Outcomes. Neurological Institute

Transcription

1 Outcomes 28 Neurological Institute

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3 Surgical Overview To promote quality improvement, Cleveland Clinic has created a series of Outcomes books similar to this one for many of its institutes. Designed for a physician audience, the Outcomes books contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a review of new technologies and innovations. Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic omission of outcomes for a particular treatment does not mean we necessarily do not offer that treatment our goal is to increase unavailable, we often report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques. In addition to our internal efforts to measure clinical quality, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives: ( ( Our commitment to providing accurate, timely information about patient care will also help patients and referring physicians make informed healthcare decisions. quality/outcomes. Neurological Institute 1

4 Dear Colleague, On behalf of Cleveland Clinic, I am pleased to present our 28 Outcomes books. The primary purpose of our annual Outcomes book initiative is to promote quality improvement at Cleveland Clinic, thereby optimizing the care we provide to our accountability, transparency and results. requiring hospitals to report more and more quality and patient safety data. We view our Outcomes books as voluntary supplements to the required public reporting and an opportunity to share selected innovations with colleagues across the country. Designed for the physician reader, each book in the annual series focuses on care provided by one of our patient-centered content informative. 2 Outcomes 28

5 what s inside Institute Overview 6 Quality and Outcomes Measures Brain Tumors 12 Cerebrovascular Diseases 28 Epilepsy 36 Neuroimaging 82 Neurosurgical Anesthesia 88 Innovations 1 Contact Information 132 Cleveland Clinic Overview 136 Neurological Institute 3

6 Chairman s Letter Dear Colleagues, Clinic s Neurological Institute. We strive continuously to enhance our monitoring of quality measures and outcomes because we view this initiative as an integral part of our clinical practice. In sharing specialized care. which we can monitor longitudinally to encourage continuous improvement. This is the core of, through which we are capturing outcomes and quality measures in each patient s electronic medical record. Our work is incomplete, however, if we focus solely on traditional medical parameters and neglect we are working toward incorporating measurement of this critical component of the healthcare treatment. We will manage your discomfort and pain. We will respond when you need us. These simple precepts serve to remind us that the practice of even the most sophisticated medicine is a human endeavor. We believe our statistics support the assertion that, in terms of both outcomes and patient of a new, laser-based system for minimally invasive treatment of brain tumors, development of 4 Outcomes 28

7 patients taking Natalizumab, development of an improved monitoring system for deep brain stimulators implementation of new paradigms to improve the nation s few dedicated biofeedback programs for chronic insomnia patients. satisfaction is an essential piece in our never-ending drive to strengthen our clinical programs and our ability to conduct research with the potential to improve patients lives. We look forward to the opportunity to partner with you in delivering the highest level of neurological care. Chairman, Neurological Institute Neurological Institute 5

8 Institute Overview 6 Cleveland Clinic s national ranking for neurology and neurosurgery in U.S.News & World Report s 28 America s Best Hospitals survey. The multidisciplinary Cleveland Clinic Neurological Institute specialists dedicated to the treatment of adult and pediatric patients with neurological and psychiatric disorders. The to care. Our unique, fully integrated model strengthens our current standard of care, allows us to measure quality and outcomes on a continual basis and enhances our ability to conduct research. U.S.News & World Report s survey has consistently ranked our neurology and neurosurgery programs among the top 1 in the nation. In 28, our pediatric neurology and neurosurgery programs neurosurgery, pediatric neurology/neurosurgery and psychiatry programs are also ranked best in Ohio. 4 U.S.News & World Report s national pediatric specialty ranking for our pediatric neurology and neurosurgery programs. 6 Outcomes 28

9 The institute model allows our patients to better access the care they need through specialized, neurosurgeons, orthopaedic surgeons, psychiatrists, psychologists, physiatrists, neuroradiologists and others into the comprehensive care of neurological and psychiatric disease: We provide care across the spectrum of neurological disorders, including primary and metastatic tumors of the brain, spine and nerves; pediatric and adult epilepsy; headache, facial pain tremor and dystonia; neurocognitive disorders; cerebral palsy and spasticity; hydrocephalus; metabolic and mitochondrial disease; fetal and neonatal neurological problems; multiple sclerosis; stroke; cerebral aneurysms; brain and spinal vascular malformations; carotid stenosis; intracranial atherosclerosis; nerve and muscle diseases, including amyotrophic lateral sclerosis, peripheral neuropathy, myasthenia gravis and myopathies; sleep disorders; and mental/behavioral health disorders and chemical dependencies. Neurological Institute 7

10 Institute Overview Expert, Specialized Diagnosis angiography, interventional neuroradiology and carotid and transcranial Doppler ultrasound. Our disease, ensuring accurate, in-depth interpretations. neuropsychological testing facilities, electromyography laboratory, autonomic laboratory and cutaneous nerve laboratory. The Latest Treatment Modalities advance such innovations as deep brain stimulation (brain pacemakers), epilepsy surgery, stereotactic spine radiosurgery, endovascular treatment of cerebral aneurysms and vascular malformations, and neuroendoscopy. Distinctive services such as our three-week outpatient program for sufferers of process of bringing novel therapeutic agents from the laboratory to the patient, while maintaining the providing the most advanced and highest quality of care to our patients. Relevant Research programs in translational research, clinical trials of drug and device interventions, neuroimaging research, epidemiology and health outcomes, behavioral and psychiatric research, and research into better diagnostic methods. Typically, more than 1 clinical research trials are under way at research grants and contracts. 8 Outcomes 28

11 Convenient Care in the Community We are committed to making access to world-class care convenient for all patients. Our Neurological Institute regional centers community. multiple specialists and provides a convenient suburban location where they may undergo procedures and use additional services required for their diagnosis and care. In addition, Cleveland Clinic neurologists oversee inpatient care at a number of Cleveland Clinic hospitals. locations throughout the community for patients convenience and comfort. Integrated Nursing Services Nursing in the institute integrates inpatient and ambulatory nursing, enhancing the continuum of patient care. This unique structure also lends itself to greater information sharing and process improvement opportunities. Through continuing education programs, we are able to broaden nursing educational opportunities from basic nursing instruction to subspecialization in neurological nursing, enabling nurses, like our physician colleagues, to provide specialized care. Pioneering the Collection of Data and Outcomes Division, is designed to harness routinely collected electronic clinical and administrative data to allow us to optimize patient care and outcomes. Data from multiple electronic sources, including imaging results and clinical information collected during that can be accessed and queried by healthcare personnel. An integral part of this initiative is the standardization of clinical guides clinical care, quality improvement and research. and to advancing medical education and research in all areas of neurology, neurosurgery and psychiatry. Neurological Institute 9

12 Institute Overview 28 Statistical Highlights Inpatient Facilities (Main Campus) Initial Outpatient Visits 9,711 Total Outpatient Visits 138,713 Admissions 7,132 Brain Tumor Neuro-Oncology 813 Cerebrovascular 1,113 Epilepsy 1,283 1 Outcomes 28

13 Inpatient Days 37,658 Neurocognitive 2,83 Surgical/Interventional Procedures 5,596 Brain Tumor Neuro-Oncology 822 Neuroimaging Studies* 32,23 * studies performed on main campus, Cleveland Clinic satellites, and family health centers Neurological Institute 11

14 Brain Tumors Brain Tumor Diagnosis Distribution (N = 1,915) , 8% Schwannoma 169, 9% Pituitary 336, 18% Meningioma 1% 419, 22% Metastasis 844, 44% Glioma Among patients diagnosed in 28, gliomas were the most common type of brain tumor. Brain Tumor Procedures (N = 822) 28 51, 6% Brain Biopsy 57, 7% Infratentorial Craniotomy 82, 1% Novalis Radiosurgery 99, 12% Pituitary Surgery 1% 215, 26% Supratentorial Craniotomy 318, 39% Gamma Knife Radiosurgery 12 Outcomes 28

15 Brain Tumor Surgical Site Infection Rates Rate per 1 Clean Cases (Percent) (N = 593) 26 (N = 64) 27 (N = 52) 28 (N = 451) encountered and, in the case of brain tumor surgery, neither the respiratory nor the alimentary tracts are entered. N = number of clean cases per year. Enrollment of Patients with Brain Tumors in Clinical Trials Number of Patients Enrolled 5 4 Therapeutic Trials Genetic Trials Clinical research trials remained an important therapeutic option for many of our brain tumor patients. Neurological Institute 13

16 Brain Tumors Brain Biopsy Brain Biopsy: Survival Percent Survival 3-Day 18-Day Number of Surgeries only those patients with available data are included in the calculation. Supratentorial Craniotomy Supratentorial Craniotomy: Survival Percent Survival 1 3-Day 18-Day Number of Surgeries Outcomes 28

17 Supratentorial Craniotomy: Inpatient Mortality Percent Mortality 1 8 Actual Expected (N = 263) 25 (N = 284) 26 (N = 299) 27 (N = 273) 28 (N = 215) severity of patient illness. Supratentorial Craniotomy: Length of Stay (LOS) Days 8 6 Actual Mean LOS Expected Mean LOS (N = 263) 25 (N = 284) 26 (N = 299) 27 (N = 273) 28 (N = 215) Neurological Institute 15

18 Brain Tumors Supratentorial Craniotomy: Karnofsky Performance Scale (KPS) N = Percent of Patients Declined Improved No Change Supratentorial Craniotomy: Survival by tumor type Glioma: Survival Percent Survival 1 3-Day 18-Day Number of Surgeries Outcomes 28

19 Meningioma: Survival Percent Survival 1 3-Day 18-Day Number of Surgeries Metastasis: Survival Percent Survival 1 3-Day 18-Day Number of Surgeries Thirty and 18-day survivals were high in 28 for supratentorial craniotomies independent of tumor type. Neurological Institute 17

20 Brain Tumors Infratentorial Craniotomy Infratentorial Craniotomy: Survival Percent Survival 1 3-Day 18-Day Number of Surgeries Infratentorial Craniotomy: Inpatient Mortality Percent Mortality 1 8 Actual Expected (N = 74) 25 (N = 98) 26 (N = 66) 27 (N = 53) 28 (N = 57) 18 Outcomes 28

21 Infratentorial Craniotomy: Length of Stay (LOS) Days 8 6 Actual Mean LOS Expected Mean LOS (N = 74) 25 (N = 98) 26 (N = 66) 27 (N = 53) 28 (N = 57) Infratentorial Craniotomy: KPS Status (N = 27) 28 Percent of Patients Declined Improved No Change Neurological Institute 19

22 Brain Tumors Infratentorial Craniotomy: Survival by Tumor Type Glioma: Survival Percent Survival 3-Day 18-Day Number of Surgeries Meningioma: Survival Percent Survival 3-Day 18-Day Number of Surgeries Outcomes 28

23 Metastasis: Survival Percent Survival 3-Day 18-Day Number of Surgeries Schwannoma: Survival Percent Survival 3-Day 18-Day Number of Surgeries Thirty-day survival for infratentorial craniotomy remained at 1 percent independent of Neurological Institute 21

24 Brain Tumors Pituitary Surgery Pituitary Surgery: Survival Percent Survival 3-Day 18-Day Number of Procedures Among patients who underwent pituitary surgery, 3- and 18-day survival rates remained stable at more than 95 percent. For 18-day survival rates in 28, data were available only for the first six months; only those patients with available data are included in the calculation. Pituitary Surgery: Inpatient Mortality Percent Mortality Actual Expected (N = 67) 25 (N = 6) 26 (N = 99) 27 (N = 81) 28 (N = 99) Inpatient mortality following pituitary surgery remained at zero percent. Expected mortality is based on national normative data and APR-DRGs, a method of adjusting for severity of patient illness.* 22 Outcomes 28

25 Pituitary Surgery: Length of Stay Days 4 3 Actual Mean (LOS) Expected Mean (LOS) (N = 67) 25 (N = 6) 26 (N = 99) 27 (N = 81) 28 (N = 99) Pituitary Surgery: KPS Status (N = 11) 28 Percent of Patients Declined Improved No Change Neurological Institute 23

26 Brain Tumors Stereotactic Radiosurgery: Gamma Knife Gamma Knife Radiosurgery: Overall Survival Percent Survival 3-Day 18-Day Number of Gamma Knife Procedures patients with available data are included in the calculation. Gamma Knife Radiosurgery: Meningioma Survival Percent Survival 3-Day 18-Day Number of Gamma Knife Procedures Outcomes 28

27 Gamma Knife Radiosurgery: Metastasis Survival Percent Survival 3-Day 18-Day Number of Gamma Knife Procedures Gamma Knife Radiosurgery: Pituitary Tumor Survival Percent Survival 3-Day 18-Day Number of Gamma Knife Procedures Neurological Institute 25

28 Brain Tumors Gamma Knife Radiosurgery: Schwannoma Survival Percent Survival 3-Day 18-Day Number of Gamma Knife Procedures Stereotactic Radiosurgery: Novalis Novalis Stereotactic Radiosurgery: Survival Percent Survival 3-Day 18-Day Number of Novalis Procedures and 18-day survival for this type of treatment, used to treat malignant and metastatic tumors available data are included in the calculation. 26 Outcomes 28

29 Novalis Stereotactic Radiosurgery: Treatment of Painful Spinal Metastases (N = 13) Brief Pain Inventory (BPI) Score Baseline (N = 13) W1 (N = 69) W2 (N = 44) W3 (N = 5) M1 (N = 75) M3 (N = 54) M6 (N = 26) M9 (N = 19) Brief Pain Inventory (BPI) scores following spine radiosurgery in patients presenting with painful spinal metastases. Individual and mean patient scores + 1 s.e on the BPI, a 1-item self-rating pain scale, are plotted for baseline and various time periods weeks 1-3 (W1-W3) and months 1, 3, 6 and 9 (M1, M3, M6, M9) after spine radiosurgery. Higher scores indicate greater pain. Spine radiosurgery is a palliative treatment for pain, typically used in end-stage cancer patients. In 27 and 28, 13 patients with painful spinal metastases were treated with single fraction Novalis spine radiosurgery. As early as week 1 after treatment, there was a statistically significant improvement in patient pain scores (P.1 for all time points except M9; P =.1 for M9). These results remained stable over time. Neurological Institute 27

30 Cerebrovascular Disease Get With The Guidelines Stroke Performance and Quality Measures Clinical Measure Measure Description National Average* GWTG Stroke Performance Measure Goal Cleveland Clinic IV tpa use (eligible < 2 hour arrival) Acute ischemic stroke patients who arrive at the ED within 12 minutes of onset of stroke symptoms and who receive IV tpa within 18 minutes of onset of stroke symptoms 72.8% 85.% 85.% 6.% 88.9% Early antithrombotics (< 48 hour arrival) Patients with ischemic stroke or TIA who receive antithrombotic therapy by the end of hospital day 2 97.% 85.% 96.7% 96.1% 94.4% Antithrombotics at discharge Patients with ischemic stroke or TIA prescribed antithrombotic therapy at discharge (e.g., warfarin, aspirin, other antiplatelet drug) 98.9% 85.% 96.2% 98.6% 99.7% Anticoagulation for atrial fibrillation Patients with ischemic stroke or TIA with atrial fibrillation who are discharged on anticoagulation therapy 98.4% 85.% 97.% 94.6% 98.4% Deep venous thrombosis (DVT) prophylaxis Patients with ischemic stroke, TIA or hemorrhagic stroke who are nonambulatory and receive DVT prophylaxis by the end of hospital day % 85.% 91.3% 93.6% 97.% Lipids measure (statin at discharge) Ischemic stroke or TIA patients with LDL >1, or LDL not measured or on cholesterol reducer prior to admission who are discharged on cholesterol-reducing drugs 88.3% 85.% 85.2% 9.9% 94.7% Smoking cessation counseling Patients with ischemic, TIA or hemorrhagic stroke with a history of smoking cigarettes who are, or whose caregivers are, given smoking cessation counseling during the hospital stay 93.6% 85.% 85.% 1.% 91.5% Get With The Guidelines SM (GWTG) is a hospital-based performance and quality improvement program for the American hospital s commitment to superior patient care using current, evidence-based guidelines. Cleveland Clinic was a 28 improvement. with acute stroke or transient ischemic attack. Circulation 28 Outcomes 28

31 Distribution of Major Cerebrovascular Procedures by Case Type Number of Procedures Ruptured Cerebral Aneurysm Nonruptured Cerebral Aneurysm Arteriovenous Malformation The number of procedures for ruptured cerebral aneurysms increased 11 percent from Ruptured Cerebral Aneurysm: Inpatient Mortality Percent Mortality 3 2 Actual Expected Neurological Institute 29

32 Cerebrovascular Disease Ruptured Cerebral Aneurysm: Length of Stay (LOS) Days 2 15 Actual Mean LOS Expected Mean LOS mortality seen in our patient population (patients may be spending more time in the hospital Nonruptured Cerebral Aneurysm: Inpatient Mortality Percent Mortality 3 2 Actual Expected Outcomes 28

33 Nonruptured Cerebral Aneurysm: Length of Stay Days 6 4 Actual Mean LOS Expected Mean LOS Neurological Institute 31

34 Cerebrovascular Disease Conditions Treated with Endovascular Therapy (N = 366) 28 Aneurysm 36% Other 3% 32 Outcomes 28

35 Endovascular Procedures: Inpatient Mortality Percent Mortality 2 15 Actual Expected (N = 51) 26 (N = 72) 27 (N = 87) 28 (N = 86) Endovascular Procedures: Length of Stay Days 2 15 Actual Mean LOS Expected Mean LOS (N = 51) 26 (N = 72) 27 (N = 87) 28 (N = 86) Neurological Institute 33

36 Cerebrovascular Disease Microsurgery: Inpatient Mortality Percent Mortality 1 8 Actual Expected (N = 81) 26 (N = 79) 27 (N = 59) 28 (N = 45) Microsurgery: Length of Stay Days 1 8 Actual Mean LOS Expected Mean LOS (N = 81) 26 (N = 79) 27 (N = 59) 28 (N = 45) 34 Outcomes 28

37 Aneurysm and Ischemic Stroke: Discharge Status 28 Ruptured Aneurysm Nonruptured Aneurysm Ischemic Stroke A Other 1% 2% 6% Stroke Stroke: Inpatient Mortality Percent Mortality 3 2 Actual Expected Neurological Institute 35

38 Epilepsy Long-Term Seizure Freedom following Frontal Lobe Surgery for Epilepsy (N = 132) Probability of Seizure Freedom Years from Surgery Time from Surgery 6 months 1 year 2 years 5 years 36 Outcomes 28

39 Long-Term Seizure Freedom following Parieto-Occipital Lobe Surgery for Epilepsy (N = 61) Probability of Seizure Freedom Years from Surgery Time from Surgery 6 months 1 year 2 years 5 years Epilepsy surgery in the parieto-occipital lobe is relatively infrequent, compared to frontal and temporal lobe Neurological Institute 37

40 Epilepsy Long-Term Seizure Freedom following Temporal Lobe Surgery for Epilepsy (N = 55) Probability of Seizure Freedom Years from Surgery Time from Surgery 1 year 2 years 5 years 1 years in seizure frequency). National seizure-free rates represent a weighted average of recent studies conducted in the. Mil Med. study. Neurology. Neurology. Neurology. Neurology. Epilepsia. JAMA. 38 Outcomes 28

41 Quality of Life before and after Epilepsy Surgery implemented practice of assessing a comprehensive set of health status measures allows us to evaluate our patients global state of health following surgery. Improvement in Quality of Life following Epilepsy Surgery (N = 22) Quality of Life in Epilepsy (QOLIE-1) Score Before Surgery After Surgery effects and mental effects of medication), mental health (energy, depression, overall quality of life) and role Neurological Institute 39

42 Epilepsy Functional Status before and after Epilepsy Surgery (N = 24) Percent of Patients 1 8 Before After None Moderate Severe Problems Performing Typical Daily Activities through November 28 and who had functional status data collected both before and after surgery. Mood Symptoms before and after Epilepsy Surgery (N = 24) Percent of Patients 8 6 Before After 4 2 None Moderate Severe Mood Symptoms (Depression/Anxiety) through November 28 and who had mood symptom data collected both before and after surgery. 4 Outcomes 28

43 Driving before and after Epilepsy Surgery (N = 22) Surgical Dates: January 27 November 28 Percent of Patients Driving 2 1 Before Surgery After Regaining driving privileges is a major goal for most epilepsy patients. Following epilepsy surgery, 14 percent of patients were able to return to driving. Mean followup was 5.7 months after surgery. Information is based on 22 adult patients who had epilepsy surgery from January 27 through November 28 and who provided driving status both before and after surgery (P =.4, chi-square test). Neurological Institute 41

44 Epilepsy Improvement in Seizure Severity following Epilepsy Surgery (N = 19) LSSS Before Surgery After Surgery In addition to seizure severity, the average seizure frequency was reduced from 12.3 seizures per month before surgery to Outcomes 28

45 Movement Disorders Parkinson s Disease: Improvement in Motor Scores with Deep Brain Stimulation (DBS) (N = 27) 28 Average Unified Parkinson s Disease Rating Scale (UPDRS) Score 4 2 Preoperative Postoperative Stimulator Off Postoperative Stimulator On Neurological Institute 43

46 Movement Disorders Parkinson s Disease: Reduction in Medication Dose with DBS (N = 27) 28 Mean Levodopa Equivalent Dose (Milligrams) Before DBS After DBS 44 Outcomes 28

47 Multiple Sclerosis Intrathecal Baclofen Therapy after the surgery. The hardware was removed, and the patient opted to have the pump reimplanted a few months later. No patients chose to discontinue the therapy. Diagnosis/Indication for ITB Number of Patients Cerebral Arteritis 1 Neurological Institute 45

48 Multiple Sclerosis 28 Spasticity Score Before After increase in tone) at baseline and after ITB therapy 1, paired t-test) reduction in spasticity after was 16 days. Treatment 46 Outcomes 28

49 Spasm Frequency before and after ITB (N=17) 28 Spasm Frequency Score Before After Treatment, paired Pain Scores before and after ITB (N = 17) 28 Mean Pain Score Before Treatment After Neurological Institute 47

50 Multiple Sclerosis Gait Speed before and after ITB Timed 25-Foot Walk (N = 7) 28 Mean Gait Speed (Seconds) Before Treatment After test, following ITB for the patients who remained ambulatory. bothersome spasticity, which may interfere with activities of daily living, sleep and quality patients after ITB. 48 Outcomes 28

51 Natalizumab (Tysabri ) Therapy administer Natalizumab. Time to Tysabri Treatment Discontinuation (N = 195) Probability of Remaining on Natalizumab Months from Treatment Initiation Neurological Institute 49

52 Multiple Sclerosis Reasons for Discontinuing Natalizumab (N = 51) Number of Reason for Discontinuation Patients Details Allergy 6 Antibodies 2 Two patients developed neutralizing antibodies against Natalizumab. Infections 2 Two patients developed infections that were neither severe nor due to opportunistic organisms. related to Natalizumab. Other 6 One patient became pregnant, one patient moved and was not able to continue Natalizumab for logistical reasons and four patients had a change in insurance resulting in lack of coverage for Natalizumab therapy. Deceased 1 One patient died; the cause was not related to Natalizumab. 5 Outcomes 28

53 Multiple Sclerosis (MS) Literacy Assessment and Patient Education Health Literacy Test Results before and after Patient Education (N = 47) Percent Correct Before After Average percentage correct on 11 multiple choice questions assessing health literacy improved following the participant attending a single educational session. Neurological Institute 51

54 Neuromuscular Disease Myasthenia Gravis Myasthenia Gravis Functional Status (N = 12) 28 Mean MG-ADL* Score Initial Follow-up Visit 52 Outcomes 28

55 Pain/Headache Infusion Therapy for Headache Pain Reduction Immediately following Infusion Therapy (N = 196) 28 Percent of Patients Percent Pain Reduction 75-1 headache and chronic daily headache may receive intravenous infusion patients treated in 28. Neurological Institute 53

56 Pain/Headache Interdisciplinary Method for the Assessment and Treatment of Chronic Headache (IMATCH) Pain Ratings before and after IMATCH (N = 64) 28 Pain Score ( = No Pain; 1 = Worst Possible Pain) Current Average Admission Discharge Pain Least Worst a more comprehensive assessment of their pain, patients are asked to rate their current pain as well as pain over the preceding week. Current pain is the level of pain at that moment; average, least and worst levels of pain are reported for the preceding week. Information is in 28. Stress, Anxiety and Depression before and after IMATCH (N = 64) 28 Depression Anxiety Stress Scale (DASS) Score 3 Admission Discharge 2 subscale scores are plotted with their standard deviations. 1 Stress (-42) Anxiety (-42) Depression (-42) 54 Outcomes 28

57 Functional Status before and after IMATCH (N = 64) 28 Disability Score 8 6 Admission Discharge 4 2 Pain Disability Index (-7) Headache Impact Test (36-78) Patient Satisfaction with IMATCH (N = 64) 28 Average Satisfaction Score Whole Program Medical Treatment Psychological Treatment Physical Therapy Treatment Program Components Neurological Institute 55

58 Pain/Headache Cleveland Clinic Chronic Pain Rehabilitation Program to the treatment of patients with chronic pain. These patients typically have pain that is distress as well. Chronic Pain Rehabilitation Program Admissions Number of Patients were disabled. 56 Outcomes 28

59 Chronic Pain Rehabilitation Program Completion Rate Percent of Patients Completing Program Pain Intensity before and after CPRP Mean Pain Score (=No Pain; 1=Worst Possible Pain) Admission Discharge 6-month Follow-up Neurological Institute 57

60 Pain/Headache Depression before and after CPRP Mean Depression Anxiety Stress Scale Score 3 2 Admission Discharge 6-month Follow-up Depression scores, as measured with the DASS depression subscale, show improvement following treatment. Higher scores indicate more severe depression. Anxiety before and after CPRP Mean Depression Anxiety Stress Scale Score 2 Admission Discharge 6-month Follow-up Anxiety scores, as measured with the DASS anxiety subscale, show improvement following treatment. Higher scores indicate more severe anxiety. 58 Outcomes 28

61 Functional Status before and after CPRP Mean Pain Disability Index (PDI) 6 4 Admission Discharge 6-month Follow-up scores indicate greater disability. Activity Level before and after CPRP Mean Hours of Rest 25 2 Admission 6-Month Follow-up improvement, as it suggests that their lives are less affected by their pain. Neurological Institute 59

62 Pediatric Neurology Pediatric Headache Headache Disability (N = 46) 28 Mean 4 3 Visit 1 Visit PedsMIDAS Headache Frequency Rescue Doses as the number of headache days in the previous three months. Comparing group means for headache frequency between visit 1 and visit 2, there was an improvement assessment on at least two occasions in Outcomes 28

63 School Days Missed (N = 17) 28 School Days Missed Visit 1 Visit 2 number of complete and partial school days missed in the preceding three months Neurological Institute 61

64 Pediatric Neurology Pediatric Neurometabolic Clinic Neurometabolic Clinic Diagnostic Yield Number of Patients New Patient Consults Diagnosis Established via Muscle, Genetic or CSF* Testing The term idiopathic developmental delay remained largely without a diagnosis. With advances in technology and improving diagnostic skills, the ability to reach conclusive diagnoses in this population has steadily improved. While there is no national standard for diagnostic yield in this patient population, tertiary care centers such as ours have the potential * mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard 62 Outcomes 28

65 Pediatric Electromyography (EMG) Pediatric EMG Number of Studies Total EMGs EMGs with OR/Sedation Cleveland Clinic is one of very few medical centers in the country that provide high-quality Neurological Institute 63

66 Pediatric Neurosurgery Pediatric Congenital Malformation: Length of Stay (LOS) Days (Mean LOS) 8 Actual Expected Number of Procedures patient illness.* Chiari Malformation: Length of Stay Days (Mean LOS) 8 Actual Expected Number of Procedures Outcomes 28

67 Chiari Malformation: Inpatient Mortality Percent Mortality 5 4 Actual Mortality Expected Mortality Spasticity: Length of Stay Days (Mean LOS) 8 Actual Expected Number of Procedures such as laminectomy with section of the spinal accessory nerve and implantation of a drug infusion device. Neurological Institute 65

68 Pediatric Neurosurgery Pediatric Hydrocephalus: Length of Stay Days (Mean LOS) 1 Actual Expected Number of Procedures Outcomes 28

69 Psychiatric Disorders Women s Mental Health Management Group for Depression Change in Depressive Symptoms with Group Medication Management (N = 29) Mean PHQ-9** Score 1 5 Baseline 1 Year scores, a measure of depression severity, were compared from baseline to one year after the Neurological Institute 67

70 Psychiatric Disorders Percent of Patients 1 75 Baseline 1 Year 5 25 % % Not at all Somewhat Very Extremely on this measure. 68 Outcomes 28

71 Inpatient Treatment for Depression Depressive Symptoms before and after Treatment (N = 22) 28 Mean Scale Score 4 3 Admission Discharge 2 1 Hamilton Depression Scale Montgomery-Asberg Depression Rating Scale Neurological Institute 69

72 Psychiatric Disorders Illness Severity and Manic Symptoms before and after Treatment (N = 22) 28 Mean Scale Score Admission Discharge Clinical Global Impression Severity Scale Young Mania Rating Scale scores of less than eight are considered normal. Binge Eating Binge Eating Disorder (BED). BED has been associated with poorer surgery outcomes, including weight regain, and is thus an important factor to assess and treat for bariatric surgery patients.*, satisfaction questionnaire. 7 Outcomes 28

73 whom information is available. Binge Eating before and after Therapy (N = 168) 28 Number 3 2 Before Treatment After Treatment 1 Average BES Average Number of Binge Eating Episodes Eat Weight Disord. a review. Psychosom Med. Addict Behav. Neurological Institute 71

74 Psychiatric Disorders Patients with 2 or More Binge Eating Episodes per Week before and after Therapy (N = 168) 28 Number of Patients Before Treatment After binge eating disorder (two or more binges per week). Only 61 patients (36 percent) met the with 33 percent afterward. 72 Outcomes 28

75 Sleep Disorders Adult Sleep Studies Number of Studies 4, 3, 2, PSG/EEG CPAP/BiPAP Split MSLT/MWT 1, There has been a progressive increase in the number of adult sleep studies over the past four years. Pediatric Sleep Studies Number of Studies The number of pediatric sleep studies has doubled in the past three years. Neurological Institute 73

76 Sleep Disorders Sleep Apnea Sleepiness before and after Treatment (N = 217) 28 Epworth Sleepiness Scale Score 15 1 Before CPAP/BiPAP After CPAP/BiPAP 5 Average Median 74 Outcomes 28

77 Fatigue before and after Treatment (N = 212) 28 Fatigue Severity Scale Score 6 4 Before CPAP/BiPAP After CPAP/BiPAP 2 Average Median Neurological Institute 75

78 Sleep Disorders Depressive Symptoms before and after Treatment (N = 212) 28 Patient Health Questionnaire-9 Score 1 8 Before CPAP/BiPAP After CPAP/BiPAP Average Median 76 Outcomes 28

79 Functional Status before and after Treatment (N = 216) 28 Functional Outcomes of Sleep Questionnaire Score 3 2 Before CPAP/BiPAP After CPAP/BiPAP 1 Average Median Neurological Institute 77

80 Sleep Disorders Functional Status Domains before and after Treatment (N = 216) Mean FOSQ Subscale Score 4 3 Before CPAP/BiPAP After CPAP/BiPAP 2 1 General Productivity Social Outcomes Activity Level Vigilance Intimate Relationships 78 Outcomes 28

81 Spinal Diseases Spine Surgical Cases 28 Number of Procedures 1, Lumbar Cervical Thoracic Distribution of Spine Surgical Cases by Disease Category 28 Number of Procedures 1,4 1,2 1, Degenerative Deformity Fracture/ Trauma Tumor Other Degenerative spine disease is the most common diagnosis among patients who undergo surgery. Neurological Institute 79

82 Spinal Diseases Patients and Cases Studied in Tumor Board Review Patients/Cases Total Patients Studied Total Cases Studied approach for diagnosis, treatment, patient satisfaction and quality for patients with tumor cases through a logic-based decision-making process. The annual increase in patients and cases studied is attributed to the unique team approach. 8 Outcomes 28

83 Center for Spine Health Total Outpatient Visits 28 Total Visits 32, 24, 16, 8, Year 28 Outpatient visits trended upward during the period in the Center for Spine Health, representing an overall increase of 34 percent in patient volume. Neurological Institute 81

84 Neuroimaging Image-Guided Procedures Number of Procedures Diagnostic Therapeutic Image-guided procedures include spinal arteriograms, Wada tests, diagnostic and and placement of subarachnoid drains. Cerebral Angiography Number of Procedures 4, 3, 2, 1, The number of cerebral angiographies performed increased by 33 percent in Outcomes 28

85 Cross-Sectional Imaging Studies Number of Studies 5, 4, 3, Head CT* Brain MRI** Neurovascular Ultrasound 2, 1, * Computed Tomography Neurological Institute 83

86 Neuroimaging Neuroradiology Interobserver Variability 28 Percent of Studies Reviewed 1 8 Strongly Disagree Mostly Agree Agree Ultrasound CT MRI Type of Imaging Study studies as an overall measure of quality assurance. Neuroradiology staff members reinterpret representative samples of their report is placed into one of three categories: (1) agree with the initial report, (2) mostly agree with the initial report, with no Because the review takes place daily, the delay in patient care is minimized. 84 Outcomes 28

87 Neuroradiology Report Turnaround Time: CT 28 Month (Number of Reports) Jan (N = 2,198) Feb (N = 2,655) Mar (N = 2,667) Apr (N = 2,915) May (N = 2,866) Jun (N = 2,638) Jul (N = 2,515) Aug (N = 2,693) Sep (N = 2,544) Oct (N = 2,946) Nov (N = 2,634) Dec (N = 2,752) Median Turnaround Time (Minutes) Neurological Institute 85

88 Neuroimaging Neuroradiology Report Turnaround Time: MRI 28 Month (Number of Reports) Jan (N = 3,339) Feb (N = 3,625) Mar (N = 3,963) Apr (N = 4,35) May (N = 3,973) Jun (N = 3,966) Jul (N = 4,2) Aug (N = 3,768) Sep (N = 3,876) Oct (N = 4,277) Nov (N = 3,662) Dec (N = 3,973) Median Turnaround Time (Minutes) 86 Outcomes 28

89 Brain Attack Head CT Reporting 28 Month (Number of Reports) Jan (N = 7) Feb (N = 16) Mar (N = 21) Apr (N = 18) May (N = 29) Jun (N = 13) Jul (N = 14) Aug (N = 19) Sep (N = 17) Oct (N = 29) Nov (N = 19) Dec (N = 1) Median Time to Notification (Minutes) Neurological Institute 87

90 Neurosurgical Anesthesia Nausea and Vomiting within 24 Hours of Craniotomy 28 Percent of Patients 1 8 Vomiting Nausea Only No Nausea or Vomiting Q1 (N = 119) Q2 (N = 149) Q3 (N = 13) Q4 (N = 11) in the hospital to evaluate the early postoperative period. One outcome measure, collected from medical record review, is postoperative nausea and vomiting. The department features the management of postoperative nausea and vomiting in its clinical quality improvement program. 88 Outcomes 28

91 Nausea and Vomiting within 24 Hours of Spine Surgery 28 Percent of Patients 1 8 Vomiting Nausea Only No Nausea or Vomiting Q1 (N = 215) Q2 (N = 167) Q3 (N = 172) Q4 (N = 161) second postoperative day in the hospital to evaluate the early postoperative period. Information on postoperative nausea and vomiting is collected from medical record review. Neurological Institute 89

92 Neurosurgical Anesthesia Patient Satisfaction with Anesthesia Care for Craniotomy 28 Percent of Patients Responding with Highest Rating Q1 (N = 35) Q2 (N = 41) Q3 (N = 22) Q4 (N = 21) During rounds on the second postoperative day, patients are asked to respond to the 9 Outcomes 28

93 Patient Satisfaction with Anesthesia Care for Major Spine Surgery 28 Percent of Patients Responding with Highest Rating Q1 (N = 117) Q2 (N = 84) Q3 (N = 8) Q4 (N = 71) rating. Neurological Institute 91

94 Surgical Quality Improvement Hospital Compare: Surgical Care Improvement Project (SCIP) data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also SCIP - Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision (N = 92) National Average* 86 Cleveland Clinic Percent of Patients * Source: discharges July 27- June Outcomes 28

95 SCIP - Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time (N = 813) National Average* 84 Cleveland Clinic Percent of Patients * Source: discharges July 27- June 28 SCIP - Prophylactic Antibiotic Selection for Surgical Patients (N = 937) National Average* 92 Cleveland Clinic Percent of Patients * Source: discharges July 27- June 28 Neurological Institute 93

96 Surgical Quality Improvement SCIP - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (N = 677) National Average* 84 Cleveland Clinic Percent of Patients * Source: discharges July 27- June 28 SCIP - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery (N = 677) National Average* 81 Cleveland Clinic Percent of Patients * Source: discharges July 27- June Outcomes 28

97 SCIP - Surgery Patients with Appropriate Hair Removal (N = 1,386) National Average* 95 Cleveland Clinic Percent of Patients * Source: discharges January - June 28 National Surgical Quality Improvement Project Neurosurgery Morbidity (N = 8) Percent Expected Observed Neurological Institute 95

98 Patient Experience way that elevates Cleveland Clinic s reputation as one of the world s best hospitals. patient- and family-based programs that support this mission. Outpatient Neurological Institute Overall Rating of Outpatient Care and Services Percent (N = 5,584) 28 (N = 6,221) 4 2 Excellent Very Good Good Fair Poor Source: Quality Data Management, a national hospital survey vendor 96 Outcomes 28

99 Rating of Outpatient Provider Percent (N = 5,584) 28 (N = 6,221) 4 2 Excellent Very Good Good Fair Poor Source: Quality Data Management, a national hospital survey vendor Recommend Outpatient Provider Percent (N = 5,584) 28 (N = 6,221) 4 2 Extremely Likely Very Likely Somewhat Likely Source: Quality Data Management, a national hospital survey vendor Somewhat Unlikely Very Unlikely Neurological Institute 97

100 Patient Experience Inpatient Neurological Institute reporting are available at HCAHPS Overall Assessment Percent % 62% 27 total survey respondents = total survey respondents = 1,113 78% 73% 4 2 Rate Hospital % respondents choosing 9 or 1 Would Recommend % respondents choosing 'definitely yes' Source: Quality Data Management and Press Ganey, national hospital survey vendors For comparison purposes, 27 and Q1 28 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS. 98 Outcomes 28

101 HCAHPS Domains of Care Percent 1 8 Respondents choosing 'always' or 'yes' 27 total survey respondents = total survey respondents = 1, Discharge Information Doctor Communication Nurse Communication Pain Management Room Clean Communication New Medications Responsiveness to Needs Quiet at Night Source: Quality Data Management and Press Ganey, national hospital survey vendors For comparison purposes, 27 and Q1 28 HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS. Neurological Institute 99

102 Innovations A Novel, Minimally Invasive Therapy for Brain Tumors Brain Tumor and Neuro-Oncology Center (BTNC) 42 Number of new Neurological Institute clinical research trials in 28. 1,69 Number of patients enrolled in Neurological Institute clinical research trials. laser-based system in a human for the minimally invasive (laser interstitial Inc. (Winnipeg, Canada), is used to coagulate tumors through a special laser probe, precisely directed into the tumor, with the heating process monitored by specialized software and thermal tumors and spare patients more invasive interventions. round, whitish area, indicated by an arrow) in the deep portion of the left temporal lobe. The image to the right shows the lesion having been essentially eradicated by (arrow). The markers to the right in each vertical line indicates an interval of 1 cm. Before-and-after treatment views of a magnetic resonance system. 1 Outcomes 28

103 Cranial Radiosurgery for the Older Old While cancer can occur at any age, its incidence increases directly with age. By the year 23, the proportion of the as 28 percent. With improvements in health and nutrition, With respect to cancer that spreads to the brain from a site elsewhere (such as lung, breast or kidney cancer), data age was associated with a poorer prognosis, irrespective of whether the patient received surgery, whole brain radiation shown to play effective roles in the treatment of brain metastasis. months, with more than a third surviving one year and brain remained the principal challenge, although recent innovations in therapies for these cancers appear to be improving overall survival as well. 1% 7% Unknown (N = 3) 7% Breast (N = 3) 7% Lung (SLC) (N =3) 9% Melanoma (N = 4) 11% GI Tract (N = 5) 2% GU Tract (N = 9) 39% Lung (NSCLC) (N = 17) the sole treatment for these brain metastases, meaning that whole brain radiation was generally not given or was given only with nonresponsiveness, which was rare, or later, when one or more brain metastases produced results comparable to the results found in younger patients, nearly all of whom Distribution of patients by type of primary cancer in study of followed by patients with tumors of the kidney and genitourinary older patients. Cancer. Neurological Institute 11

104 Innovations Stereotactic Radiosurgery of Spinal Tumors The development of metastases to the spinal column occurs lead to instability of the spinal column or compression of the spinal cord or nerve roots, and may be associated with disabling pain, neurological dysfunction and paralysis. Early treatment to prevent complications and enhance function is essential. consistent after therapy, even at 12 months following perceived to be radioresistant, such as renal cell carcinoma and melanoma. Traditional treatment options include surgery, conventional radiation therapy, chemotherapy and comprehensive pain management. Now, Cleveland Clinic s Brain Tumor and modality that delivers a high dose of radiation to spinal metastases in a conformal fashion, precisely enveloping the spread beyond the target. procedure with minimal recovery time. This highly selective, precise radiation therapy results in effective relief of pain In our recently reviewed series of more than 1 treated this observation is not likely to be due to chance alone.]) therapy. (A) The scan shows a painful metastasis to the right side lumbar vertebral body. The tumor measures nearly 6 cm. (green taking high doses of morphine but had poor pain control. After a by one month, he needed only an over-the-counter medication, ibuprofen, and by three months, he was permanently off all pain medication. (B) reduction in the size of the tumor, a reduction that has been long-standing. 12 Outcomes 28

105 Integrating Molecular Genetic Information for Tailored Treatment of Patients with Oligodendroglioma The discovery of a genetic alteration in oligodendrogliomas that was prognostic of improved response to treatment and radiation and chemotherapies. provided by analysis of this alteration, also referred to as Neuro-Oncology*, the the use of a chemotherapy-only treatment for patients with anaplastic gliomas. These studies, which are opening in patients with grade III gliomas. 1p-deleted grade III oligodendroglioma. The image on the left shows the patient before the start of chemotherapy with no radiation; and white arrows). The inset, top, shows the relative loss of one copy of chromosome 1p in the tumor tissue of a patient with the deletion (arrow shows the bottom copy missing in the tumor, T, column), compared with the normal (N) signal in blood cells. Neuro Oncol. Advance Neurological Institute 13

106 Innovations Epilepsy Center Enhanced Localization Ability with Magnetoencephalography (MEG) 17 Number of years we have hosted our International Epilepsy Symposium. launched in 28, has enhanced the center s clinical capabilities to better identify epileptic sources in patients where the area of the epileptic focus, b) help guide the placement of intracranial recording electrodes or c) ascertain that the patient is not a surgical candidate. Our Neurocomputing and Clinical Neurophysiology teams have advanced. These new developments include the following: would otherwise obscure the brain activity. direct correlation of the patient s physical actions with the online database to facilitate ongoing quality assessment. 14 Outcomes 28

107 Mellen Center for Multiple Sclerosis Treatment and Research Plasma Exchange as Treatment for Rare Natalizumab Complication unknown, and treatment options are limited. A drug called from entering the brain and attacking nerves, but the drug Natalizumab have suffered an uncommon, but usually fatal leukoencephalopathy). Optical Coherence Tomography (OCT) to Monitor Axonal Injury OCT is a rapid, noninvasive, painless test that generates utilization of OCT to measure the thickness of the retinal form the optic nerve, which connects the eye to the brain) and the volume of the macula (the nerve cell bodies treatment trials. Neurology,* This study showed that monoclonal antibodies can be needed to effectively remove Natalizumab from the bodies of with Natalizumab, which would improve the overall safety of this therapy. and restoring leukocyte function. Neurology Neurological Institute 15

108 Innovations Innovative Study Recruitment Method (N = 1,611). This novel recruitment method can dramatically accelerate research in chronic disease management. Center for Neuroimaging Correcting Motion-Corrupted High-Angular Resolution Diffusion-Weighted Imaging (HARDI) Data error on the diffusion direction is below.2 degrees. (B) tensor-reference motion correction. 16 Outcomes 28

109 Activation Data most common method of assessing connectivity is to measure the temporal correlation between two functional brain regions. Due to individual variation in functional localization in the human brain, a standard technique for imposes a serious limitation on the ability to analyze functional connectivity in the human brain in studies in which on combining anatomic landmarks with a regional measure of temporal coherence. This measure, derived from The high-resolution anatomic image on the left shows a slice through the anterior mesial temporal lobe. The red region is the Neurological Institute 17

110 Innovations Monitoring System for Deep Brain Stimulators during fmri important effort in understanding the mechanisms of this important therapy. To date, all which, when placed over the implant on the patient s chest, determines the state of the Development of Post-Processing Labs to Incorporate Qualitative and Quantitative Data for Routine Clinical Use acquisition devices throughout Cleveland Clinic health system to two post-processing labs. In CT, 2-D and 3-D reconstructions of the original data are produced and forwarded to digital reading stations for interpretation and storage in a central archive so referring one lab to produce and store qualitative maps (e.g., perfusion) for the neuroradiologists and the referring services. The other lab produces quantitative data (e.g., brain volumes, hippocampal volumes, white matter disease burden) that is incorporated into a standardized report form to aid in interpretation and longitudinal clinical follow-up. 18 Outcomes 28

111 Working with Patients to Improve fmri Studies preoperative localization of motor, speech generation and receptive speech areas with an interviews every patient to individualize the study when indicated, review the nature of the study with the patient, provide instructions for the paradigms, and emphasize the prescan patient interview in improving scan quality showed that an intensive intervention can are freely available to any institution. Attention No Attention positive regions. simpler paradigms are now available incorporating pictures and simpler language. This has than by a small subset of research scientists. Neurological Institute 19

112 Innovations Initiation of a Lateralization Score for fmri Studies for Judging Hemispheric Dominance for Speech and brain tumor patients. The important issue is to identify the essential eloquent (primary) cortical areas governing language and motor activity, so the surgeon can provide adequate margins to minimize postsurgical morbidity. Often, this issue is resolved by determining language lateralization, a process hitherto Number Wada Left Wada Bilateral Wada Right 4 2 Right fmri Lateralization Index Left 11 Outcomes 28

113 Sleep Disorders Center Multidisciplinary Continuous Positive Airway Pressure (CPAP) Compliance Group Therapy psychological reasons. The noncompliance rates are estimated to be in the range of 28 Number of dedicated beds with state-of-the-art monitoring equipment for overnight sleep studies. receive tips from professionals while also learning from other patients. They have the problem, they are given detailed individual treatment plans. The feedback from patients has been very positive. Biofeedback for Chronic Insomnia daytime fatigue, increase in workplace and driving accidents, and overall increase in the utilization of healthcare services. Although hypnotic medicines are effective in some patients, they are not always safe for long-term use. that has a dedicated biofeedback program for chronic insomnia. Biofeedback is a technique in which a patient is trained to improve his or her health by developing a greater awareness and voluntary control over the physiological processes affected by biofeedback, respiratory biofeedback, thermal biofeedback and neurofeedback. Neurological Institute 111

114 Innovations Center for Spine Health (CSH) dramatically decreases the time it takes to perform an intraoperative localizing X-ray for anterior of a conventional radiograph. Digital imaging provides information equivalent in accuracy to Time Savings with Digital Intraoperative X-Rays for Anterior Cervical Fusions Average Time (Seconds) Conventional Radiograph N = 1 Digital X-Ray N = 8 On average, digital intraoperative X-rays for anterior cervical fusions take about one-eighth the time of conventional radiographs. 112 Outcomes 28

115 Delaying Recurrences of Myxopapillary Ependymomas The Utility of Repeated Postoperative Radiographs regular intervals in asymptomatic patients following single-level anterior cervical decompression fusion and plating do not appear to be warranted and do not alter the of postoperative radiographs will reduce the amount of save about $1, per patient, reducing the overall cost of healthcare. obtaining repeated postoperative radiographs following single-level anterior cervical decompression, fusion, and plate placement. J Neurosurg Spine. 9 Percent of new Center for Spine Health patients who eventually have spinal surgery. Neurological Institute 113

116 Selected Publications The Neurological Institute staff authored more than 47 publications in 28. For a complete list go to outcomes. Brain Tumor and Neuro-Oncology Center institutional phase II study of temozolomide administered twice daily in the treatment of recurrent high-grade gliomas. Cancer. radiosurgery effectively treats recurrences from whole-brain radiation therapy. Cancer. with sporadic pituitary adenomas. Clin Endocrinol (Oxf). Appl Immunohistochem Mol Morphol. of the treatment of trigeminal neuralgia with gamma knife radiosurgery. Stereotact Funct Neurosurg. 28;86(3): and bevacizumab in progressive primary brain tumors, J Neurooncol. 28 radiosurgical treatment of brain metastases in older patients. Cancer. glioblastoma survivors: a preliminary feasibility study. Genomics. 114 Outcomes 28

117 correlation of serum alpha-subunit concentration and magnetic resonance imaging following pituitary surgery in patients with nonfunctional pituitary macroadenomas. Endocr Pract. in clinoidal meningiomas: rationale for aggressive skull base approach. Acta Neurochir (Wien). 28 Cerebrovascular Center Wingspan in-stent restenosis. Neurosurgery. 28 hemorrhagic risks after intra-arterial revascularization in acute stroke. Neurosurgery. convenience for rational neurovascular studies. J Cereb Blood Flow Metab. vasculogenesis and neurogenesis on rat brain development. Neurobiol Dis. AJNR Am J Neuroradiol. imaging in the intensive care unit. Radiol Manage. 28 Neurology. in cryptogenic TIA or stroke. Neurology. 28 Nov wingspan in-stent restenosis. AJNR Am J Neuroradiol. 28 and monocular blindness after endovascular treatment of large and giant paraophthalmic aneurysms. Neurosurgery. Neurological Institute 115

118 Selected Publications Epilepsy Center seizure genes in systemic lupus erythematosus. Epilepsia. on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord. 28 patients with medically refractory temporal lobe epilepsy. Epilepsy Res. with epilepsy: pharmacokinetic interactions, contraceptive options, and management. Int Rev Neurobiol. 28;83: Epilepsia. impact, mechanisms, and prevention. Cleve Clin J Med. white matter degeneration of the corpus callosum in patients with intractable temporal lobe epilepsy: A diffusion tensor imaging study. Epilepsy Res. medications after successful epilepsy surgery in children. Pediatr Neurol. temporal visual language center: cortical stimulation Neurology. 28 Nov J Magn Reson. 28 Mellen Center for Multiple Sclerosis Treatment and Research is associated with increased levels of ligand in circulation and tissues. Blood. Neurogenesis in the chronic lesions of multiple sclerosis. Brain. Mult Scler Outcomes 28

119 atrophy in multiple sclerosis: a longitudinal study. Ann Neurol. Arch Neurol. functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp. Neurology. orthosis in ambulatory multiple sclerosis patients. Arch Phys Med Rehabil. Annu Rev Neurosci. Ann Neurol. Center for Neuroimaging information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. in association with moya moya disease and bilateral morning glory disc anomaly broadening the clinical spectrum of midline defects. J Neurol. functional connectivity in multiple sclerosis inversely correlates with transcallosal motor pathway transverse diffusivity. Hum Brain Mapp. imaging in the intensive care unit. Radiol Manage. 28 Neurology. 28 Neurological Institute 117

120 Selected Publications Center for Neurological Restoration patients. Brain. brain stimulation in essential tremor. J Clin Neurophysiol. Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia. nucleus deep brain stimulation protocols in a datadriven computational model. J Neurophysiol. 28 in movement disorders. Neurotherapeutics. 28 illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet. J Neurosurg Anesthesiol. Neurosurgery. study on suicide outcomes following subthalamic stimulation Brain. neuronal activity. J Neurosci. Neuromuscular Center J Pain Symptom Manage. microdissection. Mol Vis. Mil Med. 28 Intrathecal baclofen for spasticity-related pain in amyotrophic relief. Muscle Nerve. Oncology (Williston Park). 118 Outcomes 28

121 dyspnea. Muscle Nerve. Neurology. 28 Nov Epilepsia. 28 J Neurol Sci. 28 Neurological Center for Pain in the acute treatment of menstrually related migraine. Headache. combination for the treatment of migraine. Expert Rev Neurother. Neurological Institute 119

122 Selected Publications serotonin syndrome: a review. Expert Opin Drug Saf. 28 management using integrated print and video materials: a multisite randomized controlled trial. Pain. Headache. screening tool for obstetric and gynecology clinics: the menstrual migraine assessment tool. Headache. 28 Center for Pediatric Neurology and Neurosurgery implications of endoscopic third ventriculostomy for the treatment of hydrocephalus. Eur J Obstet Gynecol Reprod Biol. syndrome in a genotypic male. Ophthalmic Genet. 28 hydrocephalus in the patient with gait disturbance. Geriatrics. 12 Outcomes 28

123 Neurology. of suspected mitochondrial disease. Mol Genet Metab. 28 Epilepsy surgery in epidermal nevus syndrome variant with hemimegalencephaly and intractable seizures. J Neurol. in association with moya moya disease and bilateral morning glory disc anomaly broadening the clinical spectrum of midline defects. J Neurol. Pediatr Neurol. in autism spectrum disorder patients: a cohort analysis. PLoS ONE. Department of Psychiatry and Psychology on both verbal and visual memory measures is associated with low risk for memory decline following left temporal lobectomy for intractable epilepsy. Epileptic Disord. 28 Curr Opin Organ Transplant. 28 Br J Psychiatry. Impulsivity and risk-taking behavior in focal frontal lobe lesions. Neuropsychologia. sociocultural ideals predicts weight gain. Body Image. 28 illustrative study of identical twins discordant for risk-taking behavior. Twin Res Hum Genet. heart-brain medicine. Cleve Clin J Med. and bipolar disorders. Ann Clin Psychiatry. 28 Dec;2 Cleve Clin J Med. 28 Psychiatr Clin North Am. J Clin Anesth. Neurological Institute 121

124 Selected Publications Sleep Disorders Center long-term mortality after prolonged mechanical ventilation. Lung. Epilepsia. assessment in bariatric surgery patients. Obes Surg. 28 pulmonary risk assessment and perioperative management in bariatric surgery patients. Obes Surg. Sleep Breath. obstructive sleep apnea in adults with epilepsy: a randomized pilot trial. Neurology. in patients with pulmonary hypertension. J Heart Lung Transplant. Epilepsia. Center for Spine Health stimulation for cervical fusion. Spine J. 28 J Am Acad Orthop Surg. 28 Spinal Disord Tech. of chronic low back pain with opioid analgesics. Spine J. fusion in a workers compensation population. Neurosurgery. instrumentation in the management of scoliosis. Neurosurgery. J Orthop Res. 28 marrow mesenchymal stem cells and nucleus pulposus cells Spine. 122 Outcomes 28

125 stem cells and nucleus pulposus cells. Spine J. 28 an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis. Spine J. Neurosurgical Anesthesiology spine surgery. Anesthesiology. lumbar spine surgery. J Neurosurg Anesthesiol. 28 disruption under general anesthesia: a retrospective review. J Neurosurg Anesthesiol. J Neurosurg Anesthesiol. of remifentanil to prevent movement during craniotomy in the absence of neuromuscular blockade. J Neurosurg Anesthesiol. Neurological Institute 123

126 Staff Listing Chairman Vice Chairman, Clinical Areas Vice Chairman, Research and Development Kristin Carlin, DO Department of Neurological Surgery Chairman, Department of Neurological Surgery Department of Neurology Chairman, Department of Neurology Department of Physical Medicine and Rehabilitation Chairman, Department of Physical Medicine and Rehabilitation Department of Psychiatry and Psychology Chairman, Department of Psychiatry and Psychology 124 Outcomes 28

127 Brain Tumor and Neuro-Oncology Center Director, Brain Tumor and Neuro-Oncology Center Neurological Institute 125

128 Staff Listing Lou Ruvo Center for Brain Health Randolph Schiffer, MD Director, Center for Brain Health Cynthia S. Kubu, PhD, ABPP-CN Richard Lederman, MD, PhD Richard Naugle, PhD Michael Parsons, PhD Alexander Rae-Grant, MD, FRCP (C) Stephen Rao, PhD Patrick Sweeney, MD Janice Zimbelman, PhD Center for Neuroimaging Thomas Masaryk, MD Director, Center for Neuroimaging Todd Emch, MD Stephen E. Jones, MD, PhD Mark Lowe, PhD Michael T. Modic, MD, FACR Doksu Moon, MD Micheal Phillips, MD Janet Reid, MD Paul Ruggieri, MD Alison Smith, MD Todd Stultz, DDS, MD Andrew Tievsky, MD Center for Neurological Restoration Ali Rezai, MD Director, Center for Neurological Restoration Anwar Ahmed, MD Jay Alberts, PhD Kenneth Baker, PhD Scott Cooper, MD, PhD Milind Deogaonkar, MD Darlene Floden, PhD Ilia Itin, MD Cynthia S. Kubu, PhD, ABPP-CN Richard Lederman, MD, PhD Andre Machado, MD, PhD Donald Malone Jr., MD Cameron McIntyre, PhD Samer Narouze, MD Mayur Pandya, DO Michael Stanton-Hicks, MD Patrick Sweeney, MD Stewart Tepper, MD Jerrold Vitek, MD, PhD Weidong Xu, MD Jianyu Zhang, MD Center for Pediatric Neurology and Neurosurgery Elaine Wyllie, MD Director, Center for Pediatric Neurology Mark Luciano, MD, PhD Director, Center for Pediatric Neurosurgery Bruce Cohen, MD Xiao Di, MD, PhD 126 Outcomes 28

129 Stephen Dombrowski, PhD Gerald Erenberg, MD Neil Friedman, MBChB Debabrata Ghosh, MD, DM Gary Hsich, MD Irwin Jacobs, MD Manikum Moodley, MD Sumit Parikh, MD A. David Rothner, MD Center for Regional Neurology Stephen Samples, MD Director, Center for Regional Neurology A. Romeo Craciun, MD Sheila Rubin, MD Jennifer Ui, MD Joseph Zayat, MD Center for Regional Neurological Surgery Michael Mervart, MD Director, Center for Regional Neurological Surgery Samuel Borsellino, MD Samuel Tobias, MD Center for Spine Health Edward Benzel, MD Director, Center for Spine Health Gordon Bell, MD Associate Director, Center for Spine Health Daniel Mazanec, MD Associate Director, Center for Spine Health Lilyana Angelov, MD Thomas Bauer, MD, PhD William Bingaman, MD Edwin Capulong, MD Alfred Cianflocco, MD Edward Covington, MD Russell DeMicco, DO Frederick Frost, MD Lars Gilbertson, PhD Augusto Hsia Jr., MD Serkan Inceoglu, PhD Iain Kalfas, MD Tagreed Khalaf, MD Ajit Krishnaney, MD Thomas Kuivila, MD Eric Mayer, MD Robert McLain, MD Thomas Mroz, MD R. Douglas Orr, MD Anantha Reddy, MD Judith Scheman, PhD Richard Schlenk, MD Kalyani Shah, MD Michael Steinmetz, MD Santhosh Thomas, DO Deborah Venesy, MD Fredrick Wilson, DO Adrian Zachary, DO, MPH Neurological Institute 127

130 Referral Staff Listing Contact Information Cerebrovascular Center Director, Cerebrovascular Center Epilepsy Center Imad Na Director, Epilepsy Center 128 Outcomes 28

131 Mellen Center for Multiple Sclerosis Treatment and Research Director, Mellen Center for Multiple Sclerosis Treatment and Research Erik B Neurological Center for Pain Edward Co Director, Neurological Center for Pain Neuromuscular Center Director, Neuromuscular Center Neurological Institute 129

132 Staff Listing Sleep Disorders Center Director, Sleep Disorders Center Department of Neurosciences, Lerner Research Institute Chairman, Department of Neurosciences, Lerner Research Institute Biomedical Engineering, Lerner Research Institute Cell Biology Anatomic Pathology Neuroanesthesiology Section Head, Neurological and Spine Surgery Anesthesiology Section Head, Neuro-Endovascular Anesthesiology clevelandclinic.org/staff. 13 Outcomes 28

133 Neurological Institute 131

134 Contact Information General Patient Referral Neurological Institute Appointments/Referrals On the Web at clevelandclinic.org/neuroscience Additional Contact Information General Information Hospital Patient Information Patient Appointments Medical Concierge Complimentary assistance for out-of-state patients and families Global Patient Services/International Center Complimentary assistance for international patients and families clevelandclinic.org/gps Cleveland Clinic in Florida For address corrections or changes, please call 132 Outcomes 28

135 Institute Locations Cleveland Clinic Neurological Institute physicians see when calling. Main Campus Neurological Institute Regional Centers Euclid Hospital Fairview Hospital Hillcrest Hospital Huron Hospital Lakewood Hospital Lutheran Hospital Marymount Hospital Cleveland Clinic Children s Hospital Shaker Campus Neurological Institute 133

136 Institute Locations Cleveland Clinic Family Health Centers Avon Lake Family Health Center Beachwood Family Health and Surgery Center Chagrin Falls Family Health Center Independence Family Health Center Crown Center II Lorain Family Health and Surgery Center 134 Outcomes 28

137 Solon Family Health Center Strongsville Family Health and Surgery Center Westlake Family Health Center Willoughby Hills Family Health Center Cleveland Clinic Wooster Neurological Institute 135

138 Cleveland Clinic Overview bundling all clinical specialties into integrated practice units called institutes. An institute combines all the under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the point-of-care service, institutes will improve the patient acres in Cleveland, Ohio, includes a 1,-bed hospital, outpatient clinic, specialty institutes and supporting labs multispecialty care hospital and clinic, is scheduled to open in late 212. offers all students full tuition scholarships. The program will Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1 clevelandclinic.org associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total federal agencies, non-federal societies and associations, endowment funds and other sources. In an effort to bring research from bench to bedside, Cleveland Clinic at any given time. 136 Outcomes 28

139 Resources for Physicians Cleveland Clinic Secure Online Services Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org. MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to Google TM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart. DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/ drconnect or drconnect@ccf.org. MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1, life-threatening and lifealtering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, eclevelandclinic@ccf.org or call , ext Critical Care Transport: Anywhere in the world Cleveland Clinic s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call CODE (2633). For all other transfers, call or CME Opportunities: Live and Online Cleveland Clinic s Center for Continuing Education s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 15 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the mycme Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe. Neurological Institute 137