MEDICAL TOURISM AND DIABETES CARE: EXPERIENCE FROM A TERTIARY REFERRAL CENTER

Objective: Medical tourism, a form of patient mobility across international borders to seek medical services, has gained significant momentum. We aimed to assess the outcomes of medical tourism consultations on chronic diseases, more specifically diabetes mellitus, amongst a cohort of international patients, originating from different healthcare systems, and referred to the United States for medical care. Methods: We identified international adults with established diabetes mellitus, referred globally from 6 countries to the United States between 2010 and 2016 for medical care, and were seen at the Cleveland Clinic Foundation (CCF). Group 1 included adults seen by an endocrinology provider during their CCF medical stay, whilst group 2 included those not seen by an endocrinology provider. To assess the impact of our consultations, changes in hemoglobin A1c (HbA1c) were assessed between visit(s). Results: Our study included 1,108 subjects (771 in group 1, 337 in group 2), with a mean age (± SD) of 61.3 ± 12.7 years, 62% male, and a median medical stay of 136 days (interquartile range: 57, 660). Compared to group 2, group 1 had a higher baseline mean HbA1c (8.0 ± 1.8% [63.9 mmol/mol] vs. 7.1 ± 1.4% [54.1 mmol/mol]; P<.001). After 1 visit with endocrinology, there was a significant decrease in mean HbA1c from 8.44 ± 1.98% (68.3 mmol/mol) to 7.51 ± 1.57% (58.5 mmol/mol) ( P<.001). Greatest reductions in mean HbA1c were −1.47% (95% CI: −2.21, −0.74) and −1.27% (95% CI: −1.89, −0.66) after 3 and 4 visits, respectively ( P<.001). Conclusion: Short-term diabetes mellitus consultations, in the context of medical tourism, are effective. Abbreviations: CCF = Cleveland Clinic Foundation; GCC = Gulf Cooperation Council; HbA1c = hemoglobin A1c; IQR = interquartile range; U.S. = United States

Neutrophil KLF2 Regulates Arterial and Venous Thrombosis

Experimental, clinical and pathological studies support an important link between inflammation and thrombosis. Although accumulating evidence suggests that cells of the innate immune system contribute to the thrombotic process, the identity of nodal molecular determinants operative in immune cells remains poorly understood. Our previous work in mice bearing global deletion of the transcription factor KLF2 identifiedthis factor as a critical mediator of thrombosis). Here, using cell-specific KLF2 deleted murine models (endothelial, platelet, and myeloid- deleted KLF2) we identify myeloid KLF2 as the major determinant of thrombosis. Complete blood counts and coagulation assays in myeloid KLF2 deleted mice (MY-K2-KO) were similar to those in control LysM cre mice. Using two models of vascular thrombosis (carotid artery thrombosis assay, Rose Bengal model and complete inferior vena cava ligation model of venous thrombosis) we observed a robust prothrombotic phenotype in the MY-K2-KO mice as compared to control Cre mice. As LysM Cre deletes in both neutrophils and monocyte/macrophages, we next sought to determine whether one subset was dominantly responsible for the observed phenotype. Adoptive transfer of KLF2-KO neutrophils in control mice conferred both the arterial and venous pro-thrombotic phenotype. Conversely, neutrophil depletion with Ly6G antibody (>90% depletion achieved) reversed the prothrombotic phenotype in MY-K2-KO mice. By contrast, depletion of monocytes/macrophages using clodronate liposome injection did not affect arterial or venous thrombosis. Next, we evaluated the effect of KLF2 deficiency on critical neutrophil functions that may contribute to the pro-thrombotic phenotype. As compared to controls, MY-K2-KO neutrophils demonstrated more pronounced recruitment to the endothelium. In microflow chamber assays, MY-K2-KO neutrophils showed decreased rolling and increased P-selectin induced adhesion. The importance of this was affirmed by the observation that adoptive transfer of MY-K2-KO neutrophils incubated with PSGL-1 antibody was unable to generate a prothrombotic phenotype in control mice. In addition, MY-K2-KO neutrophils demonstrated enhanced neutrophil extracellular traps generation associated with increased myeloperoxidase and neutrophil elastase expression. And finally, MY-K2-KO neutrophils (but not monocytes) demonstrated increased tissue factor expression and activity. Collectively, these studiesidentify neutrophil KLF2 as a critical determinant of both arterial and venous thrombosis and suggest that modulation of neutrophil KLF2 may be a fruitful approach to the management of thrombosis. Disclosures Schmaier: Alnylam: Research Funding; Biomotiv: Consultancy; Cleveland Clinic Foundation: Research Funding; Temple University: Patents & Royalties; Enzyme Research Laboratories: Honoraria; Shire: Consultancy, Honoraria, Research Funding.

Establishing a Clinical Laboratory in a Tertiary/Quaternary Care Greenfield Hospital in the Middle East: Recounting the Cleveland Clinic Abu Dhabi Experience

Context.— This review chronicles the establishment of a clinical laboratory in Cleveland Clinic Abu Dhabi, a greenfield tertiary/quaternary care hospital in the United Arab Emirates. It discusses the challenges faced, solutions sought, and lessons learned and shares insights and pitfalls that may be encountered in such an undertaking. Objectives.— To share our experience in building a clinical laboratory in a start-up, multispecialty hospital and how we provided support and managed people, processes, and technology for building and making operational the Cleveland Clinic Abu Dhabi. Data Sources.— The Medline (PubMed, National Center for Biotechnology Information, Bethesda, Maryland) database was used to review this topic as well as other journals, books, and Google (Mountain View, California) search engine. Conclusions.— To deliver on the promise of quality healthcare in a culturally appropriate setting close to home, Cleveland Clinic Abu Dhabi proved to be an unprecedented and ambitious project, jointly carried out by Mubadala Investment Corporation and the Cleveland Clinic Foundation. Cognizant of the scale of this task, hospital leadership engaged closely with staff and stakeholders through motivational techniques and effective communication. Excellent project planning and execution of complex tasks were required for initiation of services. Establishing the clinical laboratory served as an instructive model in fostering multidisciplinary teamwork by highlighting ways to manage operational roadblocks and opportunities in the planning, commissioning, and activation phases. Throughout the activation process, all efforts were directed to create a patient-safety culture within an intentional-learning organization.

Patient Self-Referral to Infectious Diseases Clinic: You Don’t Always Get What You Want, But Hopefully What You Need

Background Patients call into the departments at the Cleveland Clinic Foundation (CCF) to request appointments directly for all specialties. The Infectious Diseases (ID) department chose to evaluate these self-referred patients being seen in our clinic due to (1) limited outpatient clinic appointment availability and (2) patients’ perception of need may not align with the subspecialty care provided. Methods In spring 2016, all self-referred patients requesting an outpatient ID evaluation were screened by the ID Access Plus program. Patients were called by administrative staff with a request for records from a licensed practitioner, and when received, were reviewed within 72 hours of receipt by a staff ID physician. Requests were either (1) accepted for appointment, (2) declined, or (3) referred to a more appropriate department within the CCF system. Patients who were declined appointments were informed by an administrator via telephone call. All patients were also informed of the ability for urgent referrals to be accepted with an MD to MD discussion. Results During a 12-month period a total of 1000 referrals were processed through the ID Access Plus program: 25% were declined for appointments; 45% were tabled as requested records were not received; and 30% had appointments scheduled. The most common patient reported reasons for self-referral to ID clinic were “Lyme disease” (10%) and “parasites” (4%). The “no-show” rate for scheduled self-referred patients was &lt;5%. The median wait period for a new patient ID appointment in the department declined from over 40 days to &lt; 10 days. Conclusion A system of prescreening patients self-referred to ID, requiring a review of medical records by ID clinicians, resulted in improved access for patients. Disclosures All authors: No reported disclosures.

Effects of admission (adm) source, time, and provider on inpatient (inpt) oncology (onc) outcomes at the Cleveland Clinic Foundation (CCF).

140 Background: The quality of care transfers is known to influence clinical outcomes. In an inpt onc setting at a major tertiary care referral center, patient (pt) adm originate from many different areas and times. A detailed evaluation of onc adm by source of transfer, admission time, and provider type, may identify opportunities to improve inpt clinical outcomes. Methods: We retrospectively reviewed all adm to the inpt solid tumor onc service from July - December 2014 from CCF regional hospital emergency departments (ED), outside hospital (OSH) ED, OSH inpt services, and CCF outpt clinics. Pts were excluded if the adm was planned or if admitted from the CCF Main Campus ED. Data collected included pt and encounter characteristics and provider type (house-staff or nocturnal hospitalist). Clinical outcomes, including activation of the adult medical emergency team (AMET), ICU transfers, length of stay (LOS), and in-hospital mortality were compared using chi-squared test; ECOG PS and LOS with the Kruskal-Wallis tests and Wilcoxon rank sum test. Results: A total of 413 unique pt admissions were reviewed. 213 were included after exclusion criteria were applied. The probability of AMET activation, mortality, and LOS differed by origin of transfer. Pts admitted from CCF regional EDs had the lowest median LOS and no deaths. OSH int transfers demonstrated significantly higher mortality vs other origins of transfer. Pts whose first orders were placed after 5pm had no significant differences in AMET activation, ICU transfers, LOS, or mortality vs daytime adm. There were no differences in adverse outcomes by the type of admitting provider. Conclusions: Onc inpts transferred from an outside healthcare setting were at highest risk for adverse outcomes (AMETs, increased LOS, and mortality) include those originating from OSH inpt services. Process and communication interventions focused on transfers from outside inpt facilities may improve safety and outcomes in this population. [Table: see text]