Outcomes. Pain Management

Transcription

1 Outcomes Pain Management 2006

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3 Outcomes 2006 Quality counts when referring patients to hospitals and physicians, so Cleveland Clinic has created a series of outcomes books similar to this one for its institutes and departments. Designed for a health care provider 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. We hope you find these data valuable. To view all our outcomes books, visit Cleveland Clinic s Quality Web site at clevelandclinic.org/quality/outcomes.

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5 Pain Management Table of Contents Chairman s Letter 5 Department Overview 6 Quality & Outcome Measures 8 Patient Experience 20 Innovations 21 New Knowledge 22 Staff Listing 24 Department Contacts How to Refer Patients 27 Locations 28 Cleveland Clinic Overview 0 Online Services 31 Cleveland Clinic Contact Numbers 32

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7 Pain Management 5 Chairman s Letter The mission of the Cleveland Clinic and the Department of Pain Management is to provide world-class patient care in a setting of education and research. Our staff continually improves upon best practices to make them even better. Research and new technology are the backbone of our department, but when it comes to the care of our patients, it is always Patients first. Our capabilities range from the latest in surgical spinal implants to complementary and alternative treatments. The department s comprehensive approach to pain management allows us to individualize patient care plans. Our goal is to return our patients, in the most efficient manner possible, to a productive, enjoyable, life style. Our expertise covers a broad range of pain: musculoskeletal or spinal, back and neck pain, cancer pain, headache, disorders of the central nervous system (including shingles and trigeminal neuralgia), CRPS, chronic abdominal and pelvic pain, spasticity secondary to spinal cord injuries, and multiple sclerosis to name a few. In addition to having one of the busiest departments in the country, we have over 12 active clinical trials and bench research projects. Our combination of direct patient care and innovative studies makes us one of the premier destinations for pain management in the United States. Our department also has a special interest in training and education. We have the largest fellowship program in the country. Educating the next generation of pain specialists and experts guarantees maintaining such great outcomes for generations to come. This booklet was created so we can share our outcomes data, research and innovations with our colleagues. We hope you find the information in the book informative and helpful. We look forward to collaborating with you in the care of your patients. Nagy Mekhail, M.D., Ph.D. Chairman, Cleveland Clinic Pain Management Department

8 6 Pain Management 2006 Department Overview Statistics Pain Management Specialists 21 Nurse Practitioners and Physician Assistants 9 Total patient visits 111,846 Procedures performed 7,983 New patients 11,089 Patients new to Cleveland Clinic 961 Main Campus patients outside Ohio 7 % Number of countries represented by patients 21 Full-length scientific publications with resident or fellow co-authors 17 External lectures presented 96 Cleveland Clinic s Department of Pain Management is one of the first institutions of its kind in the nation. Its physicians have been pioneers in interventional and comprehensive pain management for nearly two decades; it is dedicated to serving the needs of people with pain. We are the nation s most comprehensive pain clinic, managing the whole spectrum of acute, chronic and cancer pain. By far, care is delivered to the largest number of patients with the most diverse pain conditions. Under the leadership of the Founding Chair, Nagy Mekhail, M.D., Ph.D., the department has grown dramatically from 9,000 total patient encounters in 1996 to 111,846 in Our staff performs the largest number of interventional pain procedures in the country. For 2006, 37,983 procedures were performed, including therapeutic, diagnostic and prognostic blocks in patients with acute, chronic and cancer pain. A large number of neuromodulation devices are implanted to manage intractable pain conditions. These implants include spinal cord stimulators, peripheral nerve stimulators and intrathecal pumps. Total number of new neuromodulation implants was 367, a 15% increase over Our physicians pioneered the use of some of the most innovative and cutting-edge interventions in pain management, including intradiscal electrothermal annuloplasty

9 Pain Management 7 (IDET), nucleoplasty, kyphoplasty, radiofrequency ablation, cryoneurolysis, and neuromodulation devices. Some innovative and novel applications of new technologies include the use of spinal cord stimulation to treat chest wall pain, pelvic pain, headache, neuropathic pain as well as peripheral vascular disease. We are first in the nation to master and utilize transdiscal radiofrequency ablation, a novel technique to treat symptomatic degenerative disc disease. Inpatient acute-pain and chronic-pain consult services are provided. A large number of neuraxial and peripheral nerve catheters for perioperative pain have been placed and managed. We also manage intravenous patient-controlled analgesia pumps for a large number of patients referred by various surgical services. In addition to providing consults for chronic pain patients, patients admitted with implanted devices or catheters are managed. The department also boasts an active complementary pain management service, including acupuncture and spinal manipulation therapy. The Department of Pain Management is a leader in a number of areas of clinical and basic research. We are involved in and lead a large number of prospective, randomized, controlled trials. These trials include medication management, interventional blocks, and devices and implantable neuromodulation technology. Our research projects on calcium regulation of sensory neurons and in locomotion are funded by substantial grants from the American Heart Association and the National Institutes of Health. The Pain Management fellowship program is one of the largest and most prestigious programs in the nation. Advanced training to residents, fellows and practice physicians from around the world is provided. We believe in the comprehensive interdisciplinary and multimodal approach to the management of pain. For that reason, a Cancer Pain Clinic service is being established in collaboration with our oncology and palliative care services; similar cooperative services with the Headache Center, pediatric rehabilitation and Digestive Disease Center are underway. Pain Management is committed to providing quality comprehensive care to patients as well as continued communication with referring physicians.

10 8 Pain Management 2006 Quality & Outcome Measures Spinal Cord Stimulation for Intractable Visceral Pelvic Pain Kapural L, Narouze SN, Janicki TI, Mekhail N. Spinal cord stimulation is an effective treatment for the chronic intractable visceral pelvic pain. Pain Med 2006; 7: Improvement is noted in the quality of life in patients receiving spinal cord stimulation for chronic intractable visceral pelvic pain. Pain Disability Index (PDI) is a functional outcome measure that examines disability levels in seven activities of daily living: family, recreation, occupation, social, sexual, life support and selfcare activities. 10 VAS* Pain Score 8 Score Pre-treatment *Visual Analog Scale Post-treatment

11 Pain Management 9 60 PDI after Spinal Cord Stimulation Pain Disability Index Pre-treatment Post-treatment 25 Opiate Consumption 20 mg of MSO 4 per day Pre-treatment Post-treatment

12 10 Pain Management 2006 Lumbar Spinal Stenosis Value of magnetic resonance imaging (MRI) in patients with painful lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid injection. Kapural L, Bena J, Mekhail N, McLain R, Tetzlaff J, Kapural M, Polk, S. This study examined the severity of lumbar spinal stenosis per MRI affects, if any, on the outcomes of lumbar epidural steroid injection. Changes in pain scores were evaluated 8-12 weeks after a series of steroid injections. The percentage of patients who responded to the injection with pain reduction of greater than 2 points was similar, regardless the severity of the spinal stenosis. Data suggest, however, that patients with severe spinal stenosis at multiple levels (greater than 3 segments) were less likely to benefit from epidural steroid injections. 4 Average Pain Score Change 3 Score Mild Moderate Severe Severity of Stenosis

13 Pain Management 11 4 Average Pain Score Change 3 Score Spinal Levels 3 or more 4 Average Pain Score Change 3 Score Stenosis Pain Index

14 12 Pain Management 2006 Management of Chronic Cluster Headache The Efficacy of Sphenopalatine Ganglion Block in the Management of Chronic Cluster Headache. Narouze SN, Kapural L. Cluster headache is a primary neurovascular headache. It is a strictly unilateral head pain associated with cranial autonomic symptoms and usually has circadian and circannual pattern. The sphenopalatine ganglion (SPG) is the largest extracranial neural structure located in the pterygopalatine fossa. It has sensory, motor, and autonomic components and is involved in the pathophysiology of cluster headache. SPG block was shown to improve episodic cluster headache rather than chronic cluster headache. Despite that, we were interested to examine the efficacy of SPG block in patients with intractable chronic cluster headache who failed pharmacological management. The pain score decreased from 8.6 pre-spg block to 3.9, 6 months post-spg block (p<0.02). The Pain Disability Index decreased from 53.8 pre-spg block to 18.3, 6 months post-spg block (p<0.0001). 10 VAS Pain Score 8 Score Pre- Procedure Post- Procedure 1 month 3 months 6 months p<0.001 p<0.001 p<0.01 p<0.02

15 Pain Management PDI after SPG Block Pain Disability Index Pre-treatment Post-treatment Lateral view showing the tip of the needle in the pterygopalatine fossa to target the sphenopalatine ganglion.

16 14 Pain Management 2006 Lumbar Discogenic Pain A Novel Radiofrequency System (Intervertebral Disc Biacuplasty) for the Treatment of Lumbar Discogenic Pain: Results of a 6-month Pilot Study. Kapural L, Ng A, Dalton J, Mascha E, Kapural M, de La Garza M, Mekhail N. Low back pain commonly arises from ruptured discs of the lumbar spine. A novel approach was tested to seal the ruptured discs by a technique known as Transdiscal Intervertebral Disc Biaculoplasty. Performed as a minimally invasive procedure, preliminary data shows it is quite effective in improving functional capacity (Oswestry and SF-36) and reduces pain scores (VAS) and opioid use (morphine sulphate equivalents). 30 Oswestry Pain Score 20 Score 10 0 Baseline 1 month 2 months 3 months p<0.001 p<0.001 p<0.002

17 Pain Management VAS Pain Score Score 5 0 Baseline 1 month 3 months 6 months p< p< p< Intervertebral disc biacuplasty: a final position of the electrodes from anterior - posterior and lateral view.

18 16 Pain Management 2006 Long-term Opioid Therapy in Chronic Nonmalignant Pain Interdepartmental Study. Brown L, Cheng J, Moufawad S, Mekhail N. It is controversial whether the use of opioids is beneficial for patients with nonmalignant pain. Favorable long-term outcomes have not been clearly demonstrated. This study was conducted in a highly selective group of 67 patients who had exhausted interventional therapeutic modalities, signed an opioid agreement, and were compliant with medical and legal regulations. The medical outcome survey showed significant improvement in physical functioning, role playing, bodily pain, general health, vitality, social functioning, emotional role, and mental health, over a follow-up period of 6 to 36 months. However, no significant changes were observed in pain scores, disability status and return to work. We concluded that certain functional improvement may be achieved through judicious use of opioids in a highly selective population of patients with nonmalignant pain. Medical Outcome Survey (SF-36) Physical functioning * Role playing Bodily pain * * Pre-treatment Post-treatment General health * Vitality * Social functioning * Role emotional * Mental health Reported health transition *Statistically Significant Differences * Points

19 Pain Management 17 Treatment of the Cervicogenic Headache Efficacy of Lateral Atlantoaxial Intra-articular Steroid Injections on the Treatment of the Cervicogenic Headache. Narouze SN, Casanova J, Mekhail N. Headaches commonly arise from changes in the cervical spine. Arthritic changes in the lateral atlantoaxial joint may be one of the sources. Intra-articular steroid injection into the atlantoaxial joint were performed in 32 patients with headaches. The majority of patients (26/32) had significant pain relief up to three months. 10 VAS Pain Score Score 5 0 Pre- Procedure Post- 1 Month 3 Months Procedure p<0.001 p<0.001 p<0.01 Illustration shows the relationship of the atlanto-axial and atlanto-occipital joints to the vertebral artery.

20 18 Pain Management 2006 Recovery Approaches to Frozen Shoulder Syndrome and Chronic Knee Joint Disorders Tunneled Epidural Catheter Facilitates Functional Rehabilitation after Surgeries for Shoulder and Knee Arthropathies. Narouze SN, Mekhail N, Govil H. A novel approach to assist functional recovery and improve pain control after surgeries of the shoulder and knee for patients with frozen shoulder syndrome and chronic knee joint disorders after multiple knee surgeries was introduced and studied. Continuous infusion of local anesthetic and opiates through a tunneled cervical epidural catheter (shoulder surgery, Table 1) or lumbar epidural catheter (knee surgery, Table 2), placed before surgery and kept a few weeks after surgery, significantly improved range of motion and reduced pain associated with surgery. In addition, physical therapy for rehabilitation was facilitated. The success of the techniques requires a team effort and open communications among the surgeon, pain management specialist, home care nurse, physical therapist and the patient. We concluded that this technique is safe and can significantly improve clinical outcome in patients undergoing surgeries for shoulder and knee arthropathies.

21 Pain Management 19 Placement Removal (Removal - Placement) Outcome N Mean (SD) Mean (SD) Mean (SD) 95% CI P-Value VAS Pain Score (0-10) (2.7) 2.5 (2.3) -2.6 (3.2) (-4.2, -1.0) ROM - Forward Flexion (Degrees) ROM - External Rotation (Degrees) ROM - Internal Rotation (Degrees) (28.7) (21.1) 61.4 (35.4) (43.8, 79.0) < (10.8) 48.9 (20.8) 39.4 (22.6) (28.2, 50.7) < (6.6) (24.0) (30.9, 59.9) <0.001 Student s Paired t-test for mean difference equal to 0. Table 1: Summary statistics and one-sample tests for patients (N=21) receiving a tunneled epidural catheter (TEC) for postoperative pain control after undergoing surgery for treatment of refractory frozen shoulder. Placement Removal Change: Removal - Placement Outcome N Mean (SD) Mean (SD) Mean (SD) 95% CI P-Value VAS Pain Score (0-10) (3.1) 3.0 (2.5) -2.0 (3.4) (-3.6, -0.5) 0.01 ROM - Flexion (Degrees) (35.2) 95.7 (30.8) 6.8 (36.3) (-9.3, 22.9) 0.39 Total Knee ROM (Degrees) (38.7) 94.5 (31.0) 18.8 (36.1) ( 2.4, 35.3) 0.03 N ( % ) N ( % ) Opioid Use Yes 24 8 (33.3) 2 (8.3) No 16 (66.7) 22 (91.7) 0.04 Paired Student s t-test for mean difference equal to 0. McNemar s test for equal proportions receiving opioids before and after TEC placement. Table 2: Summary statistics and one-sample tests for patients (N=26) receiving a tunneled epidural catheter (TEC) for postoperative pain control after undergoing elective knee surgery.

22 20 Pain Management 2006 Patient Experience We ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we provide excellent care, we are committed to continuous improvement. 100 Outpatient Overall Rating of Care % Excellent Very Good Good Fair Poor 100 Outpatient Would Recommend Provider % Extremely Likely Very Likely Somewhat Likely Somewhat Unlikely Very Unlikely

23 Pain Management 21 Innovations Infusion Technique Assists Functional Recovery and Pain Control Post-surgery A novel approach to assist functional recovery and improve pain control after surgeries of the shoulder and knee for patients with frozen shoulder syndrome and chronic knee joint disorders after multiple knee surgeries was introduced and studied. Infusion of local anesthetic and opiates through a tunneled epidural catheter placed before surgery and kept a few weeks after surgery significantly improved range of motion and reduced pain associated with surgery and subsequent physical therapy for rehabilitation. Success of the techniques requires a team effort and open communication among the surgeon, pain management specialist, home care nurses, physical therapist and the patient. We concluded this technique is safe and can significantly improve clinical outcomes in patients undergoing surgeries for common shoulder and knee arthropathies. A Novel Radiofrequency System (Intervertebral Disc Biacuplasty) for the Treatment of Lumbar Discogenic Pain: Results of a Six-month Pilot Study Minimally invasive procedures used to heat the intervertebral disc (nucleus or annulus) in current clinical practice brought variable results when used in the treatment of discogenic pain. A sixmonth follow-up after intervertebral disc biacuplasty (IDB), a novel radiofrequency procedure, revealed significant improvements in patients functional capacity (Oswestry and SF-36), pain scores (VAS) and opiate requirements. Supraorbital Nerve Stimulation for the Treatment of Intractable Postherpetic Trigeminal Neuralgia Postherpetic trigeminal neuralgia is often refractory to medical management. Peripheral nerve stimulation has been used for years in the treatment of intractable neuropathic pain from peripheral nerve injury. Gasserian ganglion stimulation, however, has not been reliable in controlling trigeminal neuralgia, especially postherpetic neuralgia. We report a relatively simple, safe and effective treatment for intractable postherpetic trigeminal neuralgia with supraorbital nerve stimulation. A surgical flat paddle lead for the permanent implant is used to provide better current distribution, less current surges and better pain control.

24 22 Pain Management 2006 New Knowledge Acute Pain Narouze S. Epidural steroid injections after epidurography may prevent otherwise devastating complications. Anesth Analg 2006;102:1585. Derby R, Linetsky F, Miguel R, Saberski L, Stanton-Hicks M. Pain management with regenerative injection therapy (RIT). In: Bowell MV, Cole BE, eds. Weiner s Pain Management: A Practical Guide for Clinicians, 7th ed. Boca Raton, FL: CRC Taylor & Francis Press; 2006: Alternative Pain Management Narouze S, Casanova J, Farrago E, Tuzla J. Inadvertent dural puncture during attempted thoracic epidural catheter placement complicated by cerebral and spinal subdural hematoma. J Clin Anesth 2006;18: Narouze S. Is it time to perform all thoracic epidural placements under fluoroscopy? Anesth Analg 2006;102:1585. Narouze S. Ultrasound-guided cervical periradicular injection: cautious optimism. Reg Anesth Pain Med 2006;31:88. Biochemical Research Biswas A, Miller A, Oya-Ito T, Santhoshkumar P, Bhat M, Nagaraj RH. Effect of sitedirected mutagenesis of methylglyoxal modifiable arginine residues on the structure and chaperone function of human A-crystallin. Biochem 2006,45: Miller AG, Smith DG, Bhat M, Nagaraj RH. Glyoxalase I is critical for human retinal capillary pericyte survival under hyperglycemic conditions. J Biol Chem 2006;281: Chronic Pain Mekhail N, Brown J. Pain Management: Advances in Diagnosis & Treatment. Norwalk, CT: Belvoir Media Group (ISBN ), Cheng J, Abdi S. Complications of joint tendon and muscle injections. Tech Reg Anesth Pain Manage In Press

25 Pain Management 23 Narouze S. Medical management of chronic shoulder pain. In: Iannotti J, Williams G, eds. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006: Complex Regional Pain Syndrome Stanton-Hicks M. Complex regional pain syndrome: manifestations and the role of neurostimulation in its management. J Pain Symptom Manage 2006;31(4 Suppl): S Stanton-Hicks M. Pain and vasomotor disturbances. In: Creager M, Dzau V, Loscale J, eds. Vascular Medicine: A Companion to Braunwald s Heart Disease. Philadelphia, PA: W.B. Saunders; 2006: Hayek S, Paige B, Girgis G, Kapural L, Fattouh M, Xu M, Stanton-Hicks M, Mekhail N. Tunneled epidural catheter infections in non-cancer pain: increased risk in patients with neuropathic pain/complex regional pain syndrome. Clin J Pain 2006;22: Interventional Pain Management Samuel S, Hayek S, Stanton-Hicks M. Interventional procedures for pain control. In: Von Roenn JH, Paice J, Preodor M, eds. Current Diagnosis and Treatment of Pain. New York, NY: McGraw-Hill; 2006: Spine Treatments Rosenow J, Stanton-Hicks M, Rezai A, Henderson J. Failure modes of spinal cord stimulation hardware. J Neurosurg Spine 2006; 5: Kapural L, Mekhail N, Kapural M, Hicks D. Histological and temperature distribution studies of the novel transdiscal heating system in degenerated and non-degenerated human cadaver lumbar discs. ASA Newsl 2006;105:A705. Vallajo R, Benjamin R, Floyd B, Casto JM, Joseph NJ, Mekhail N. Percutaneous cement injection into a created cavity for the treatment of vertebral body fracture: preliminary 110 results of a new vertebroplasty technique. Clin J Pain 2006;22:

26 24 Pain Management 2006 Staff Listing Chairman Nagy Mekhail, M.D., Ph.D. Chairman, Pain Management Department Appointed: 1992 Medical School: Ain Shams University Faculty of Medicine, Cairo, Egypt Specialty Training: Fellowship Cleveland Clinic, Cleveland, Ohio; Internship Ain Shams University Hospitals, Cairo, Egypt; Internship Cleveland Clinic, Cleveland, Ohio; Residency Ain Shams University Hospitals, Cairo, Egypt; Residency Cleveland Clinic, Cleveland, Ohio Other Education: M.S. Ain Shams University, Cairo, Egypt; Ph.D. Ain Shams University, Cairo, Egypt Specialty Interests: Pain management, neuroanesthesiology and research

27 Pain Management 25 Chairman Nagy Mekhail, M.D., Ph.D. Quality Review Officer Teresa Dews, M.D. Staff Main Campus Ayman H. Basali, M.D. Philippe Berenger, M.D. Manju Bhat, Ph.D., Research Staff Jeffery Biro, M.D. Jianguo Cheng, M.D., Ph.D. Leonardo Kapural, M.D., Ph.D. Qing Liu, Ph.D., Research Fellow Samer Narouze, M.D. Nilesh Patel, M.D. Timothy Rhudy, M.S., L.Ac., Acupuncturist Michael Ritchey, M.D. Pasha Saeed, M.D. Michael Stanton-Hicks, M.D. Sameh Yonan, M.D.

28 26 Pain Management 2006 Community Ayman H. Basali, M.D. Lorain Jeffery Biro, M.D. Twinsburg Emad Daoud, M.D., Ph.D. Lutheran/Westlake Teresa Dews, M.D. Hillcrest Kenneth Grimm, D.O. Strongsville/Lorain Riad Laham, M.D. Hillcrest Jill Mushkat, Ph.D. Euclid/Hillcrest/South Pointe/Strongsville Sherif Salama, M.D. Beachwood/South Pointe Samuel Samuel, M.D. Euclid/Marymount Hong Shen, M.D. Hillcrest/Lutheran William Welches, D.O., Ph.D. Euclid/South Pointe Sameh Yonan, M.D. Hillcrest/South Pointe

29 Pain Management 27 Department Contacts How to Refer Patients Cleveland Clinic Operator (800.CCF.CARE) ext Main Campus Appointments Pain Management Beachwood Appointments Pain Management Euclid Appointments Pain Management Hillcrest Appointments Pain Management Lorain Appointments Pain Management Lutheran Appointments Pain Management Marymount Appointments Pain Management Solon Appointments Pain Management South Pointe Appointments Pain Management Strongsville Appointments Pain Management Twinsburg Appointments Pain Management Westlake Appointments Pain Management Willoughby Hills Appointments Pain Management For more details about Pain Management, visit clevelandclinic.org/painmanagement

30 28 Pain Management 2006 Locations Lake Erie Euclid Cleveland Cleveland Clinic Huron Hillcrest Westlake Lakewood Lutheran Beachwood Lorain South Pointe Marymount Solon Strongsville Twinsburg Main Campus Pain Management Center W.O. Walker Building, Desk C Euclid Avenue Cleveland, OH Beachwood Pain Management Center Cedar Road Beachwood, OH Euclid Pain Management Center Lakeshore Boulevard Euclid, OH Hillcrest Pain Management Center Mayfield Road, Suite 200 Mayfield Heights, OH Lorain Pain Management Center Cooper Foster Park Road Lorain, OH Lutheran Pain Management Center West 25th Street, Cleveland, OH 44113

31 Pain Management 29 Marymount Pain Management Center McCracken Road, Suite 357 Garfield Heights, OH Solon Family Health Center Pain Management Center Bainbridge Road Solon, OH South Pointe Pain Management Center Warrensville Center Road Warrensville Heights, OH Strongsville Pain Management Center SouthPark Center Strongsville, OH Twinsburg Pain Management Center Edison Boulevard, Suite 500 Twinsburg, OH Westlake Medical Campus Pain Management Center Columbia Road, Suite 105 Westlake, OH 44145

32 30 Pain Management 2006 Cleveland Clinic Overview Cleveland Clinic, founded in 1921, is a not-for-profit academic medical center that integrates clinical and hospital care with research and education. Today, 1,700 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties. Cleveland Clinic s main campus, with 41 buildings on 130 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, subspecialty centers and supporting labs and facilities. Cleveland Clinic also operates 13 family health centers, eight community hospitals, two affiliate hospitals, and a medical facility in Weston, Florida. At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based research. Total annual research expenditures exceed $150 million from federal agencies, non-federal societies and associations, and endowment funds. In an effort to bring research from bench to bedside, Cleveland Clinic physicians are involved in more than 2,400 clinical studies at any given time. In September 2004, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University opened and will graduate its first 32 students as physicianscientists in For more details about Cleveland Clinic, visit clevelandclinic.org

33 Pain Management 31 Online Services ecleveland Clinic ecleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second opinions through a secure Web site to patients around the world; personalized medical record access for patients; patient treatment progress access for referring physicians (see below); and imaging interpretations by the Department of eradiology s subspecialty trained academic radiologists. For more information, please visit eclevelandclinic.org. DrConnect Online Access to Your Patient s Treatment Progress Whether you are referring from near or far, our new ecleveland Clinic service, DrConnect, can streamline communication from Cleveland Clinic physicians to your office. This new online tool offers you 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 Web site. To establish a DrConnect account, visit eclevelandclinic.org or drconnect@ccf.org MyConsult MyConsult Remote Second Medical Opinion is a secure, online service providing specialist consultations and remote second medical opinions for more than 600 life-threatening and life-altering diagnoses. MyConsult remote second medical opinion service allows you to gather information from nationally recognized specialists without the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, eclevelandclinic@ccf.org or call , ext 43223

34 32 Pain Management 2006 Cleveland Clinic Contact Numbers How to Refer Patients 24/7 Hospital Transfers or Physician Consults General Information Hospital Patient Information Patient Appointments or Medical Concierge Complimentary assistance for out-of-state patients and families , ext , or International Center Complimentary assistance for international patients and families or visit Cleveland Clinic in Florida

35 Cleveland Clinic is determined to exceed the expectations of patients, families and referring physicians. In light of this goal, we are committed to providing accurate and timely information about our patient care. Through participation in national initiatives, we support transparent public reporting of healthcare quality data and participate in the following public reporting initiatives: Joint Commission Performance Measurement Initiative ( Centers for Medicare and Medicaid (CMS) Hospital Compare ( Leapfrog Group ( Ohio Department of Health Service Reporting ( In addition, this publication was produced to assist patients and referring physicians in making informed decisions. To that end, information about care and services is provided, with a focus on outcomes of care. For more information, please visit the Cleveland Clinic Quality Web site at clevelandclinic.org/quality.

36 Cover photograph by Stephen Travarca