of Care Cleveland Clinic All-Cause 3-Day Readmission Rate to Any Cleveland Clinic Hospital Percent of Discharges N b = Q1 Cleveland Clinic Rate Cleveland Clinic CMI UHC a Academic Medical Centers CMI Q ,991 a These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu b N = Total discharges ,14 Case Mix Index Q3 Q4 Q1 Q2 Q3 Q4 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. Cleveland Clinic s CMI remains one the highest among American Academic Medical Centers Orthopaedic & Rheumatologic Institute 81

84 Innovations Postoperative Analysis of Implant Position on Three Dimensional Computed Tomography Following Total Shoulder Arthroplasty Glenoid component loosening is the most common complication following total shoulder arthroplasty (TSA). Accurate determination of component position has been limited using routine imaging, with the predictors of loosening and their impact on clinical outcomes still not well defined. New technology for analysis of implant position following TSA has been developed using three dimensional computed tomography (3D CT) with metal artifact reduction (MAR). CT images are imported into custom-designed 3D imaging software that allows for precise and accurate analysis of component position, including the relationship of glenoid and humeral head components, assessment of bone implant interfaces, and evidence of component shift over time. Accurate evaluation of component position over time can lead to a better understanding of the causes of implant failure following TSA. Use of iterative metal artifact reduction (imar) on postoperative CT scan following TSA demonstrates minimization of metal artifact, improving the ability to measure postoperative component position. Original CT imar CT Original CT Image Reconstructed Shoulder Original CT Image Reconstructed Shoulder Digital templating of glenoid component position on sequential postoperative CT scans demonstrates a change in position of the glenoid component between the immediate postoperative CT1 (labeled in red) and the follow-up postoperative CT2 (labeled in blue) after the two scans have been superimposed on each other. CT1 CT2 82 Outcomes 213

85 Double-Bundle Anterior Cruciate Ligament Reconstruction Device With Independent Tensioning Through a Single Tunnel Double-bundle anterior cruciate ligament (ACL) reconstructions have continued to decrease over the years. This is largely because drilling two tunnels increases failure rate, makes the procedure more technically demanding, and requires more time in surgery. The natural ACL is composed of two bundles, so a double-bundle reconstruction can yield a more anatomic solution. Anthony Miniaci, MD, has developed an implant to resolve these technical challenges. The device allows two graft bundles to be placed in a single tibial bone tunnel. The grafts are separated by an anchor that independently expands within the tunnel to secure them against the bone. The design received a patent (8,491,652) in July 213 and offers the following advantages: Anatomic reconstruction through a single tunnel Independent locking allowing differential tensioning of tendon and suture material Novel dual cam locking technology Exploded view of internal cams Orthopaedic & Rheumatologic Institute 83

86 Innovations Interphalangeal Fusion System for the Hand and Foot More than 58, interphalangeal fusions are performed each year in the US. Typically, these are done using Kirschner wires or compression screws. The difficulty with these options is that they do not result in good bone fixation in the proximal phalanx. Furthermore, strong compression of the joint may not be achieved. Peter Evans, MD, has developed an implant system to overcome these challenges. The system comprises a distal compression bolt and a proximal anchor. The distal bolt s low profile easily passes through the phalanx while the proximal anchor can be significantly larger in diameter for superior fixation in the proximal bone. This is demonstrated to the right against competitive screws. Additionally, the system can be used for multiple-joint fusions as shown below. Evans Compression Screw Standard Compression Screw Herbert Screw 84 Outcomes 213

87 Sternal Closure System Sternotomies are common in the cardiac and thoracic surgical arena. The challenge lies in the postoperative sternal closure. Cerclage wires are normally used for fixation but can result in dehiscence, mediastinitis, tis, and sternal nonunion. Current screw and plate designs allow screws to loosen over time under cyclic loading caused by respiration. The unmet needs are distribution of tension and stable fixation. In a joint effort between Wael Barsoum, MD (Orthopaedic & Rheumatologic Institute), and Douglas Johnston, MD (The Sydell and Arnold Miller Family Heart & Vascular Institute), the surgeons designed d a novel plate, screw, and cable fixation system for sternal closure, which includes: Interlocking plates that secure the sternal halves in two planes Screws that provide bone fixation while acting as tensionrelieving posts Simple tension adjustability No need to pass wires beneath the sternum Orthopaedic & Rheumatologic Institute 85

88 Innovations Acetabular Cup Positioning Using Hip Real-Time Instrumentation Poor placement of hip and shoulder implants can shorten implant survival and increase risk of complications after joint replacement procedures. Technologies such as patientspecific instruments and computer navigation seek to improve the accuracy of implant placement. Cleveland Clinic has developed a type of patientspecific instrument, known as the real-time instrument, that incorporates the information derived from a three dimensional (3D), software-generated preoperative plan into a patient-specific surrogate bone model. Bone cement can be molded in the surrogate model to capture patient-specific features and the orientation of the guide wire from the software, and then transferred to the surgical site. Preclinical studies in bone models and cadavers compared the use of 3D planning and the real-time instrument with standard planning and instrumentation. These preclinical studies showed that the real-time instrument combined with 3D planning improves implant positioning in the hip and shoulder. A randomized controlled trial is underway. Slide guide wire into the model. Mold bone cement. When cement is cured, remove from the model. 86 Outcomes 213

89 Transfer to patient and drill a guide wire. Place the implant in parallel to the guide wire. Orthopaedic & Rheumatologic Institute 87

90 Innovations Fibromyalgia Multidisciplinary Clinic for Improved Patient Outcomes Fibromyalgia is a chronic condition that manifests clinically with widespread pain, fatigue, impaired memory and concentration, and poor sleep. Cleveland Clinic s Orthopaedic & Rheumatologic Institute, in agreement with expert guidelines from North America, Asia, and Europe and the need for care improvement, has initiated the Fibromyalgia Clinic. This clinic is a multidisciplinary program that includes experts in rheumatology, psychology, and physical therapy working together to provide patients access to multiple treatment modalities. Patients complete validated measures of disease status, pain, and mental and physical function on an ipad mobile digital device, with scores immediately available to the exam room clinician and in the electronic medical record. This allows clinicians to assess disease status and response to treatment in real time using objective outcome measures. Knowledge about fibromyalgia is a key first step towards improvement of the condition. A 1-day intensive fibromyalgia session that focuses on education, mechanisms of disease, treatments, exercise, and coping strategies enrolled 52 patients in 213. Patient satisfaction with the session was high. Patient-Reported Outcome Measures GAD: general anxiety disorder FIQ: fibromyalgia impact questionnaire SS: symptom severity MDQ: mood disorder questionnaire SIS: symptom intensity scale WPI: widespread pain index Pain VAS: pain visual analog scale PHQ: patient health questionnaire FVAS: fatigue visual analog scale Fatigue Visual Analog Scale Serial Measures Date: FVAS Outcomes 213

91 An Open-Label Trial of Abatacept (CTLA4-IG) in Relapsing Granulomatosis With Polyangiitis (Wegener s) Granulomatosis with polyangiitis (Wegener s) (GPA) is characterized by necrotizing granulomatous inflammation affecting the upper and lower respiratory tract with necrotizing vasculitis of small- to medium-sized vessels. After initial treatment, relapses occur in more than 5% of patients. Relapses are associated with organ damage and long-term glucocorticoid therapy. Because drug treatments for GPA may have toxicity, alternative treatments represent an unmet need for patients with nonsevere relapses. a A trial conducted by the Vasculitis Clinical Research Consortium (VCRC) b investigated abatacept (CTLA4-Ig) in 2 patients with nonsevere relapsing GPA. Support for this trial and the VCRC was provided by the NIH. Intravenous abatacept was administered with continued methotrexate, azathioprine, or mycophenolate mofetil. Up to 3 mg of prednisone was permitted for the first 2 months. Of 2 patients, 18 (9%) had disease improvement and 16 (8%) achieved disease remission (defined as a BVAS/WG = ) c ; 14 patients (7%) remained on study until closing. Ten of 15 patients were able to discontinue glucocorticoids. For the six patients who did not complete the study, all had active but nonsevere disease. 1 This study provides a signal supporting efficacy of abatacept in nonsevere GPA. Patients enrolled in this study had prior relapses despite significant immunosuppressive therapy. Abatacept was well tolerated and led to disease remission and reduction in glucocorticoid therapy in a large percentage of patients. a nonsevere relapse (no renal, lung with respiratory compromise, major element on BVAS/WG, c no pulse steroids or cyclophosphamide required, prednisone > 15 mg) b VCRC institutions participating in this study include the University of Pennsylvania, Boston University, Cleveland Clinic, Johns Hopkins University, Mayo Clinic, and the Data Management and Coordinating Center at the University of South Florida. c BVAS/WG = Birmingham Vasculitis Activity Score for Wegener s Granulomatosis; improvement defined as a reduction in score, and remission defined as a score of Reference 1. Langford CA, Monach PA, Specks U, Seo P, Cuthbertson D, McAlear CA, Ytterberg SR, Hoffman GS, Krischer JP, Merkel PA; for the Vasculitis Clinical Research Consortium. An open-label trial of abatacept (CTLA4-IG) in nonsevere relapsing granulomatosis with polyangiitis (Wegener s). Ann Rheum Dis. 213 Dec [Epub ahead of print]. Orthopaedic & Rheumatologic Institute 89

92 Innovations Role for Peptide Endothelin-1 in Reversible Cerebral Vasoconstriction Syndrome Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by the sudden onset of recurrent thunderclap headache and is associated with reversible diffuse segmental vasoconstriction of intracranial vessels confirmed by angiographic studies. It is important to differentiate this syndrome from primary vasculitis of the central nervous system because cytotoxic agents are not necessary. Mediators of the syndrome at molecular levels have not been elucidated. Endothelins are peptides that are secreted by vascular endothelial cells; the most potent vasoconstrictor is endothelin-1 (E1). The role of E1 in the pathogenesis of RCVS was investigated in five patients who were matched to 1 healthy controls for race, gender, and age. E1 levels were compared in two patients during an attack (ictal stage) and after resolution. RCVS Ictal Stage N = 5 Matched Healthy Controls N = 1 Patients E1 Level (pg/ml) Age (Years) Gender Mean E1 Level (pg/ml) Mean Age (Years) Gender F F F F F F F F F F Average E1 level (pg/ml) 2.52 (95% CI ) 1.48 (95% CI ) P =.2 9 Outcomes 213

93 Plasma E1 Levels (pg/ml) Patients RCVS Ictal Stage (pg/ml) RCVS Resolution Phase (pg/ml) Average E1 level (pg/ml) Conclusions: Plasma E1 levels are significantly elevated in RCVS patients during the ictal stage as compared with healthy controls. E1 levels declined after resolution of the vasoconstriction to the level of healthy controls in two patients. These preliminary results suggest a potential role of E1 in the pathogenesis of RCVS. These findings endorse the vasoconstrictive pathogenesis of RCVS. Orthopaedic & Rheumatologic Institute 91

94 Contact Information Orthopaedic & Rheumatologic Institute Appointments or , ext Orthopaedic & Rheumatologic Institute Referrals 855.REFER.123 ( ) On the Web at clevelandclinic.org/ortho 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 25 publications in 213. For a complete list, go to clevelandclinic.org/outcomes. Locations For a complete listing of Orthopaedic & Rheumatologic Institute locations, please visit clevelandclinic.org/ortho. 92 Outcomes 213

95 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 93

96 About Cleveland Clinic 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 3,2 Cleveland Clinic staff physicians and scientists in 13 medical specialties and subspecialties care for more than 5.5 million patients across the system, performing more than 22, surgeries and conducting more than 476, emergency department visits. Patients come to Cleveland Clinic from all 5 states and more than 13 nations around the world. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1,44-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 44 buildings on 167 acres. Cleveland Clinic patients represent the highest CMS case-mix index in the nation. Cleveland Clinic encompasses 75 northern Ohio outpatient locations, including 16 full-service family health centers, eight community 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) scheduled to begin offering services in the spring of 215. Cleveland Clinic is the secondlargest employer in Ohio, with more than 43,4 employees. It generates $1.95 billion of economic activity a year. The Cleveland Clinic Model Cleveland Clinic was founded in 1921 by four 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 system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 199s with the development of 16 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and six other community hospitals joined Cleveland Clinic over the past decade and a half, 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 around specific diseases or body systems under single 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. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Riyadh, Saudi Arabia; London, England; Istanbul, Turkey; and Dubai, UAE, as well as El Salvador, Panama, Guatemala, Honduras, the Dominican Republic, and other Caribbean nations. 94 Outcomes 213

97 Cleveland Clinic Lerner Research Institute At the Lerner Research Institute, hundreds of principal investigators, project scientists, research associates, and postdoctoral fellows are involved in laboratory-based translational and clinical research. Total research expenditures from external and internal sources exceeded $248 million in 213. Research programs include cardiovascular, oncology, neurology, musculoskeletal, allergy and immunology, ophthalmology, metabolism, and infectious diseases. Cleveland Clinic Lerner College of Medicine Lerner College of Medicine of Case Western Reserve University is known for its small class size, unique curriculum, and fulltuition scholarships for all students. The program is open to 32 students who are preparing to be physician investigators. Cleveland Clinic is building a new Health Education Campus as the new home for the college and for its partner Case Western Reserve University s schools of medicine, dental medicine, and nursing. Graduate Medical Education In 213, nearly 1,8 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, and its heart and heart surgery program has been ranked No. 1 in the nation since In 213, five programs were ranked No. 2 in the nation diabetes and endocrinology, gastroenterology and GI surgery, nephrology, rheumatology, and urology. For more information about Cleveland Clinic, please visit clevelandclinic.org. Orthopaedic & Rheumatologic Institute 95

98 Resources Referring Physician Center and Hotline For the 24/7 hotline to streamline access to an array of medical services and schedule patient appointments, call 855.REFER.123 ( ), org, or visit clevelandclinic.org/refer123. A free Physician Referral App is now available so you can get in touch immediately with one click of your iphone, ipad, or Android phone or tablet. Remote Consults Online medical second opinions from Cleveland Clinic s MyConsult are particularly valuable for patients who wish to avoid the time and expense of travel. Cleveland Clinic offers online medical second opinions for more than 1,2 life-threatening and life-altering diagnoses. For more information, visit clevelandclinic.org/myconsult, eclevelandclinic@ccf.org, or call , ext Request Medical Records or , ext Medical Records Online Cleveland Clinic continues to expand and improve electronic medical records (EMRs) to provide faster, more efficient, and more accurate care by sharing patient data through a highly secure network. Patients using MyChart can renew prescriptions and review test results and medications from their personal computers. MyChart provides a link to Microsoft HealthVault, a free online service that helps patients securely gather and store health information. It connects to Cleveland Clinic s social media and Internet site, currently the most visited hospital website in America. For more information, visit clevelandclinic.org/mychart. Critical Care Transport Worldwide Cleveland Clinic s critical care transport team and fleet of mobile ICU vehicles, helicopters, and fixed-wing aircraft serve critically ill and highly complex patients across the globe. 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 Track Your Patients Care Online DrConnect offers referring physicians secure access to their patients treatment progress while at Cleveland Clinic. To establish a DrConnect account, visit clevelandclinic.org/drconnect or drconnect@ccf.org. MyPractice Community gives referring physicians online access to their patients test results, medications, and treatment plans during Cleveland Clinic care. Cleveland Clinic's eradiology system offers teleradiology consultation for physicians nationwide. CME Opportunities: Live and Online Cleveland Clinic s Center for Continuing Education operates one of the largest and most successful CME programs in the country. The center s website (ccfcme.org) is an educational resource for healthcare providers and the public. Available 24/7, it houses programs that cover topics in 3 areas. Among other resources, the website contains a virtual textbook of medicine (Disease Management Project) and mycme, a system for physicians to manage their CME portfolios. Live courses, however, remain the backbone of the center s CME operation. Most live courses are held in Cleveland, but outreach plans are underway. 96 Outcomes 213

99 Clinical Trials Cleveland Clinic has promoted research from its earliest days, and has since participated in historic, large, multicenter clinical trials. Today, Cleveland Clinic is running more than 2,2 clinical trials of various types. Researchers are focused on an array of 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. To learn more, go to clevelandclinic.org/research. Cancer Clinical Trials is a new mobile app that provides up-to-date information on the more than 1 active clinical trials available for cancer patients. Download the free Cancer Clinical Trials App at clevelandclinic.org/ cancertrialapp. Healthcare Executive Education Cleveland Clinic s executive education program offers its programs to caregivers worldwide seeking insights into the business, operations, and logistics of a major medical center. The Executive Visitors Program is an intensive three-day behind-the-scenes view of Cleveland Clinic's organization for the busy executive. The Samson Global Leadership Academy is a two-week immersion into the challenges of leadership, management, and innovation. The curriculum includes coaching and a personalized three-year leadership development plan. Learn more at clevelandclinic.org/execed. Orthopaedic & Rheumatologic Institute 97