eRounds - Spring 2013

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Moving Toward Higher-Quality, Cost-Efficient Healthcare

Quality Alliance members and their patients benefit from integrated data, ambitious metrics, favorable payer relationships and more.

As the delivery of healthcare evolves, Tarek Elsawy, MD, wants to make sure Northeast Ohio evolves with it.

“Everyone in healthcare is on this journey from a fee-for-service world to a value-based world. Unless you’re clinically integrated, that’s almost impossible to achieve,” says Dr. Elsawy, an internist in Cleveland Clinic’s Medicine Institute.

Dr. Elsawy serves as Chief Medical Officer for the Quality Alliance, a clinical integration platform offered through Cleveland Clinic’s Community Physician Partnership. The Quality Alliance allows independent community physicians and Cleveland Clinic physicians to work together for higher-quality and more-efficient healthcare. With 1,150 independent physicians and 5,100 members total, the Quality Alliance is the third-largest clinically integrated network in the United States.

The list of benefits to Quality Alliance members is lengthy, but one of the most attractive is certainly the ability to share integrated data. “The more data you have as a physician, the better you can manage your patients,” says Dr. Elsawy. “We’ve created a powerful registry that facilitates true population-driven health management. Already we’ve seen improvements in metrics around diabetes, hypertension, colorectal cancers and a range of other conditions.”

Indeed, those metrics are key reasons why the quality of care is high among alliance members. “We have identified ambitious targets for Cleveland Clinic physicians and our community-based physician partners,” says David Longworth, MD, Chairman of the Medicine Institute and a Quality Alliance board member. “Physicians want to do the right thing.”

Quality Alliance members also benefit from performance-based contracting with third-party payers as well as helpful electronic tools, improved patient outcomes and satisfaction, access to “best practice” Clinical Care Guidelines, and affiliation with a physician practice network recognized for innovation and high-quality care.

“This arrangement is the vehicle through which we’re able to transition from an older way of healthcare delivery to a scenario in which we all work together for the greater good of our patients,” says Dr. Elsawy. “Together, we want to deliver a positive, high-quality, cost-efficient experience to the patient. Quality Alliance member physicians in the community and at Cleveland Clinic have a role to play in the collective quality of healthcare in Northeast Ohio, and I believe they will leave it much better off than it has been before.”

Physicians interested in learning more about the Quality Alliance can visit cccpp.org or call 216.986.1277.


Young-Onset Dementia Examined

You may notice younger patients in your practice with cognitive problems — memory loss and/ or speech problems — and behavioral problems, such as being unable to handle their day-to-day tasks or tend to their personal hygiene. These changes may be subtle or increasing at an alarming rate. And it may be unclear why. But Cleveland Clinic’s young-onset dementia program can help.

“In young patients, those under 65, early diagnosis is critical,” says geriatric psychiatrist Brian Appleby, MD, of Cleveland Clinic’s Lou Ruvo Center for Brain Health. “I would recommend younger patients who display any cognitive symptoms at all see a specialist.”

It’s a population that should be handled carefully, he says, because there is a greater possibility that the cause may be able to be treated when compared with dementia in older adults.

At Cleveland Clinic, neurologists, psychiatrists and neuroimaging specialists work together to provide comprehensive care to patients with young-onset dementia. Patients are thoroughly evaluated with a clinical history and exam, including blood work, a brain MRI and sometimes further neuropsychological testing. Additional imaging studies, a spinal tap, amyloid imaging and genetic testing also may be needed.

“Getting the correct diagnosis is of utmost importance in young patients,” Dr. Appleby stresses. Unlike in older patients whose dementia is most often caused by Alzheimer disease, the differential diagnosis list is much longer in younger patients. Other culprits include neurodegenerative diseases such as frontotemporal dementia, Creutzfeldt-Jakob disease, other metabolic abnormalities or psychiatric illnesses. Once the exact cause is known, a customized treatment or management plan can be designed accordingly.

“People with a diagnosis of dementia are not at the end of the road,” says neurologist Jagan Pillai, MD, PhD, also of the Lou Ruvo Center for Brain Health and the young-onset dementia program. “I have had people who have checked into a nursing home saying they have a degenerative problem or a dementia diagnosis, but in fact they have a very treatable condition.”

Unfortunately, most patients with young-onset dementia don’t get a diagnosis for two to three years. This time lost can be devastating in many ways — even in the severest of cases. For example, treating what is actually a neurodegenerative disease with multiple psychoactive medications can actually worsen the disease course, Dr. Pillai says.

Early diagnosis can improve quality of life and help patients make important life decisions, such as whether to continue working, make appropriate financial decisions or apply for fast-tracked Social Security disability benefits under the compassionate allowance for such conditions.

To refer a patient to the young-onset dementia program, call 866.588.2264.


Faster Discharge after Joint Replacement

Rapid recovery methodology reduces postoperative pain and increases patient engagement.

There was a time when postoperative rehabilitation after joint replacement surgery was conducted in a virtually identical manner at most centers. Whether the patient was elderly with a weak support system at home or young and healthy with strong support, the treatment plan was the same.

“We looked at that system and said there had to be a better way,” says Wael Barsoum, MD, Chairman of Surgical Operations and Vice Chairman of the Department of Orthopaedic Surgery at Cleveland Clinic.

That “better way” is the Rapid Recovery Program, a protocol designed to shorten length of hospital stay, reduce postoperative pain, and increase early function after joint replacement. Patients are seen by a physical therapist the day of surgery, with many up and walking just hours after their procedure. Some are discharged by the end of postoperative Day 1, with even more going home on postop Day 2.

“This was a fairly significant shift in how we managed our postoperative care, and it required a strong team to make it work,” says Dr. Barsoum. “We involve the surgeon, the physical therapist, nurses and the case manager. Preoperatively, we ask a set of defined questions revolving around general health, help at home, and the surgery the patient is going to have. Based on those factors, we predict how long they will be in the hospital and what discharge program will work best. Patients who are predicted to go straight home with no comorbidities are enrolled in the program.”

Postoperative pain is managed largely through the use of nerve catheters, says Cleveland Clinic staff anesthesiologist Sherif Zaky, MD. “The nerve catheters provide two main benefits,” says Dr. Zaky. “First, they allow for early ambulation. Patients can walk and start their physical therapy right away, which improves their course of treatment and shortens hospital stay. Second, there is a reduced requirement for pain medication, which leads to fewer side effects. The instance of readmission for pain is significantly reduced.”

Managing patient expectations is key to the program, notes Dr. Barsoum. “Many folks come in expecting a stay of three to five days and then a trip to a rehabilitation facility because that’s what their parents or their friends did,” he says. “A lot of effort goes into educating patients on their needs and their planning for discharge. If a patient is really not comfortable with it, we don’t send them home.”

For more information on the Rapid Recovery Program, email Dr. Barsoum at barsouw@ccf.org.


Sidestepping Stroke in A-Fib Patients

Coumadin® (warfarin) used to be the only answer for reducing stroke risk in patients with atrial fibrillation. No longer. Today, Cleveland Clinic offers an entire range of medications, surgical procedures and implantable devices to help protect your a-fib patients.

“Patients with a-fib are five times more likely to suffer a stroke than those without a-fib. We now have so many more options for reducing this risk that we can discuss with patients,” says Walid Saliba, MD, Director of the Electrophysiology Lab in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.

Coumadin and the new anti-coagulants

Medication is still the most widespread approach to keeping stroke risk in check, with more prescriptions written for Coumadin than any other anti-coagulant to date. And with good reason.

“It has done the job,” Dr. Saliba says. “In clinical trials, Coumadin has demonstrated a 78 percent reduction in stroke in patients.” That said, Coumadin requires regular follow-up for blood work to monitor international normalized ratio (INR) levels to ensure patients take an adequate but safe dose. This has opened the door for a handful of alternatives: Pradaxa® (dabigatran etexilate), Xarelto® (rivaroxaban) and Eliquis® (apixaban).

In major clinical trials, all three new drugs fare the same — if not slightly better in certain subgroups of patients — when compared with Coumadin for stroke-reduction risk, Dr. Saliba notes. The alternatives have two main problems, however. They’re more expensive. They also have no antidote that can be given to reduce their blood-thinning effects, should there be a need for it (although they have short half-lives and do wear off rather quickly).

Surgical options

The source of stroke in more than 90 percent of a-fib patients is the left atrial appendage (LAA), a small, ear-shaped tissue flap located in the left atrium.

“We know from the surgical literature that if we excise, occlude or obliterate the left atrial appendage appropriately, the risk of stroke is decreased,” Dr. Saliba explains.

During surgical procedures to treat atrial fibrillation, the LAA is removed and the tissue is closed with a special stapling device. However, surgery is not for everyone. Not every patient wants to undergo surgery or is a surgical candidate, he says. This has led to the rise of a third category of treatments: implantable devices.

Implantable devices

When it comes to devices, a new era is dawning. “Device implants are becoming an attractive option for reducing the risk of stroke without the need to be on anti-coagulation, or in patients who are at high risk of bleeding while on anticoagulants,” Dr. Saliba says.

To date, there are three devices to be considered:

  • Watchman® (Boston Scientific) is a device designed to close off the LAA to reduce the risk of stroke. It is currently in its last phase of investigation, and Dr. Saliba says many hope the device will receive FDA approval within a matter of months. “The good thing about Watchman is that so far it is the only device that has been looked at in a large clinical trial and has been shown to be equal — if not superior — to Coumadin for stroke reduction,” he says. Patients who receive the device would need to take Coumadin for only 45 days after the implant. “It’s an attractive option because you don’t have to take any medications for blood thinning and your risk of stroke is relatively low. The procedure is a fairly easy one for an electrophysiologist, requiring only an overnight hospital stay and a couple of follow-ups.”
  • The LARIAT ® Suture Delivery Device (SentreHEART) is an FDA-approved option similar to surgical ligation of the LAA, Dr. Saliba says. “By using a transseptal approach (from the right to the left side of the heart) and an epicardial approach (access to the outside surface of the heart), the left atrial appendage is actually caught and ligated by using a preformed knot on a catheter,” he explains. “That also is a fairly easy procedure for an electrophysiologist.” There is not yet data to support that the procedure reduces the risk of stroke, he notes, but says extrapolation from the surgical literature suggests this is probable. Thus, the device is attractive for patients who have contraindications to anti-coagulants.
  • The AMPLATZER™ Cardiac Plug (St. Jude Medical) is another option, similar to the Watchman, which is currently being investigated. The device was engineered to occlude the LAA at the base of the orifice, regardless of the LAA anatomy.

“These devices are things that we are very excited about for the future,” Dr. Saliba says. “Down the road, it may even be possible to place one of them in conjunction with an a-fib ablation.”

All of these solutions, he says, are promising for reducing stroke risks in your patients. Whether your patients have problems adhering to their medication regimen, would prefer not to take medication, or are at high risk of bleeding or other contraindications, we can work with them to find a solution that helps reduce their stroke risk.

To refer a patient to the Cardiac Electrophysiology and Pacing Section, call 216.444.6697.

Share this with your a-fib patients!

Cleveland Clinic offers a useful online tool to help your a-fib patients prepare for their next doctor’s visit. The interactive survey asks a series of questions about the patient’s history, symptoms and current treatment — including medications, cardioversions and ablations. The responses can then be downloaded and printed to help patients guide their discussion of the most appropriate treatment plan for them.

Here, patients also will find a series of videos on a-fib, including those on understanding a-fib, medical management, stroke prevention, ablation and surgery.

Check it out today at clevelandclinic.org/afibtool.


Your Cancer Patients Are Not Alone

You know how difficult it is to deliver the news when you suspect a patient has cancer. You want him or her to receive not only the most advanced diagnosis and treatment, but also to feel supported every step of the way. To help patients through this difficult time in their life, the Taussig Cancer Institute has created My Journey.

This new personal guidebook, a resource given to every patient treated for cancer at Cleveland Clinic, refines the way information is provided to patients about our comprehensive patient support services.

“We want patients to realize they are not alone,” says Brian Bolwell, MD, Chairman, Taussig Cancer Institute. “A cancer diagnosis is different. We wanted to create a go-to guide that connects with our patients along their journey and ensures they are able to take advantage of everything that we have to offer.”

How can it help? My Journey explains what newly diagnosed patients can expect. It features a medication tracker and calendar for medical appointments. It includes information on clinical trials, billing questions, support services and finding their way around Cleveland Clinic. And it serves as an all-important central location to keep track of handouts from physicians and other care team members.

“Every patient will get the core of the binder. Then, they’ll get disease-specific information from their specialist,” explains Megan Kilbane, Administrator of Patient Support Services, Taussig Cancer Institute. “They can continue adding information that’s relevant to them to create a personalized treatment aid.”

My Journey also serves as a tool kit, highlighting all of Taussig Cancer Institute’s programs and resources, including:

  • Cancer Answer Line
  • Appointment Line
  • Foreign Language and Deaf Services Interpreters
  • Social Work Services
  • Patient Resource Center
  • Psychology and Psychiatry
  • Genetic Counseling and Testing Services
  • Financial Counseling
  • Ombudsman
  • The 4th Angel Mentoring Program
  • Chemotherapy Orientation
  • chemocare.com
  • Symptom Control/Palliative Medicine
  • Tobacco Cessation
  • Nutrition
  • Pharmacy
  • Reflections Wellness Program
  • High Tea at Taussig
  • Spiritual Care
  • Art Therapy

“Our main goal is to get more patients to come to our classes and use our services,” Kilbane says. “We know that utilizing these services improves not only the patient experience, but overall well-being. We want patients to know that we will take care of them no matter where they come to us in their journey.”

This resource, which will be coming soon in mobile app form, complements the patients’ electronic medical record and DrConnect in helping primary care physicians stay connected with their patients’ care and easing the transition to the survivorship phase of the journey.

If you would like help with a patient referral or want more information about our services, please call our Cancer Answer Line at 1.866.223.8100.

Download this app!

Search clinical trials by disease, phase or hospital location and “click to call” our Cancer Answer Line for enrollment information. Our free Cleveland Clinic Cancer Clinical Trials app is now available for iPhone, iPad, and Android phone and tablet. Visit the App Store or Google play today.

Cleveland Clinic Mobile Site