Digestive Disease Institute - Cleveland Clinic · 9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org 15-OUT-340 Digestive Disease Institute 2014 Outcomes 97970_CCFBCH_15OUT340_Cover_ACG.indd

9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org

15-OUT-340

Digestive Disease Institute

2014 Outcomes

97970_CCFBCH_15OUT340_Cover_ACG.indd 1 7/6/15 2:40 PM

Measuring Outcomes Promotes Quality Improvement

This project would not have been possible without the commitment and expertise of a team led by Laura Buccini, DrPH, MPH; and Charmaine Jones, MBA.

Graphic design and photography were provided by Cleveland Clinic’s Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015


Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its clinical institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with a focus on outcomes data and a review of new technologies and innovations.

The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical and procedural techniques.

In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data. The following reports are available to the public: • Joint Commission Performance Measurement Initiative (qualitycheck.org)

• Centers for Medicare and Medicaid Services (CMS) Hospital Compare (HospitalCompare.hhs.gov), and Physician Compare (medicare.gov/PhysicianCompare)

• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR)

Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic’s culture of continuous improvement and may help referring physicians make informed decisions.

We hope you find these data valuable, and we invite

your feedback. Please send your comments and

questions via email to:

[email protected] or scan here.

To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.

97970_CCFBCH_Rev0_1-128.pdf 1 7/7/15 7:44 AM

2

Dear Colleague:

Welcome to this 2014 Cleveland Clinic Outcomes book. Every year, we publish Outcomes books for 14 clinical institutes with multiple specialty services. These publications are unique in healthcare. Each one provides an overview of medical or surgical trends, innovations, and clinical data for a particular specialty over the past year. We are pleased to make this information available.

Cleveland Clinic uses data to manage outcomes across the full continuum of care. Our unique organizational structure contributes to our success. Patient services at Cleveland Clinic are delivered through institutes, and each institute is based on a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Institutes define quality benchmarks for their specialty services and report on longitudinal progress.

All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic.org/QPR). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites.

Our practice of releasing annual outcomes books has become increasingly relevant as healthcare transforms from a volume-based to a value-based system. We appreciate your interest and hope you find this information useful and informative.

Sincerely, Delos M. Cosgrove, MD CEO and President

Outcomes 2014

97970_CCFBCH_Rev0_1-128.pdf 2 7/7/15 7:44 AM

3Digestive Disease Institute 3

Prefer an e-version?

Visit clevelandclinic.org/OutcomesOnline, and

we’ll remove you from the hard copy mailing list

and email you when next year’s books are online.

what’s inside

Chairman’s Letter 04

Institute Overview 05

Quality and Outcomes Measures

Procedure and Outcomes Overview 06

Esophageal and Gastric Disease 11

Small Bowel Disease and Intestinal Transplantation 18

Nutrition 27

Large Bowel Disease 30

Trauma and Acute Care Surgery 48

Pancreaticobiliary Disease 50

Liver Disease and Liver Transplantation 53

Obesity and Metabolic Disease 69

Breast Disease 80

Cleveland Clinic Florida 88

Institute Quality Improvement 100

Surgical Quality Improvement 104

Institute Patient Experience 108

Cleveland Clinic – Implementing Value-Based Care 110

Innovations 116

Contact Information 122

About Cleveland Clinic 124

Resources 126

97970_CCFBCH_Rev0_1-128.pdf 3 7/7/15 7:44 AM

Chairman LetterChairman LetterChairman’s Letter

I am pleased to present the 2014 Outcomes book for Cleveland Clinic’s Digestive Disease Institute. This is the 13th year that we have shared our clinical outcomes and innovations with referring physicians, alumni, patients, and other individuals around the nation interested in digestive diseases. The book reflects our ongoing goal to provide patients with care of the highest quality and the deepest compassion.

This past year, the Digestive Disease Institute had many exciting achievements, including:

• Receiving Centers for Medicare & Medicaid Services’ approval for the liver and kidney transplant programs at our Weston, Florida, campus, and approval from the United Network for Organ Sharing for our heart transplant program

• Forming an affiliation with Doctors Hospital at Renaissance in South Texas to consult on best practices in bariatric medicine and surgery, including patient and safety initiatives, clinical pathways, and protocols

• Hosting the first US TARGIT Academy — a training course on treating breast tumors using intraoperative radiotherapy

• Contributing the largest single-center enrollment in the clinical trial of the bioartificial Extracorporeal Liver Assist Device (ELAD® System) for management of acute alcoholic hepatitis

We welcome your feedback, questions, and ideas for collaboration. Please contact me via email at [email protected] and reference the Digestive Disease Institute in your message.

Sincerely,

John Fung, MD, PhD Chairman, Digestive Disease Institute Medical Director, Allogen Laboratories Professor of Surgery, Cleveland Clinic Lerner College of Medicine

Outcomes 20144

97970_CCFBCH_Rev1_4-4.pdf 1 7/15/15 9:43 AM

Institute OverviewInstitute Overview

Digestive Disease Institute 5

Cleveland Clinic’s Digestive Disease Institute is regarded as one of the top digestive disease centers in the nation and unites all specialists within one unique, fully integrated model of care aimed at optimizing the patient experience. Through the years, Digestive Disease Institute physicians have pioneered many technologies and procedures for treating digestive disorders. This rich history of innovation continues today, whether through the development of new surgical techniques, participation in clinical trials, or operation of outcomes research databases or registries. U.S. News & World Report’s “Best Hospitals” survey has ranked the institute’s digestive disease services as No. 2 in the nation since 2003.

The institute is located on Cleveland Clinic’s main campus as well as in 25 additional locations and includes the Departments of Gastroenterology and Hepatology, Colorectal Surgery, and General Surgery (including hepatopancreatobiliary surgery, transplant surgery, and breast surgery); the Bariatric and Metabolic Center; and the Center for Human Nutrition. The institute’s 174 staff physicians, 132 residents and fellows, and 236 nurses offer the most advanced, safe, and proven treatments performed in the most effective and patient-friendly way.

Total admissions 9196

Patient days 61,041

Evaluation and management visits 113,782

Locations 26

Research studies 488

Publications 463

Physicians 174

Inpatient nurses 174

Ambulatory nurses 62

Fellows 66

Residents 66

2014 | Statistics

The Digestive Disease Institute staff authored 463 publications in 2014.For a complete list, go to clevelandclinic.org/outcomes.

2014 | Statistics

97970_CCFBCH_Rev0_1-128.pdf 5 7/7/15 7:44 AM

6

Endoscopic and Surgical Procedure Overview

Endoscopic Procedures 2012 – 2014

2012 2013 2014

Digestive Disease Institute (total) 57,353 61,142 62,576

Colonoscopy 26,397 27,952 27,641

Esophagogastroduodenoscopy/other esophagoscopy 16,729 18,496 21,297

Endoscopic retrograde cholangiopancreatography 1123 1289 1190

Endoscopic ultrasound 1367 1548 1675

Pouchoscopy 1339 1420 1493

Sigmoidoscopy and proctosigmoidoscopy 2840 2766 2741

Upper and lower motility 3945 4504 3769

Othera 3613 3167 2770

aIncludes anoscopy, capsule endoscopy, and small bowel endoscopy

Outcomes 20146

Procedure and Outcomes Overview

97970_CCFBCH_Rev0_1-128.pdf 6 7/7/15 7:44 AM

7

Outpatient Surgical Visits by Department/Section 2012 – 2014

Minimally Invasive Surgical Procedures by Department/Sectiona 2012 – 2014

Inpatient Surgical Visits by Department/Section 2012 – 2014

2012 2013 2014

Digestive Disease Institute (total) 9345 10,393 10,086

Bariatric 381 335 292

Breast 1415 1789 1533

Colorectal 1683 1836 1695

General surgery 5866 6433 6566

2012 2013 2014

Digestive Disease Institute (total) 5463 6163 6607



General surgery 3792 4502 4972aIncludes inpatient and outpatient laparoscopic and robotic surgical procedures

2012 2013 2014

Digestive Disease Institute (total) 7154 7594 8030



General surgery 3606 4051 4540


97970_CCFBCH_Rev0_1-128.pdf 7 7/7/15 7:44 AM

8

Surgical Outcomes Overview

Breast Surgerya Mean Length of Stay 2012 – 2014

Bariatric Surgerya Mean Length of Stay 2012 – 2014

Includes all Cleveland Clinic regional hospitals (excludes Cleveland Clinic Florida)

aSurgical procedures include other skin, subcutaneous tissue breast procedures with complication or comorbidity (cc) and without cc/major cc (mcc) and mastectomies for malignancy with and without cc/mcc.

These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu

Includes Cleveland Clinic main campus and Fairview Hospital, a Cleveland Clinic regional hospital

aSurgical procedures include OR procedures for obesity with mcc, OR procedures for obesity with cc, and OR procedures for obesity without cc/mcc.


5

0

N = 417 429 426

4

3

2

1

Days

2012 2013 2014

ObservedExpected

4

0

N = 595 662 649

3

2

1

Days

2012 2013 2014

ObservedExpected

Outcomes 20148


97970_CCFBCH_Rev0_1-128.pdf 8 7/7/15 7:44 AM

9

Colorectal Surgerya Mean Length of Stay 2012 – 2014

Colorectal Surgerya In-Hospital Mortality 2012 – 2014

aSurgical procedures are defined as all major small/large bowel, minor small/large bowel, anal, and stomal procedures; rectal resection procedures; and other digestive system OR procedures.


aSurgical procedures are defined as all major small/large bowel, minor small/large bowel, anal, and stomal procedures; rectal resection procedures; and other digestive system OR procedures.


10

0

N = 2650 2702 2779

6

8

4

2

Days

2012 2013 2014

ObservedExpected

2.0

0

N = 2650 2702 2779

1.2

1.6

0.8

0.4

Percent

2012 2013 2014

ObservedExpected


97970_CCFBCH_Rev0_1-128.pdf 9 7/7/15 7:44 AM

10

General Surgerya Mean Length of Stay 2012 – 2014

General Surgerya In-Hospital Mortality 2012 – 2014

aSurgical procedures are defined as all hernia, pancreas, and cholecystectomy procedures.



aSurgical procedures are defined as all hernia, pancreas, and cholecystectomy procedures.



8

0

N = 1446 1509 1442

6

4

2

Days

2012 2013 2014

ObservedExpected

2.0

0

N = 1446 1509 1442

1.2

1.6

0.8

0.4

Percent

2012 2013 2014

ObservedExpected

Outcomes 201410


97970_CCFBCH_Rev0_1-128.pdf 10 7/7/15 7:44 AM

11

Accuracy of Tumor Staging by Endoscopic Ultrasound: Percent Agreement With Pathology (N = 33) 2012 – 2014

Esophageal Adenocarcinoma

The incidence of esophageal adenocarcinoma is rising rapidly, and this is now the predominant esophageal cancer type in the United States.

Accurate T staging for esophageal cancer is necessary to ensure patients receive the optimal treatment. Radiologic imaging alone is unable to accurately determine T staging for esophageal cancer. Endoscopic ultrasound (EUS) allows for detailed examination of the esophageal wall to determine depth of tumor involvement. The Digestive Disease Institute performs many endoscopic ultrasounds for the preoperative evaluation of esophageal cancer treatment. Comparing the surgical pathology with preoperative endoscopic ultrasound staging in a representative sample of patients shows 100% accuracy for EUS staging of T2 and T3 tumors. Errors were limited to differentiating stages T1a from T1b, which is a known limitation of EUS. These results demonstrate the benefits of EUS preoperative staging of esophageal cancer.

100

40

60

80

0

20

Percent

Overall MeanAccuracy

T1a T1b T2 T3

Mean Accuracy by Tumor Stage


Esophageal and Gastric Disease

97970_CCFBCH_Rev0_1-128.pdf 11 7/7/15 7:44 AM

12

Hiatal Hernia Surgery

Hiatal hernias are graded according to severity and are often associated with gastroesophageal reflux disease. For patients with severe symptoms, surgery may be indicated. Patients who are offered a minimally invasive approach — the standard of care at Cleveland Clinic — benefit from decreased pain, shorter length of stay, and better overall recovery.

Median Length of Stay, Laparoscopic Hiatal Hernia Repair 2012 – 2014

30-Day Readmission Rate, Laparoscopic Hiatal Hernia 2012 – 2014

5

0

N = 64 65 75

4

3

2

1

Days

2012 2013 2014

20

0

N = 64 65 75

15

10

5

Percent

2012 2013 2014

Outcomes 201412


97970_CCFBCH_Rev0_1-128.pdf 12 7/7/15 7:44 AM

13

Median Length of Stay, Post-Neurostimulator Surgery 2013 – 2014

30-Day Readmission Rate, Post-Neurostimulator Surgery 2013 – 2014

Gastroparesis Surgery

Gastroparesis, also called delayed gastric emptying, is a disorder that slows the movement of food from the stomach to the small intestine. It often occurs in people with type 1 or type 2 diabetes. Patients often seek hospital treatment for complications of the disease such as malnutrition, dehydration, and pain. Treatment ranges from dietary changes and/or medications to surgery requiring the removal of most of the stomach and more recently the insertion of gastric neurostimulators.

With increased awareness of disease symptoms, the institute’s multidisciplinary program has been able to identify and treat patients preemptively and decrease the overall hospital readmission rate.

2.5

0

N = 22 19

1.5

2.0

1.0

0.5

Days

2013 2014

20

0

N = 22 19

15

10

5

Percent

2013 2014


97970_CCFBCH_Rev0_1-128.pdf 13 7/7/15 7:44 AM

14

Median Arcuate Ligament Syndrome

Median arcuate ligament (MAL) syndrome, also known as celiac artery compression syndrome, is a rare condition resulting in postprandial abdominal pain and weight loss. Cleveland Clinic has formed a collaborative team of gastroenterologists, minimally invasive surgeons, and vascular surgeons to evaluate and treat MAL syndrome. Treatment consists of releasing the MAL. Since 2012, the yearly volumes of MAL release have tripled. Likewise, conversion to open procedure has decreased from 25% to < 10%.

Conversion From Minimally Invasive to Open MAL Release Surgical Procedure 2012 – 2014

aJimenez JC, Harlander-Locke M, Dutson EP. Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc Surg. 2012 Sep;56(3):869-873.

40

0

N = 5 12 15

0

30

20

10

Percent

2012 2013 2014

Cleveland ClinicBenchmarka

14 Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 14 7/7/15 7:44 AM

15

Median Length of Stay, MAL Release Surgical Procedure 2012 – 2014

Celiac Artery Velocity (N = 32) 2012 – 2014

Decreased celiac artery velocity is a marker for successful release of the ligament and occurred in 82.6% of the Digestive Disease Institute’s patient population.

4

0

N = 5 12 15

3

2

1

Days

2012 2013 2014

00

400400

200200

300300

100100

Median Velocity (cm/s)Median Velocity (cm/s)

Preoperative Postoperative

201220132014


97970_CCFBCH_Rev0_1-128.pdf 15 7/7/15 7:44 AM

16

Esophageal Surgery Volume and In-Hospital Mortality

2014 Volume (N = 192)

2010 – 2014

Cleveland Clinic thoracic surgeons performed 192 procedures in 2014 and achieved a lower-than-expected in-hospital mortality rate (1.56% vs 3%).

Both the in-hospital and 30-day mortality rates for esophagectomy were 0% at Cleveland Clinic in 2014. The expected rates were 3.10% and 2.8%, respectively.

20122010

Volume400400

300300

200200

100100

00

44

33

22

11

002011 2013 2014

Mortality (%) Observed Expected

Esophagectomy In-Hospital and 30-Day Mortality

2014

4

Percent

3

2

030-Day

0%0%

1

In-Hospital

Expected

Source: Data from the UHC Clinical Data Base/Resource ManagerTM used by permission of UHC. All rights reserved.

Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database 2014.

Outcomes 201416


97970_CCFBCH_Rev0_1-128.pdf 16 7/7/15 7:44 AM

17

The majority of esophageal surgeries at Cleveland Clinic in 2014 were to treat patients with esophageal cancer and complex paraesophageal hernias who have had multiple failed operations.

Cleveland Clinic surgeons performed 142 esophagectomy procedures for patients with esophageal cancer from July 2011 to June 2014. The combined morbidity and mortality risk-adjusted rate was better than the national average.

Risk-adjusted Standardized incidence Eligible procedures Unadjusted rate rate (95% CI) ratio (95% CI)

142 21.1% 22.0% (16.1-28.9) 0.80 (0.58-1.05)

Distribution of Esophageal Surgeries by Indication (N = 192)

Esophagectomy for Esophageal Cancer, Combined Morbidity and Mortality

July 2011 – June 2014

2014

29% Cancer (N = 55)29% Cancer (N = 55)

7% Reflux (N = 14)7% Reflux (N = 14)

23% Achalasia (N = 45)23% Achalasia (N = 45)

5% Other (N = 10)5% Other (N = 10)

28% Paraesophageal hernia repair (N = 53)28% Paraesophageal hernia repair (N = 53)

8% Esophageal reconstruction (N = 15)8% Esophageal reconstruction (N = 15)

100%100%

Min0.52

25th0.94

Cleveland Clinic

Median1.04

75th1.17

Max1.81

= STS standardized incidence ratio Source: STS General Thoracic Surgery Database, July 2010–June 2013


97970_CCFBCH_Rev0_1-128.pdf 17 7/7/15 7:44 AM

18

SmartPill Procedures 2012 – 2014

Capsule Endoscopy

The Digestive Disease Institute’s Center for Capsule Endoscopy has extensive experience with the SmartPill®. The SmartPill is an ingestible capsule that measures pressure, pH levels, and temperature as it passes through the GI tract. It is used to diagnose motility disorders such as gastroparesis and colonic inertia. The SmartPill has been used at Cleveland Clinic since 2009.

120100

0

N = 47 105 107

80

604020

Number

2012 2013 2014

Outcomes 201418

Small Bowel Disease and Intestinal Transplantation

97970_CCFBCH_Rev0_1-128.pdf 18 7/7/15 7:44 AM

19

Video Capsule Procedures 2012 – 2014

The Center for Capsule Endoscopy routinely performs video capsule endoscopy, a now well-established method to detect and diagnose lesions of the small bowel in patients with suspected bleeding of the GI tract, inflammatory conditions such as Crohn’s disease, and small bowel neoplasms and tumors.

Remote Video Capsule Reads 2012 – 2014

The Center for Capsule Endoscopy has continued the IntelliCap® program, which allows institute physicians to review and interpret small bowel video capsule endoscopy performed at other medical centers.

800

0

N = 566 513 668

600

400

200

Number

2012 2013 2014

160

120

0

N = 27 105 158

80

40

Number

2012 2013 2014


97970_CCFBCH_Rev0_1-128.pdf 19 7/7/15 7:44 AM

20

Crohn’s Disease Organ Space Surgical Site Infection Rate 2012 – 2014

Crohn’s Disease Postoperative Outcomes 2012 – 2014

Crohn’s Disease

The surgical volume for Crohn’s disease is high, with a particular focus on techniques that conserve the small bowel. The multidisciplinary team includes surgeons, gastroenterologists, nutritionists, pathologists, and radiologists.

10

2

4

00

N = 296 60 295 82 238 101

Percent

2012 2013 2014

OpenLaparoscopic

6

8

2012 2013 2014

Open Lap Open Lap Open Lap Postoperative Outcomes (N = 296) (N = 60) (N = 295) (N = 82) (N = 238) (N = 101)

Median length of stay, days 9 7 8 7 8 6

30-day readmission rate, % 10 8 11 20 12 7

In-hospital mortality rate, % 0 0 0 0 0 0

Surgical site infection rate, % Superficial 5 3 7 5 3 3 Deep 1 0 1 0 0 0

Urinary tract infection rate, % 3 7 2 1 1 1

Venous thromboembolism rate, % 4 3 4 2 1 3

Lap = laparoscopic

20 Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 20 7/7/15 7:44 AM

21

Median Length of Stay, Inpatient Small Bowel Obstruction Proceduresa 2012 – 2014

30-Day Readmission Rate, Inpatient Small Bowel Obstruction Proceduresa

2012 – 2014

Small Bowel Obstruction

Mechanical small-bowel obstruction (SBO) is the most frequently encountered surgical disorder of the small intestine. Cleveland Clinic’s annual SBO admissions have increased over the past 3 years. The section of Acute Care Surgery is developing an SBO clinical care path that will standardize nonoperative and operative SBO management.

aProcedures represent those conducted by the Department of General Surgery only.

aProcedures represent those conducted by the Department of General Surgery only.

25

5

10

00

N = 169 111 185 114 200 165

Percent

2012 2013 2014

OperativeNonoperative

15

20

8

2

4

00

N = 169 99 102 185 135 200

Days

2012 2013 2014

OperativeNonoperative

6


97970_CCFBCH_Rev0_1-128.pdf 21 7/7/15 7:44 AM

22

Median Length of Stay for HIPEC Patients 2011 – 2014

Management of Carcinomatosis

Hyperthermic intraoperative peritoneal chemotherapy (HIPEC) is a surgical procedure used to treat cancers that have spread to the lining of the abdominal cavity, such as cancers arising in the appendix, colon, stomach, and ovaries, as well as pseudomyxoma peritonei and peritoneal mesothelioma. This is a 2-step surgical procedure, which includes debulking of visible disease (tumor), followed by HIPEC. HIPEC delivers heated chemotherapy directly into the abdomen, which circulates for 90 minutes, treating the microscopic disease that may remain.

Cancer Type Patients Percent

Colon cancer 15 23.1

Appendix carcinoma 12 18.5

Pseudomyxoma peritonei 8 12.3

Ovarian cancer 8 12.3

Peritoneal mesothelioma 6 9.2

Peritoneal carcinomatosis 5 7.7

Undefined 3 4.6

Cancer Type Patients Percent

Retroperitoneal cancer 2 3.1

Gastric cancer 1 1.5

Adenocarcinoma unknown primary 1 1.5

Breast carcinoma 1 1.5

Desmoplastic round cell tumor 1 1.5

Small bowel cancer 1 1.5

Thyroid cancer 1 1.5

Cancer Type for Patients Undergoing HIPEC Procedure (N = 65) 2011 – 2014

10

0

N = 11 16 18

8

6

4

2

Days

2012 2013 2014

20

2011

Outcomes 201422


97970_CCFBCH_Rev0_1-128.pdf 22 7/7/15 7:44 AM

23

Median Length of Stay, Inpatient Inguinal Hernia Repairs 2012 – 2014

Hernia Center

Surgeons from Cleveland Clinic’s Hernia Center perform more than 1700 hernia repairs each year, from the routine to the most complex cases. The center is designed so that patients receive individualized care, undergoing a comprehensive evaluation to determine the best surgical procedure for their specific type of hernia.

The indications for inpatient inguinal hernia repairs are limited to patients with serious concomitant medical illnesses.

1.2

0.20.4

0

N = 83 18 79 24 93 27

Days

2012 2013 2014

OpenLaparoscopic

0.60.81.0

23Digestive Disease Institute

97970_CCFBCH_Rev0_1-128.pdf 23 7/7/15 7:44 AM

24

Median Length of Stay, Inpatient Incisional/Ventral Hernia Repairs 2012 – 2014

2012 (N) 2013 (N) 2014 (N)

Inguinal (%)

Open 1.5 (957) 1.9 (1012) 0.7 (986)

Laparoscopic 1.0 (411) 0.7 (552) 0.3 (596)

Incisional/ventral (%)

Open 2.9 (481) 3.7 (485) 2.9 (485)

Laparoscopic 1.2 (161) 2.6 (192) 1.5 (202)

30-Day Reoperation Rate, Inpatient/Outpatient Post Hernia Repair 2012 – 2014

2.5

0.5

0

N = 160 114 188 121 177 106

Days

2012 2013 2014

OpenLaparoscopic

1.0

1.5

2.0

Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 24 7/7/15 7:44 AM

25

Nontransplant Intestinal Reconstruction 2013 – 2014

Center for Gut Rehabilitation and Transplantation

The Center for Gut Rehabilitation and Transplantation was established as a continuation of Cleveland Clinic’s efforts to enhance the multidisciplinary team approach for the management of patients with acute and chronic gut failure. The center accepts all patients with acute intestinal ischemia, with the intent to restore blood flow to the intestine and other abdominal organs by using combined radiologic and surgical techniques. With chronic gut failure, all efforts are made to restore gut function with medical and surgical modalities including autologous surgical reconstruction and bowel lengthening. Intestinal and multivisceral transplantations continue to be used as rescue therapies for those who fail intravenous nutritional therapy.

Bowel Lengthening With Serial Transverse Enteroplasty Procedure

100

20

40

0

Percent

Midgut Reconstruction Bowel LengtheningProcedure

Foregut GastricReconstruction

2013 (N = 98)2014 (N = 114)

60

80


97970_CCFBCH_Rev0_1-128.pdf 25 7/7/15 7:44 AM

26

Intestinal Transplantation 1-Year Patient Survivala (N = 8) July 2011 – December 2013

Intestinal Transplantation 1-Year Graft Survivala,b (N = 11) July 2011 – December 2013

aScientific Registry of Transplant Recipients national average for 1-year graft survival = 70.87% srtr.org

aScientific Registry of Transplant Recipients national average for 1-year graft survival = 70.87% srtr.org bIncludes 3 intestinal retransplants

00

100100

4040

6060

8080

2020

Percent SurvivalPercent Survival

0 200100Days After Transplantation

300

00

100100

4040

6060

8080

2020

Percent SurvivalPercent Survival


300

Outcomes 201426


97970_CCFBCH_Rev0_1-128.pdf 26 7/7/15 7:44 AM

27

The Center for Human Nutrition evaluates, educates, and treats disease-related nutrition problems in addition to providing preventive, sports, and wellness counseling. Specialty focus nutrition teams work closely with healthcare providers in the Center for Gut Rehabilitation and Transplantation to support the nutritional needs of critically ill, organ transplant, and severe-gastrointestinal-failure patients. As part of the overall care, the center offers intensive diet counseling, tube feeding, and oral rehydration techniques, along with medication, growth factor therapy, and restorative surgery.

1-Year Readmission Rate for Patients Discharged on Home Parenteral Nutrition 2012 – 2014

40

0

N = 737 755 801

30

20

10

Percent

2012 2013 2014

60

15

30

0

Percent

CRBSI Dehydration Othera

2012 (N = 109)2013 (N = 82)2014 (N = 221)45

Complication Rate of Home Parenteral Nutrition-Related Readmissions per Year 2012 – 2014

Home parenteral nutrition frequently results in hospital readmission. The most common reason for readmissions is CRBSI.

CRBSI = catheter-related bloodstream infection

aOther complications include noninfectious catheter complications, electrolyte disturbances, and venous thrombosis.


Nutrition

97970_CCFBCH_Rev0_1-128.pdf 27 7/7/15 7:44 AM

28

Safety (Adverse Events) of Cycling Parenteral Nutrition From 24 to 12 Hours in 1 Step in Patients Requiring Long-Term Therapy (N = 63) 2013 – 2014

This Cleveland Clinic study aimed to test the hypothesis that patients without diabetes mellitus or major organ dysfunction requiring long-term parenteral nutrition could be cycled from 24 hours to 12 hours in 1 step without increasing the risk of parenteral nutrition-related adverse events compared with the standard 2-step process. In the 63 patients studied, the most prevalent parenteral nutrition-related adverse event was hyperglycemia, occurring in 24% of patients in the fast-track (1-step) group and 30% of patients in the standard (2-step) group. Overall, no significant difference was seen in the prevalence of parenteral nutrition-related minor adverse events between fast-track (33%) and standard (53%) groups (P = 0.5).1

Fast-track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long-term parenteral nutrition. Fast-track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.1Austhof S, Dechicco B, Cresci G, Corrigan M, Suryadevara S, Parisian K, Sourianarayanane A, Kumaravel A, Lopez R, Steiger E. Cycling parenteral nutrition from 24 to 12 hours in one step is safe in patients requiring long-term therapy. Abstract presented at American Society of Parenteral and Enteral Nutrition, Clinical Nutrition Week, Savannah, GA: Jan. 20, 2014.

100100

180180

140140

160160

120120

Average Glucose (mg/dL)Average Glucose (mg/dL)

12 am 11 am6 amTime

Day 0

5 pm100100

180180

140140

160160

120120


12 am 11 am6 amTime

Day 1

5 pm

100100

180180

140140

160160

120120


12 am 11 am6 amTime

Day 2

5 pm100100

180180

140140

160160

120120


12 am 11 am6 amTime

Day 3

5 pm

200200 200200

1-step2-step

200200 200200

Outcomes 201428

Nutrition

97970_CCFBCH_Rev0_1-128.pdf 28 7/7/15 7:44 AM

29

Wound Prevention Outcomes Based on Nutrition Therapy 2014

These data show the impact of the registered dietitian nutritionist’s involvement, including assessing existing nutrition status, developing nutrition care plans for patients, and preventing wound development among a sample of hospitalized patients who were identified as at risk for wound development based on criteria in a new pressure ulcer prevention care path.

Wound/ Wound Developed/ Wound Developed/ Wound Status Not Developed Healed Not Healed Unknown Nutrition Therapy (N = 84) (N = 9) (N = 12) (N = 7)

Oral diet with oral supplements, % 36 22 8 29

Oral diet with no oral supplements, % 16 0 8 0

Enteral feeding, % 27 56 50 14

Enteral feeding plus oral supplements, % 17 22 8 14

Parenteral nutrition, % 2 0 25 0

Unknown mode, % 2 0 0 43


97970_CCFBCH_Rev1_29-29.pdf 1 7/15/15 9:43 AM

30

Cecal Intubation Rate for Colonoscopy 2012 – 2014

30-Day Colonoscopy-Related Complications 2012 – 2014

aRex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb GJ, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110:72-90.

Colonoscopy

Colonoscopy is a common endoscopic procedure, with more than 3 million examinations performed in the United States annually. The efficacy of colonoscopy to prevent colorectal cancer is dependent on the quality of the procedure. National benchmarks have been established as minimal targets to meet or exceed in order to maximize the benefit of the colonoscopy. Three important metrics include the percentage of procedures in which the endoscopist reaches the cecum (cecal intubation rate), the time spent looking at the colon mucosa on withdrawal of the colonoscope (withdrawal time), and the polyp detection rate, which is a surrogate for the adenoma detection rate.

100

0

N = 26,397 27,952

60

80

40

20

Percent

2012 2013


27,641

2014

1.0

0.0

N = 26,397 27,952

0.6

0.8

0.4

0.2

Percent

2012 2013

27,641

2014

Outcomes 201430

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 30 7/7/15 7:44 AM

31

Mean Scope Withdrawal Time for Colonoscopies Without Maneuvers 2012 – 2014

Polyp Detection Rate During Screening Colonoscopy 2012 – 2014

aRex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb GJ, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110:72-90.

aGohel TD, Burke CA, Lankaala P, Podugu A, Kiran RP, Thota PN, Lopez R, Sanaka MR. Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist. Clin Gastroenterol Hepatol. 2014 Jul;12(7):1137-1142.

12

0

N = 2941 6774

6

9

3

Minutes

2012 2013

9527

2014


50

0

N = 4257 4590

20

30

40

10

Percent

2012 2013

6368

2014



97970_CCFBCH_Rev0_1-128.pdf 31 7/7/15 7:44 AM

32

Mean Lymph Nodes Harvested 2012 – 2014

Colon Cancer Organ Space Superficial Infection Rate 2012 – 2014

Through the implementation of a surgical site infection bundle, the Department of Colorectal Surgery has been able to drastically reduce surgical site infections for all its cancer patients.

Colon Cancer

In 2014, more than 200 patients underwent surgery for tumors of the colon by the Department of Colorectal Surgery. Despite increasing patient acuity (average American Society of Anesthesiologists score 2.9), surgeons in the Department of Colorectal Surgery achieved a 30-day mortality rate of 0% for patients undergoing laparoscopic resection and 1% for those having an open colectomy.

The average lymph node harvest remained almost 3 times higher than the 12-node minimum that has become a national benchmark for quality of surgery and pathology assessment.

aAmerican Joint Committee on Cancer (AJCC) and National Cancer Institute (NCI) recommend harvesting for examination at least 12 lymph nodes in patients with colon cancer to confirm the absence of nodal involvement by tumor.

12

0

N = 104 104

468

10

2

Percent

2012

90 98

2013

114 104

2014

OpenLaparoscopic

40

0

N = 104 104

20

30

10

Number

2012

90 98

2013

114 104

2014

OpenLaparoscopicAJCC/NCI benchmarka

Outcomes 201432

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 32 7/7/15 7:44 AM

33

Postoperative Outcomes 2012 2013 2014

Open Lap Open Lap Open Lap

N = 104 104 90 98 114 104

ASA scorea, mean 2.9 2.8 2.9 2.8 3.1 2.8




Surgical site infection rate, %

Superficial 5 4 7 8 3 3 Deep 0 0 1 0 0 1



ASA = American Society of Anesthesiologists, Lap = laparoscopic aASA score is a subjective assessment of a patient’s severity of illness based on five classes (1–5) where 1 represents a completely healthy/fit patient and 5 represents a moribund patient not expected to live more than 24 hours.

Colon Cancer Postoperative Outcomes 2012 – 2014

Colon Cancer Survival by Stage 2000 – 2013

Stage-specific, 5-year disease-free survival rates for Cleveland Clinic-treated patients with colon cancer continue to exceed national averages: stage I (74%), stage II (59%), stage III (46%), and stage IV (6%).

00

100100

4040

6060

8080

2020

Survival (%)Survival (%)

0 2412Time (Months)

36 6048

Stage I (N = 362)Stage II (N = 538)Stage III (N = 486)Stage IV (N = 275)


Multidisciplinary Tumor Conference

Patients with colorectal cancer are reviewed by a multidisciplinary tumor board consisting of caregivers from anatomic pathology, colorectal surgery, medical oncology, radiation oncology, gastroenterology, genomic medicine, hepatobiliary surgery, and radiology.

During tumor board conferences, patients’ pathology and radiologic images are reviewed for diagnosis and clinical staging; an individualized treatment plan is then formulated. Cleveland Clinic’s colorectal cancer multidisciplinary tumor board strives to discuss 100% of patients presenting to the clinic with a new diagnosis of colorectal cancer.

97970_CCFBCH_Rev0_1-128.pdf 33 7/7/15 7:44 AM

34

Restorative and Nonrestorative Procedures (Na = 89) 2014

Rectal Cancer

In 2014, nearly 180 patients underwent surgery for cancer of the rectum. Despite a referral pattern consisting of a preponderance of lower rectal tumors, more than 70% of patients were successfully treated without a permanent colostomy. This restorative procedure rate compares favorably with data from a large internationally recognized trial conducted in Europe.

aRepresents a subset of all rectal cancer surgical patients

bKapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001 Aug;345(9):638-646.

100

0

60

80

40

20

Percent

Restorative Non Restorative

Cleveland ClinicBenchmarkb

Outcomes 201434

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 34 7/7/15 7:44 AM

35

Circumferential Resection Margin Status (Na = 89) 2014

One of the major factors influencing rectal cancer survival is the surgeon’s ability to remove the tumor with a clear margin of surrounding normal tissue. Achieving a clear circumferential resection margin (CRM) is highly predictive of survival after rectal cancer surgery and serves as a useful indicator of surgical quality.

Cleveland Clinic’s rate of clear CRM (96%) exceeds the national recognized rate of 84%.


bMarijnen CA, Nagtegaal ID, Kapiteijn E, Kranenbarg EK, Noordijk EM, van Krieken JH, van de Velde CJ, Leer JW; Cooperative investigators of the Dutch Colorectal Cancer Group. Radiotherapy does not compensate for positive resection margins in rectal cancer patients: report of a multicenter randomized trial. Int J Radiat Oncol Biol Phys. 2003;55(5):1311-1320.

100

0

60

80

40

20

Percent

Involved Uninvolved



97970_CCFBCH_Rev0_1-128.pdf 35 7/7/15 7:44 AM

36

Completeness of Total Mesorectal Excision (Na = 88) 2014

Cleveland Clinic’s rate of completeness (96%) exceeds the nationally recognized rate of 57%. As well, the rates of near complete and incomplete TMEs are significantly lower than the nationally recognized rates of 19% and 24%, respectively.

Total mesorectal excision (TME) refers to the en bloc surgical removal of the rectum, attached lymph node-containing mesorectum, and the surrounding connective tissue envelope. TME surgery has become the contemporary standard of care for patients with rectal cancer. While circumferential resection margin (CRM) is the most significant predictor of local recurrence, the completeness of the TME also contributes to the reduction of local recurrence and is another important quality metric. Incomplete TME for rectal cancer is associated with increased local and overall recurrences.


bNagtegaal ID, van de Velde CJ, van der Worp E, Kapiteijn E, Quirke P, van Krieken JH; Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol. 2002;20(7):1729-1734.

100

0

60

80

40

20

Percent

Complete Near Complete


Incomplete

Outcomes 201436

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 36 7/7/15 7:44 AM

37

Rectal Cancer Organ Space Superficial Infection Rate 2012 – 2014



N = 134 31 126 47 140 39

ASA scorea, mean 2.9 2.7 2.8 2.7 3.0 2.7



Surgical site infection rate, %




ASA = American Society of Anesthesiologists, Lap = laparoscopic

aASA score is a subjective assessment of a patient’s severity of illness based on five classes (1–5) where 1 represents a completely healthy/fit

patient and 5 represents a moribund patient not expected to live more than 24 hours.

Rectal Cancer Postoperative Outcomes 2012 – 2014

15

0

N = 134 31

6

9

12

3

Percent

2012

126 47

2013

140 39

2014

OpenLaparoscopic


97970_CCFBCH_Rev0_1-128.pdf 37 7/7/15 7:44 AM

38

Rectal Cancer Survival by Stage 2000 – 2013

Stage-specific, 5-year, disease-free survival rates for Cleveland Clinic-treated patients with rectal cancer continue to exceed national averages: stage I = 74%, stage II = 52%, stage III = 45%, and stage IV = 6%.

00

100100

4040

6060

8080

2020


0 2412Time (Months)

36 6048

Stage I (N = 683)Stage II (N = 415)Stage III (N = 507)Stage IV (N = 233)

Outcomes 201438

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 38 7/7/15 7:44 AM

39

Hereditary Colon Cancer

The Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia was established in 2008. It is staffed by a multidisciplinary team dedicated to the care of patients affected by hereditary colorectal cancer syndromes. It houses the David G. Jagelman Inherited Colorectal Cancer Registries, which were established in 1979. The mission of the Jagelman Registries and the Weiss Center is to prevent death from cancer and maintain quality of life through excellent patient care, effective education, and clinically relevant research. The Weiss Center is the largest and one of the most well-established registries of its type in the world.

To help reduce the risk of inherited colon cancer, the team follows generations of families. The graph below shows the rate at which cancer is detected in patients with familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC) according to the generations to which they belong. The data show decreasing cancer detection rates across three generations.

Cancer Detection Rate Over 3 Generations 1979 – 2014

50

0

20

30

40

10

Percent

FAP (N = 98) HNPCC (N = 112)

.12

Generation 1Generation 2Generation 3


97970_CCFBCH_Rev0_1-128.pdf 39 7/7/15 7:44 AM

40

Cancer Detection Rate in Lynch Syndrome Under Surveillance 2012 – 2014

Polyp Removal Rate in Patients With Lynch Syndrome 2012 – 2014

The graph above depicts the rate of cancer diagnosis in patients affected by Lynch syndrome who are undergoing a yearly colonoscopy. Note that the number of patients under surveillance is increasing, but the rate of cancer diagnosis is decreasing. Most cancers are diagnosed at the patient’s first colonoscopy.

The process of carcinogenesis is accelerated in patients with Lynch syndrome. Many patients form new adenomas within 1 year of their prior colonoscopy. Continued surveillance and polyp removal are essential to preventing cancer.

10

0

N = 45 63

6

8

4

2

Percent

2012 2013

86

2014

60

0

N = 51 51

40

20

Percent

2012 2013

29

2014

Outcomes 201440

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 40 7/7/15 7:44 AM

41

In addition to treating patients with hereditary nonpolyposis colorectal cancer and familial adenomatous polyposis syndromes, the Weiss Center cares for patients and families with other less common hereditary syndromes associated with a high risk for colorectal and other cancers. These include Peutz-Jeghers syndrome, juvenile polyposis syndrome, MYH-associated polyposis, and serrated polyposis syndrome.

Weiss Center Families Enrolled in the Familial Adenomatous Polyposis and Hereditary Nonpolyposis Colorectal Cancer Registry 2012 – 2014

Families Treated by the Weiss Center for Less Common Polyposis Syndromes 2012 – 2014

aIncludes Cowden syndrome, Cronkhite-Canada syndrome, and oligopolyposis

2400

0

N = 1849 1952

1800

1200

600

Number

2012 2013

2075

2014

200

0

80

120

160

40

Number

Peutz-JeghersSyndrome

N = 35 36 37

Juvenile PolyposisSyndrome

51 54 59

MYH-AssociatedPolyposis

44 49 52

Serrated PolyposisSyndrome

115 122 136

Othera

85 185 190

201220132014


97970_CCFBCH_Rev0_1-128.pdf 41 7/7/15 7:44 AM

42

Ulcerative Colitis

Cleveland Clinic is a referral center for patients diagnosed with ulcerative colitis. Minimally invasive laparoscopic surgical approaches as well as the ability to salvage problematic pouches are available for those patients requiring surgery.

Ulcerative Colitis Organ Space Surgical Site Infection Rate 2012 – 2014



N = 315 142 326 116 224 149




Surgical site infection rates




Lap = laparoscopic

Ulcerative Colitis Postoperative Outcomes 2012 – 2014

10

0

N = 315 142

4

6

8

2

Percent

2012

326 116

2013

224 149

2014

OpenLaparoscopic

Outcomes 201442

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 42 7/7/15 7:44 AM

43

Continent Ileostomy

Cleveland Clinic’s Department of Colorectal Surgery is one of the few sites in the world that performs continent ileostomies. The continent ileostomy (Kock pouch) is an internal reservoir that allows patients to avoid wearing an external stomal appliance. The pouch is emptied by inserting a soft catheter through the stoma. A continent ileostomy can be constructed from an existing end ileostomy and, in some cases, from failed pelvic J pouches.

Continent Ileostomy Volume 2011 – 2014

80

0

60

40

20

Number

Creation Revision

N = 16 67


97970_CCFBCH_Rev1_43-43.pdf 1 7/15/15 9:44 AM

4444

Center for Ileal Pouch Disorders

Cleveland Clinic is one of the highest-volume centers in the US and for more than 3 decades, has offered restorative proctocolectomy with ileal J pouch surgery as an alternative to permanent stoma. The Center for Ileal Pouch Disorders was established to treat pouch disorders and remains at the forefront of new approaches to the management of pouch complications.

Surgical Pouch Construction 2012 – 2014

The Center for Ileal Pouch Disorders is the world’s first and largest multidisciplinary pouch center, which sees more than 1200 patients each year.

Pouch disorders are classified and managed based on the following categories:

• Surgical/mechanical

• Inflammatory/infectious

• Functional

• Neoplastic

• Systemic/metabolic

200

0

N = 172 195

120

160

80

40

Number

2012 2013

190

2014

Cleveland Clinic gastroenterologists have helped pioneer endoscopic therapy for various pouch-associated complications, which have been the major cause of pouch failure. The Digestive Disease Institute is the only medical center in the world that treats such pouch complications with less invasive endoscopic techniques.

Novel Endoscopic Therapy for Pouch Leak and Stricture 2013 – 2014

20

0

N = 4 7

10

15

5

Number of Patients

Needle Knife Stricturotomyfor Pouch Stricture

7 12

Endoscopic Closureof the Tip of “J” Leak

11 18

Needle Knife Sinusotomyof Anastomotic Leak

20132014

Outcomes 201444

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 44 7/7/15 7:44 AM

45

Diverticulitis

Diverticulitis is a condition resulting from inflammation and infection in 1 or more diverticula. Surgery becomes necessary when antibiotics fail to eradicate the infection and when a large abscess, perforation, peritonitis, or continued rectal bleeding is present.

The percentage of diverticulitis surgical cases completed via a minimally invasive laparoscopic approach has increased over the past 3 years. The colorectal department has a national and international referral base for highly complex cases.

Diverticulitis Organ Space Surgical Site Infection Rate 2012 – 2014



N = 76 113 80 132 140 137




Surgical site infection rates




Lap = laparoscopic

Diverticulitis Postoperative Outcomes 2012 – 2014

15

0

N = 76 113

6

9

12

3

Percent

2012

80 132

2013

140 137

2014

OpenLaparoscopic


97970_CCFBCH_Rev0_1-128.pdf 45 7/7/15 7:44 AM

46

Total Inpatient and Outpatient Visits for Stoma Therapy 2013 – 2014

Stoma Therapy

The Digestive Disease Institute has an active Wound Ostomy Care (WOC) program that helps patients with the practical, social, and psychological issues related to bowel diversion. WOC nurses are board-certified by their professional organization and care for patients each day in the inpatient setting and outpatient clinic. For patients with an ileostomy or a colostomy, having the support of an experienced enterostomal therapy nurse (ETN) is critical. The institute’s ETNs conducted more than 17,000 inpatient and outpatient visits in 2014, making them some of the most experienced ETNs in the country. This depth and breadth of experience allows them to manage even the most complex issues related to the care of ostomy patients.

Cleveland Clinic’s R.B.

Turnbull, Jr., MD, School

of Wound, Ostomy, and

Continence Nursing (WOCN)

was established as the first

WOCN school in the world

50 years ago. More than

3000 WOCN specialists

have graduated from the

program and are practicing

throughout the world.

The program prepares nurses to:

• Manage ostomies pre- and postoperatively

• Prevent and treat pressure ulcers, fistulas, and other skin disorders

• Care for patients with urinary and fecal incontinence

15,000

0

N =

6000

9000

12,000

3000

Number of Visits

11,544 3813

2013

12,842 3915

2014

InpatientOutpatient

Outcomes 201446

Large Bowel Disease

97970_CCFBCH_Rev0_1-128.pdf 46 7/7/15 7:44 AM

47

Ventral Rectopexy by Procedure Type 2008 – 2014

Complications of Ventral Rectopexy 2008 – 2014

SBO = small bowel obstruction

Pelvic Floor Disorders

The pelvic floor team is a multidisciplinary group of physicians that focuses on female pelvic floor disorders and is one of the most experienced groups of such specialists in the region. Specialists treat the entire spectrum of bowel disorders, including fecal incontinence, chronic constipation, and other difficulties. They also treat anal pain, hemorrhoids, fissures, anal and rectovaginal fistulas, and rectal prolapse. The National Association for Continence has designated the Section of Female Pelvic Medicine and Reconstructive Surgery in Cleveland Clinic’s Ob/Gyn & Women’s Health and Digestive Disease Institutes as a Center of Excellence for Continence Care in Women.

60

0

N = 58 20

304050

2010

Number

Robotic Laparoscopic

11

Open

6

Converted

80

0

N = 4 4

40

60

20

Number

SBO Ileus

4

Respiratory

6

Wound

6 8

Urinary UTI

22

Other

75

None


97970_CCFBCH_Rev0_1-128.pdf 47 7/7/15 7:44 AM

4848

Mean Length of Stay, Trauma Casesa 2013 – 2014

Trauma

The Department of General Surgery provides coverage for trauma care. The Northeast Ohio Trauma System, created in 2010, is a partnership between Cleveland Clinic Health System and MetroHealth Medical Center. Together they provide integrated trauma care to the citizens of Northeast Ohio. Since its inception, the collaboration has proved successful in controlling length-of-stay and mortality rates.

ISS = injury severity scoreaData from Hillcrest Hospital, a Cleveland Clinic regional hospital, a level II trauma center

8

6

0

N = 1538 1578 129 135

4

2

Days

No Injuries orNoncodeable

Minor(ISS 1 – 9)

Moderate(ISS 10 – 15)

77 70

Severe(ISS 16 – 24)

40 39

Critical(ISS ≥ 25)

20132014

99 196

48 Outcomes 2014

Trauma and Acute Care Surgery

97970_CCFBCH_Rev0_1-128.pdf 48 7/7/15 7:44 AM

49

Acute Care Surgery

The acute care surgery section located at Cleveland Clinic main campus consists of surgeons who are fellowship trained in surgical critical care. The team manages a wide range of emergent and complex general surgery patients who are admitted through the Emergency Department or transferred to Cleveland Clinic from outside hospitals. As board-certified intensivists, the team also practices in the surgical ICU at Cleveland Clinic main campus.


APR DRG Severity of Illness at Admissiona for Acute Care Surgeryb 2012 – 2014

In-Hospital Mortality 2012 – 2014

aAPR DRG severity of illness at admission is defined as the extent of physiologic decompensation or loss of organ system function.

bData represent Cleveland Clinic main campus only.

Source: The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG-Software

These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu

In 2014, the acute care surgery team was involved in the care of more than 900 patients. Most presented with moderate to major severity of illness.

Percent

02012

1055N = 1295 952

2013 2014

30

20

10

40 MinorModerateMajorExtreme

10

2

4

0

N = 1055 1295 952

Percent

2012 2013 2014

ObservedExpected

6

8

97970_CCFBCH_Rev0_1-128.pdf 49 7/7/15 7:44 AM

50

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose and treat disorders of the bile and pancreatic ducts.

Post-ERCP Acute Pancreatitis, Adult and Pediatric 2012 – 2014

Placement of a prophylactic pancreatic duct stent in high-risk patients has been shown to reduce the risk for pancreatitis following ERCP.

Pancreatic Stent Placement, Adult and Pediatric 2012 – 2014

ERCP = endoscopic retrograde cholangiopancreatography

10

4

6

8

0

N = 1123 1289 1190

2

Percent

2012 2013 2014

15

5

10

0

N = 1123 1289 1190

Percent

2012 2013 2014

Outcomes 201450

Pancreaticobiliary Disease

97970_CCFBCH_Rev0_1-128.pdf 50 7/7/15 7:44 AM

51

Management of Gallbladder Disease

Cholecystectomy is one of the most common general surgical procedures for the treatment of symptomatic gallstones and other gallbladder conditions. The majority of these operations are performed laparoscopically.

The indications for inpatient cholecystectomy are limited to patients with concomitant medical illnesses or in whom complications from gallstones require immediate cholecystectomy.

2012 2013 2014

Open, % (N) 3.4 (58) 1.5 (68) 2.0 (51)

Laparoscopic, % (N) 0.2 (820) 0.3 (895) 0.1 (799)

Median Length of Stay, Open and Laparoscopic Inpatient Cholecystectomies 2012 – 2014

30-Day Readmission Rate, Open and Laparoscopic Inpatient Cholecystectomies 2012 – 2014

30-Day Mortality Rate, Open and Laparoscopic Inpatient Cholecystectomies 2012 – 2014

8

6

0

N = 58 68 51820 895 799

4

2

Days

2012 2013 2014

OpenLaparoscopic

20

12

16

0

N = 58 68 51820 895 799

8

4

Percent

2012 2013 2014

OpenLaparoscopic


97970_CCFBCH_Rev0_1-128.pdf 51 7/7/15 7:44 AM

52

Median Length of Stay, Pancreatectomy Procedures 2012 – 2014

30-Day Readmission Rate, Pancreatectomy Procedures 2012 – 2014

Management of Pancreatic Disease

Cleveland Clinic’s Pancreas Disorder Clinic cares for patients across the spectrum of pancreatic disease, both benign and malignant, and offers multidisciplinary care teams for pancreatic cancer and chronic pancreatitis.

Lap = laparoscopic

Days

0Open

WhippleN =

Lap DistalPancreatectomy

Open DistalWhipple

Lap/RoboticPancreatectomy

TotalPancreatectomy

6

4

2

8

10

104 107 124 31 34 25 4 4 7 8 17 13 29 11 11

201220132014

Percent

0Open

WhippleN =

Lap DistalPancreatectomy

Open DistalWhipple

Lap/RoboticPancreatectomy

TotalPancreatectomy

15

10

5

20

25

30

104 107 124 31 34 25 4 4 7 8 17 13 29 11 11

0

201220132014

Outcomes 2014

Pancreaticobiliary Disease

97970_CCFBCH_Rev0_1-128.pdf 52 7/7/15 7:44 AM

Liver Biopsy

Severe Adverse Events Following Outpatient Liver Biopsya (N = 775)

The cumulative frequency of severe adverse events (SAEs) during 2012–2014 outpatient liver biopsies was 1.8% (14 of 775). This surgical complication rate compares favorably with the reported frequency of these events in the medical literature.1

2012 – 2014

Type of SAE Number of SAEs SAE Rate (%)

Bleedinga 7 0.9

Severe pain 7 0.9

Hypotension 0 0.0

Pneumothorax 0 0.0

Total 14 1.8

aIncludes outpatient liver biopsies performed by the hepatology service only

1Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD; American Association for the Study of Liver Diseases. Liver biopsy. Hepatology. 2009 Mar;49(3):1017-1044.


Liver Disease and Liver Transplantation

97970_CCFBCH_Rev0_1-128.pdf 53 7/7/15 7:44 AM

54

Paracentesis

Paracentesis is a diagnostic and therapeutic procedure. Large volume paracentesis is the first-line treatment for cirrhotic patients with tense and/or refractory ascites.

Severe Adverse Events Following Paracentesis 2012 – 2014

30-Day Readmission Rate for Paracentesis 2012 – 2014

Of the 756 patients who underwent paracentesis procedures in the hospital between 2012 and 2014, 41% were readmitted within 30 days related to severity of underlying liver failure.

Of the 4209 procedures performed between 2012 and 2014, 76 (1.81%) resulted in an Severe Adverse Events, defined as death within 72 hours or hemoperitoneum.

4

0

N = 1371 1290 1548

3

2

1

Percent

2012 2013 2014

80

0

N = 228 238 290

60

40

20

Percent

2012 2013 2014

Outcomes 201454


97970_CCFBCH_Rev0_1-128.pdf 54 7/7/15 7:44 AM

55

Patients with community-acquired spontaneous bacterial peritonitis (SBP) have outpatient paracentesis with an ascitic fluid neutrophil count > 250 cells/mm3. The prevalence of SBP in outpatients with ascites evaluated at Cleveland Clinic between 2012 and 2014 was 1.01%. This compares with previous reports indicating rates of SBP in outpatients with ascites of 1.5%–3.5%.1

Spontaneous Bacterial Peritonitis 2012 – 2014

1Evans LT, Kim WR, Poterucha JJ, Kamath PS. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology. 2003 Apr;37(4):897-901.

4

0

N = 847 764 860

3

2

1

Percent

2012 2013 2014


Coronal multiplanar reconstruction of CT of the abdomen with contrast that demonstrates contrast opacification of existing left portal vein to middle hepatic vein shunt corresponding to patent Transjugular Intrahepatic Portosystemic Shunt (TIPS). The stent extends inferiorly in the main portal vein.

Portogram: Direct portogram obtained through transjugular approach that demonstrates contrast opacification of the main portal vein and patent TIPS.

97970_CCFBCH_Rev0_1-128.pdf 55 7/7/15 7:44 AM

56

Admissions or Readmissions Within 30 Days of TIPS 2012 – 2014

Indications for TIPS 2012 – 2014

Transjugular Intrahepatic Portosystemic Shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat portal hypertension-related complications, such as bleeding esophageal or gastric varices, refractory ascites, and hepatic hydrothorax. Cleveland Clinic is among the top institutions in the nation in the number of TIPS procedures it performs. A multidisciplinary approach, which includes hepatologists and radiologists, is employed in the selection of candidates best suited for TIPS procedures.

40

0

N = 82 127 84

30

20

10

Percent

2012 2013 2014

60

0

20304050

10

Percent

2012

N = 82

2013

127

2014

84

Hepatic hydrothoraxAscitesVariceal bleeding

Readmissions include need for management of all complications related to severity of underlying liver disease.

Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 56 7/7/15 7:44 AM

5757

Nonalcoholic Steatohepatitis Patients Receiving Drug Therapy 2012 – 2014

Nonalcoholic Steatohepatitis

Cardiovascular disease is the main cause of death in patients with nonalcoholic steatohepatitis (NASH). Statin therapy has proved safe in NASH patients and improves cardiovascular outcomes. Renal-angiotensin system blockade with angiotensin receptor blockers (ARBs) has an antihypertensive effect, and current evidence suggests it has a role in inhibiting liver fibrosis.

60

0

N =

20304050

10

Percent

643

Diabetic

1490

Nondiabetic

StatinsARBs


97970_CCFBCH_Rev1_57-57.pdf 1 7/15/15 9:44 AM

58

HCV Patients Treated With Antiviral Medications 2012 – 2014

Hepatitis C

There are 30,000 new cases of hepatitis C virus (HCV) in the US each year. It is the leading reason for liver transplantation.

In 2013 there was a significant reduction in the number of patients treated with antiviral medications as the institute was awaiting approval of direct-acting antiviral agents. The number of patients increased in 2014 because these agents were approved.

200

0

N = 164 69

120

160

80

40

Number

2012 2013

101

2014

Sustained Virologic Response in Patients With and Without Cirrhosisa 2012 – 2014

aIncludes patients with liver biopsy or radiologic imaging

In 2014, the number of patients who achieved sustained virologic response significantly increased in comparison with previous years, reflective of treatment with new direct-acting antiviral agents such as sofosbuvir and simeprevir.

100

0

N = 56 76

40

60

80

20

Percent

2012

21 33

2013

50 51

2014

CirrhoticNoncirrhotic

58 Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 58 7/7/15 7:44 AM

59

Median Number of Days From Initial Visit to Intervention 2012 – 2014

Median Length of Stay, Liver Resection 2012 – 2014

Liver Tumor Clinic

Cleveland Clinic’s Liver Tumor Clinic uses a multidisciplinary approach to treat benign and malignant liver tumors. Treatment options include surgical resection (open, laparoscopic, and robotic) and nonsurgical treatment (chemoembolization, radioembolization, external beam radiation, radiofrequency ablation). The team includes medical and radiation oncologists, interventional radiologists, hepatologists, and transplant/hepatobiliary surgeons.

40

0

N = 207 157 189

30

20

10

Days

2012 2013 2014

8

0

Na = 92 113 149

6

4

2

Days

2012 2013 2014

aData not available for all patients who underwent liver resection


97970_CCFBCH_Rev0_1-128.pdf 59 7/7/15 7:44 AM

60

30-Day Readmission Rate, Liver Resection 2012 – 2014

aData not available for all patients who underwent liver resection

20

0

Na = 92 113 149

15

10

5

Percent

2012 2013 2014

Outcomes 201460


97970_CCFBCH_Rev0_1-128.pdf 60 7/7/15 7:44 AM

61

Patients Referred, Evaluated, and Listed 2012 – 2014

Patient Removals From the Wait-List 2012 – 2014

Liver TransplantationCleveland Clinic performed its first adult liver transplantation on Nov. 8, 1984, and has completed 2094 liver transplantations to date, including 2001 liver transplantations alone and 93 multiorgan transplantations: 73 liver/kidney, 5 liver/heart, 4 liver/lung, 4 liver/pancreas, 6 liver/intestine/pancreas and 1 liver/intestine/pancreas/kidney.

Liver Transplant Patients and Short-Term Outcomes

aIncludes all removals for reasons other than death and transplantation bPatient deaths while on the liver transplant wait-list

800

0

200

400

600

Number of Patients

2012

N = 393619 214

2013

405611 178

2014

331579 164

ReferredEvaluatedListed

100

0

20

40

60

80

Number of Patients

2012

N = 3073

2013

1457

2014

2465

Removalsa

Deathsb


97970_CCFBCH_Rev0_1-128.pdf 61 7/7/15 7:44 AM

62

Solitary Liver Transplantation 2012 – 2014

200

0

N = 143 128

120

160

80

40

Number of Transplantations

2012 2013

132

2014

Transplant rate is calculated in person-years (days converted to fractional years): the number of days from Jan. 1 or from the date of first wait-listing until death, transplantation, 60 days after recovery, transfer, or Dec. 31. The expected transplant rate is adjusted for age, blood type, medical urgency status, time on the wait-list, and previous transplantation.

Transplant Rate for Patients Waiting for Liver Transplantation 2011 – 2013

aObserved rates for 2011, 2012, and 2013 were all statistically significantly higher than the expected rates (P < 0.01). bScientific Registry of Transplant Recipients (SRTR). srtr.org

80

0

20

40

60

Rate per 100 Person Years

July 2011 – June 2012

N = 139

July 2012 – June 2013

130

July 2013 – June 2014

136

Observeda

Expectedb

Outcomes 201462


97970_CCFBCH_Rev0_1-128.pdf 62 7/7/15 7:44 AM

63

Liver Transplantation Median Length of Stay 2009 – 2014

30-Day Liver Transplantation Readmission Rate 2012 – 2014

MELD = model for end-stage liver disease aCalculated MELD scores do not reflect exception MELD points. bData not available for all liver transplant patients

Cleveland Clinic’s liver transplant team started a project in 2010 to streamline the postoperative clinical care pathways, which resulted in an immediate reduction in length of stay.

Monthly monitoring and review of readmissions resulted in a reduction in the rate of readmissions from 32% in 2012 to 26% in 2014.

40

0

N = 143 128 132

30

20

10

Percent

2012 2013 2014

18

0

Nb = 135

12

6

30

0

20

10

Days MELDa

2009

DaysMELD Score

128

2010

119

2011

134

2012

124

2013

127

2014


97970_CCFBCH_Rev0_1-128.pdf 63 7/7/15 7:44 AM

64

Patient and Graft Survival, All Donor Types

1-Year Adult Patient Survival 2012 – 2014

3-Year Adult Patient Survival 2012 – 2014

Scientific Registry of Transplant Recipients (SRTR) srtr.org

Each reporting year reflects transplants performed over a 2.5 year period



100

0

20

40

60

80

Percent

2012

N = 277

2013

293

2014

295

ObservedExpected

100

0

20

40

60

80

Percent

2012

N = 304

2013

302

2014

277

ObservedExpected

64 Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 64 7/7/15 7:44 AM

65

1-Year Adult Graft Survival 2012 – 2014

3-Year Adult Graft Survival 2012 – 2014





100

0

20

40

60

80

Percent

2012

N = 316

2013

327

2014

319

ObservedExpected

100

0

20

40

60

80

Percent

2012

N = 289

2013

293

2014

302

ObservedExpected


97970_CCFBCH_Rev0_1-128.pdf 65 7/7/15 7:44 AM

66

1-Year Patient Survival: Adult Primary Liver Transplantation Only 2012 – 2014

3-Year Patient Survival: Adult Primary Liver Transplantation Only 2012 – 2014

Patient and Graft Survival by Donor Types

DBD = donation after brain death, DCD = donation after cardiac death

Scientific Registry of Transplant Recipients (SRTR). National Average for 1-Year Patient Survival = 90.83%. srtr.org


Scientific Registry of Transplant Recipients (SRTR). National Average for 3-Year Patient Survival = 81.24%. srtr.org

00

100100

4040

6060

8080

2020



180 360240 300

DBD (N = 274)DCD (N = 42)Living donor (N = 34)

00

100100

4040

6060

8080

2020



400 1000600 800


Outcomes 201466


97970_CCFBCH_Rev0_1-128.pdf 66 7/7/15 7:44 AM

67

1-Year Graft Survival: Adult Primary Liver Transplantation Only 2012 – 2014

3-Year Graft Survival: Adult Primary Liver Transplantation Only 2012 – 2014


Scientific Registry of Transplant Recipients (SRTR). National Average for 1-Year Graft Survival = 88.26%. srtr.org


Scientific Registry of Transplant Recipients (SRTR). National Average for 3-Year Graft Survival = 77.97%. srtr.org

00

100100

4040

6060

8080

2020



180 360240 300


00

100100

4040

6060

8080

2020



1000600 800



97970_CCFBCH_Rev0_1-128.pdf 67 7/7/15 7:44 AM

68

3-Year Patient Survival, Within and Beyond Milan Criteria 2009 – 2014

3-Year Graft Survival, Within and Beyond Milan Criteria 2009 – 2014

Liver Transplantation for Hepatocellular CarcinomaHepatocellular carcinoma (HCC) is the 5th most common cancer in men and the 7th most common cancer in women. Liver transplantation is the standard of care for patients with HCC complicated by cirrhosis and portal hypertension. In order to be acceptable candidates for liver transplantation, patients must have HCC lesions within the Milan criteria. Locoregional therapy has been used to downstage HCC in selected patients who fall outside the Milan criteria in order to proceed to liver transplantation.

00

100100

4040

6060

8080

2020



1000600 800

Within Milan (N = 187)Beyond Milan (N = 64)

00

100100

4040

6060

8080

2020



1000600 800

Within Milan (N = 187)Beyond Milan (N = 64)

Outcomes 201468


97970_CCFBCH_Rev0_1-128.pdf 68 7/7/15 7:44 AM

69

Bariatric Surgery

In 2014, Cleveland Clinic’s Bariatric and Metabolic Institute marked its 9th anniversary and continued to be accredited as a designated Bariatric Surgery Center of Excellence by the American Society for Metabolic & Bariatric Surgery and the American College of Surgeons. This designation is awarded to programs that meet high quality standards and perform a minimum of 125 procedures annually.

Bariatric Surgery Cases by Type

2007 – 2014In 2014, laparoscopic Roux-en-Y gastric bypass accounted for 56% of all cases and was the most frequently performed bariatric procedure at Cleveland Clinic. Laparoscopic sleeve gastrectomy continued to grow and was the 2nd most commonly performed procedure (36% of all cases). Due to patient preference, laparoscopic adjustable gastric banding has shown large declines over the past several years. Nine percent, or 72 cases, were performed at a Cleveland Clinic regional hospital.aOther includes other bariatric procedures such as gastric plication +/- band, duodenal switch, distal bypass,

and band removal.

Gastric Plication Sleeve Duodenal Switch Ringed Bypass BandBypass Banded Plication

SINCE 2012, 92 BARIATRIC CASES WERE PERFORMED ROBOTICALLY.

Cases

0

800

600

400

200

2007 2008 2009 2010 2011

Othera

RevisionBandingSleeveBypass

2012 2013 2014438 589 561 692 609 647 724 680N =

More Common Procedures Less Common Procedures


Obesity and Metabolic Disease

97970_CCFBCH_Rev0_1-128.pdf 69 7/7/15 7:44 AM

70

Comorbidities at Baseline Among Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass

2014

Comorbidities at Baseline Among Patients Undergoing Laparoscopic Sleeve Gastrectomy

2014

aMBSC = Michigan Bariatric Surgery Collaborative

Source: Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, Schram JL, Kole KL, Finks JF, Birkmeyer JD, Share D, Birkmeyer NJ; Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791-797.

Percent

0

100

80

60

40

20

Cleveland Clinic (N = 357)MBSCa (N = 2949)

Hypertension SmokingDiabetesMellitus

ObstructiveSleepApnea

Hyper-lipidemia

VenousThrombo-embolism

RenalFailure

0.20.3

Percent

0

100

80

60

40

20

Cleveland Clinic (N = 219)MBSCa (N = 2949)

Hypertension SmokingDiabetesMellitus

ObstructiveSleepApnea

Hyper-lipidemia

VenousThrombo-embolism

RenalFailure

0.32.3

Outcomes 201470


97970_CCFBCH_Rev0_1-128.pdf 70 7/7/15 7:44 AM

71

aThese data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu

aCleveland Clinic data are non-risk-adjusted. bMBSC = Michigan Bariatric Surgery Collaborative

Source: Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, Schram JL, Kole KL, Finks JF, Birkmeyer JD, Share D, Birkmeyer NJ; Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791-797.

Laparoscopic Sleeve Gastrectomy and Roux-en-Y Length of Stay

2012 – 2014

30-Day Complication Rate for All Bariatric Cases

2014

8

6

0

4

2

Percent

Bleeding Wound Infection/Evisceration

IntestinalObstruction

AnastomoticLeak

Deep VeinThrombosis

RespiratoryFailure

Cleveland Clinica (N = 619)MBSCb (N = 2929)

1.2 1.2 0.5 0.7 0.5 0.2

5

4

0

3

2

1

Days

N = 551 589 5592012 2013 2014

Cleveland ClinicTop ranked U.S. News hospitalsa


97970_CCFBCH_Rev0_1-128.pdf 71 7/7/15 7:44 AM

72

In-Hospital Types of Complication

None

Atrial fibrillation

Nausea/vomiting

Hypoxia

Othera

30-day all-cause readmissions

Complications (%)

89.0

3.3

2.2

2.2

3.3

6.5

Number

82

3

2

2

3

6

*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu

aOther includes bleed, superficial wound infection, delirium, and urinary tract infection.

Percentage of Patients Requiring Intensive Care Unit Admission: Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy

2012 – 2014

Robotic Bariatric Surgery Roux-en-Y Complications (N = 92)

2012 – 2014

8

6

0

4

2

Percent

N = 551 589 5592012 2013 2014

Cleveland ClinicUHC Top Hospitalsa

Outcomes 201472


97970_CCFBCH_Rev0_1-128.pdf 72 7/7/15 7:44 AM

73

100

75

0

50

25

Percent

161 178 192 273N =Sleep Apnea Diabetes Hyperlipidemia Hypertension

Comorbidity Resolution at 3-Year Follow-Up for All Bariatric Surgery Cases

2008 – 2014


Type

All bariatric surgeries, % (N)

Laparoscopic Roux-en-Y gastric bypass, % (N)

Laparoscopic sleeve gastrectomy, % (N)

0.0 (680)

0.0 (382)

0.0 (244)

BOLD

0.1 (186,567)a

0.14 (136,036)

0.08 (15,964)

Cleveland Clinic

BOLD = Bariatric Outcomes Longitudinal Database, a database of the American Society for Metabolic & Bariatric Surgery

aNational Comparisons of Bariatric Surgery Safety and Efficacy: Findings from the BOLD Database 2007–2010. Paper presented at: 29th Annual Meeting of the American Society for Metabolic & Bariatric Surgery; June 17–22, 2012; San Diego, CA. Abstract PL-104.

Source: Inabet WB 3rd, Winegar DA, Sherif B, Sarr MG. Early outcomes of bariatric surgery in patients with metabolic syndrome: an analysis of the bariatric outcomes longitudinal database. J Am Coll Surg. 2012;214(4):550-556.

30-Day Mortality Rates for Bariatric Surgery

2014

97970_CCFBCH_Rev1_73-74.pdf 1 7/15/15 9:44 AM

74

Mean Percent Weight Lossa Toward Ideal Body Mass Index at Follow-Up (All Case Types)

2008 – 2014

aWeight loss formula: (baseline BMI – follow-up BMI) / (baseline BMI – ideal BMI [25]) x 100

For cases followed ≤ 5 years, the weight loss toward ideal BMI was 51%. The laparoscopic Roux-en-Y gastric bypass at 5 years had the highest percentage of weight loss toward ideal BMI at 59%.

80

0

60

40

20

Percent

2220 1399 764 412 213N =Year 1 Year 2 Year 3 Year 4 Year 5

Outcomes 2014


97970_CCFBCH_Rev1_73-74.pdf 2 7/15/15 9:44 AM

75

Mean Body Mass Index Before and After Bariatric Surgery for Obese Diabetic Patients With Baseline HbA1c Values > 6.5% (N = 394)

2004 – 2014

Mean Hemoglobin A1c Values Before and After Bariatric Surgery for Diabetic Patients With Baseline A1c Values > 6.5% (N = 394)

2004 – 2014

Over the past 11 years, approximately 77% of obese diabetic patients had laparoscopic Roux-en-Y gastric bypass, 11% had sleeve gastrectomy, and 8% had gastric banding. The mean body mass index (BMI) difference before and after surgery was statistically significant with baseline BMI at 46.6 and follow-up at 35.4. The mean follow-up duration was 5.5 years.

Since 2004, Cleveland Clinic has performed bariatric surgery on 1914 obese diabetic patients. Of these patients, 1011 (58%) had baseline HbA1c values > 6.5%. Of the 1011 patients, 39% (N = 394) had recent HbA1c values available at least 90 days postsurgery. Improvement from baseline values was statistically significant, with a mean A1c baseline of 8.3% before surgery and most recently available A1c of 6.5% after surgery. The average time between pre- and postoperative HbA1c values was 16 months.

Bariatric Surgery for Diabetes

BMI (kg/m2)

25

50

45

40

35

30

Before Surgery After Surgery

(P < .001)

Percent

5

10

9

8

7

6

Before Surgery After Surgery

(P < .001)


97970_CCFBCH_Rev0_1-128.pdf 75 7/7/15 7:44 AM

76

Bariatric Behavioral Health

Parameter

Age, mean, years

Gender, % male

BMI, mean, kg/m2

Length of stay, mean, days

60-day morbidity

Readmission rate, %

Excess weight loss, mean %

Psychosis Cohort (N = 11)

45.8

36.4

57.8

3.7

18.2

9

44.6

Nonpsychosis Control Cohort (N = 33)

46.1

36.4

57.3

3.0

12.0

6

50.1

Bariatric Surgery Outcomes in Patients With Psychotic Disorders

2008 – 2014

Patients with psychiatric disorders that include psychotic features (e.g., delusions and auditory or visual hallucinations) are at high risk of morbid obesity. Most bariatric surgery programs do not consider these patients as surgical candidates. The institute assessed outcomes in bariatric surgery patients with well-stabilized psychotic disorders, comparing a study cohort with a matched control group of bariatric patients without psychotic disorders.

All study cohort patients were on psychiatric medications (median of 3), with 91% taking antipsychotic medications and 46% with a previous suicide attempt. Two patients had perioperative complications (18%), namely, respiratory failure and rhabdomyolysis, and 1 patient had a marginal ulcer 2 years after Roux-en-Y gastric bypass. No statistical differences occurred between the groups in length of stay, 60-day morbidity, late complications, or readmission. Although not all patients with psychotic features are candidates for bariatric surgery, appropriately screened candidates, with intensive multidisciplinary assessment, can cope successfully with weight-loss surgery.

Outcomes 201476


97970_CCFBCH_Rev0_1-128.pdf 76 7/7/15 7:44 AM

77

Impact of a History of Eating Disordered Behaviors on Weight Loss and Early Adjustment After Bariatric Surgery (N = 221)

2010 – 2014

Eating disorders (ED) (e.g., loss of control over eating, grazing, and vomiting to control weight) after bariatric surgery may be common. Staff examined the prevalence of purging behaviors and past treatment of ED in 870 bariatric surgery candidates and the impact of this history on 1-month psychological adjustment and BMI loss in the 1st year in a subset of 221 patients.

A reported history of purging and/or eating disorders treatment was rare (8.9%). Women and African Americans were more likely to have an ED history. Baseline scores on a measure of binge eating and clinician ratings of ED pathology were significantly higher for those with an ED history. No differences were found in weight loss at any time. Patients with an ED history indicated greater fear of failure and greater grieving over the loss of food at their 1-month follow-up visit. Although weight loss in the 1st year was equivalent, those with an ED history may have greater difficulty with the early postoperative psychological adjustment.

6

0

4

2

Fear of Failure

P < 0.001P < 0.09

Grieving the Loss of Food

8

10

12

Percent18

14

16

Positive historyNegative history


97970_CCFBCH_Rev0_1-128.pdf 77 7/7/15 7:44 AM

78

Psychosocial Factor

Past alcohol abuse

Past substance abuse

Use of psychotropic medicines

Inpatient psychiatric treatment

Use of laxatives/diuretics

History of vomiting

Number of psychotropic medicines

Revisional Bariatric Surgery (%)

(N = 57)

21.1

20

76.2

14.3

6.7

6.7

2.0

First-Time Bariatric Surgery (%)

(N = 1311)

12.9

13.7

56.3

11.3

6.3

4.4

0.7

Psychosocial Factors Between First-Time Bariatric Patients and Revisional Bariatric Patients

2010 – 2014

Patients presenting for revisional bariatric surgery because of inadequate weight loss were compared with first-time bariatric candidates. Groups did not differ on BMI, gender, ethnicity, or history of outpatient psychiatric treatment. However, patients seeking a revision of previous bariatric surgery may have more complicated psychiatric histories than bariatric populations as a whole.

Outcomes 201478


97970_CCFBCH_Rev0_1-128.pdf 78 7/7/15 7:44 AM

79

Brief COPE Significant Subscales Pre- and Post-Test Scores (N = 77)

2013 – 2014

Brief 4-Session Cognitive Behavioral Training Group Increases Knowledge and Coping Skills in a High-Risk Bariatric Surgery Population (N = 77)

March 2013 – March 2014

The effectiveness of a brief, 4-session group called “Getting Expertise Today for a Successful Experience Tomorrow” (GET SET) was examined for bariatric surgery candidates deemed to have limited knowledge or coping skills. Pre- and post-group measures were completed by participants to evaluate knowledge using a 15-item quiz. Participants also completed the Brief COPE, a measure used to assess a range of coping strategies.

Participants’ mean knowledge quiz scores increased, and several subscales of the Brief COPE also demonstrated significant change.

6

0

4

2

(P < .001)

GET SET Quiz

8

10

12Quiz # Correct

PrePost

3

0

2

1

Self-Distraction

P < 0.001

P < 0.05

Active Coping

P < 0.05

Emotional Support

P < 0.001

Positive Reframing

4

5

6

Subscale Score

7

8

PrePost


97970_CCFBCH_Rev0_1-128.pdf 79 7/7/15 7:44 AM

80

Percentage of Screening Mammograms Resulting in Callback 2012 – 2014

Core Biopsy Rate (Needle Core Biopsy/Fine Needle Aspirate Biopsy Prior to Surgical Treatment of Breast Cancer) 2012 – 2014

Cleveland Clinic offers a diagnostic callback program for patients with abnormal screening mammograms.

20

15

0

N = 7914 8985 8909

10

5

Percent

2012 2013 2014

Data from Cleveland Clinic tumor registry for main campus and family health center locations

Cleveland Clinic’s performance was 89.3% (711 of 796 patients) from 2012–2013 for this Commission on Cancer (CoC) standard of care quality measure (95% confidence interval [CI], 87.2–91.5). Cleveland Clinic performs within the acceptable range for biopsy prior to surgical treatment of breast cancer.

100%100%

10.7% Not performed (N = 85)

89.3% Performed (N = 711)

Outcomes 201480

Breast Disease

Cleveland Clinic’s Comprehensive Breast Cancer Program offers a multidisciplinary team of highly skilled specialists who provide comprehensive care to patients with breast cancer. A full array of services ranges from initial screening and diagnosis to high-risk genetic counseling to innovative breast cancer treatment and supportive therapies. Cleveland Clinic has 5 multidisciplinary comprehensive breast center locations: Fairview Hospital, Hillcrest Hospital, Beachwood Family Health Center, Strongsville Family Health Center, and Cleveland Clinic main campus. The Breast Centers at Cleveland Clinic’s main campus, Fairview Hospital, and Beachwood Family Health Center have been accredited by the American College of Surgeons’ National Accreditation Program for Breast Centers.

97970_CCFBCH_Rev0_1-128.pdf 80 7/7/15 7:44 AM

81

Immediate Breast Reconstruction 2012 – 2014

Breast Conservation Surgery for Breast Cancer (Lumpectomy) 2012 – 2014

Breast Surgery for Breast Cancer (Mastectomy)a 2012 – 2014

More than 30% of breast cancer surgeries in 2014 included immediate reconstruction performed by a plastic surgeon specializing in breast reconstruction.

aIncludes all breast cancers plus prophylactic mastectomy with breast reconstruction

40

30

0

N = 1198 1420 1157

20

10

Percent

2012 2013 2014

60

45

0

N = 664 815 570

30

15

Percent

2012 2013 2014

60

45

0

N = 534 605 587

30

15

Percent

2012 2013 2014


97970_CCFBCH_Rev0_1-128.pdf 81 7/7/15 7:44 AM

82

5-Year Overall Survival of Female Patients With All Stages of Breast Cancer (N = 5694)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV breast cancer

00

100100

4040

6060

8080

2020


0 21Years After Diagnosis

3 4 5

Percent Survival(Number at Risk) =

98.6(5227)

96.5(4201)

94.6(3328)

93.1(2620)

91.3(1984)

5-Year Overall Survival of Female Patients With All Stages of Breast Cancer by Racea (N = 5528)

2006 – 2013

Percent Survival and (Number at Risk) by Racea

Years After Diagnosis

Race 1 2 3 4 5

Black 97.3 (735) 93.8 (582) 90.4 (438) 88.7 (330) 86.9 (249)

White 98.9 (4354) 97.0 (3517) 95.3 (2809) 93.9 (2221) 92.1 (1679)

aSelf-reported

00

100100

4040

6060

8080

2020



3 4 5

Black (N = 870)White (N = 4658)

Outcomes 201482

Breast Disease

97970_CCFBCH_Rev0_1-128.pdf 82 7/7/15 7:44 AM

83

5-Year Overall Survival by ER, PR, and HER2 Status for Breast Cancer Patients (N = 4022)

2006 – 2013

Percent Survival and (Number at Risk) by Receptor HER2 Status


Status 1 2 3 4 5

ER or PR positive 99.1 (2557) 97.5 (2038) 96.0 (1584) 94.5 (1278) 92.0 (1041)

HER2 positive 98.6 (669) 97.3 (534) 94.4 (414) 92.2 (326) 90.0 (268)

Triple negative 95.5 (489) 87.6 (373) 83.4 (279) 80.8 (220) 79.2 (193)

ER = estrogen receptor, HER2 = human epidermal growth factor receptor 2, PR = progesterone receptor

00

100100

4040

6060

8080

2020



3 4 5

ER or PR positive (N = 2765)HER2 positive (N = 715)Triple negative (N = 542)


97970_CCFBCH_Rev0_1-128.pdf 83 7/7/15 7:44 AM

84 Outcomes 201484

Breast Disease

5-Year Overall Survival of Female Patients With Stage 0 and I Breast Cancer (N = 3234)

2006 – 2013

CC = Cleveland Clinic

AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.

Percent Survival and (Number at Risk) by Stage


Stage 1 2 3 4 5

0 99.5 (864) 98.9 (694) 98.2 (563) 97.8 (458) 97.3 (338)

I 99.7 (2121) 99.1 (1725) 98.2 (1394) 97.6 (1116) 96.2 (869)

00

100100

4040

6060

8080

2020



3 4 5

Stage 0 CC (N = 953)Stage 0 AJCCStage I CC (N = 2281)Stage I AJCC

97970_CCFBCH_Rev0_1-128.pdf 84 7/7/15 7:44 AM


5-Year Overall Survival of Female Patients With Stage II Breast Cancer (N = 1556)

2006 – 2013





Stage 1 2 3 4 5

IIA 99.3 (990) 98.1 (797) 97.4 (647) 96.4 (509) 93.7 (395)

IIB 99.0 (469) 95.7 (365) 93.6 (274) 90.5 (197) 89.4 (143)

00

100100

4040

6060

8080

2020



3 4 5

Stage IIA CC (N = 1055)Stage IIA AJCCStage IIB CC (N = 501)Stage IIB AJCC

97970_CCFBCH_Rev0_1-128.pdf 85 7/7/15 7:44 AM

86 Outcomes 201486

Breast Disease

5-Year Overall Survival of Female Patients With Stage IIIA and IIIB Breast Cancer (N = 442)

2006 – 2013





Stage 1 2 3 4 5

IIIA 97.6 (307) 93.5 (257) 89.1 (199) 86.1 (158) 82.3 (108)

IIIB 99.0 (95) 86.4 (67) 72.0 (43) 66.5 (33) 64.2 (23)

00

100100

4040

6060

8080

2020



3 4 5

Stage IIIA CC (N = 341)Stage IIIA AJCCStage IIIB CC (N = 101)Stage IIIB AJCC

97970_CCFBCH_Rev0_1-128.pdf 86 7/7/15 7:44 AM


5-Year Overall Survival of Female Patients With Late Stage Breast Cancer (N = 330)

2006 – 2013





Stage 1 2 3 4 5

IIIC 95.2 (114) 84.7 (92) 76.2 (60) 73.4 (46) 68.2 (35)

IV 82.4 (150) 72.8 (109) 60.6 (66) 49.7 (45) 44.7 (31)

00

100100

4040

6060

8080

2020



3 4 5

Stage IIIC CC (N = 128)Stage IIIC AJCCStage IV CC (N = 202)Stage IV AJCC

97970_CCFBCH_Rev0_1-128.pdf 87 7/7/15 7:44 AM

88

Upper and Lower GI Diagnostic Procedures Cecal Intubation Rate for Colonoscopy 2013 – 2014

Polyp Detection Rate During Screening Colonoscopy 2013 – 2014

aRex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb GJ, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110(1):72-90.

aGohel TD, Burke CA, Lankaala P, Podugu A, Kiran RP, Thota PN, Lopez R, Sanaka MR. Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist. Clin Gastroenterol Hepatol. 2014 Jul;12(7):1137-1142.

100

0

N = 6535 7174

60

80

40

20

Percent

2013 2014


50

0

N = 3262 3639

30

40

20

10

Percent

2013 2014


Outcomes 201488

Cleveland Clinic Florida

97970_CCFBCH_Rev0_1-128.pdf 88 7/7/15 7:44 AM

89

Pancreatic Stent Placement, Adult and Pediatric 2012 – 2014

Postendoscopic Retrograde Cholangiopancreatography Pancreatitis, Adult and Pediatric 2012 – 2014

Placement of a prophylactic pancreatic duct stent in high-risk patients has been shown to reduce the risk for postendoscopic retrograde cholangiopancreatography pancreatitis.

10

0

N = 272 323 219

8

6

4

2

Percent

2012 2013 2014

10

0

N = 272 323 219

8

6

4

2

Percent

2012 2013 2014


97970_CCFBCH_Rev0_1-128.pdf 89 7/7/15 7:44 AM

90

Rectal Cancer Surgical Procedures 2013 2014

N 85 94

Median length of stay, days 9 7.8

30-day readmission rate, % 19 12.7

In-hospital mortality, % 0 0

Ulcerative Colitis Surgical Procedures 2013 2014

N 51 44

Median length of stay, days 9 8.7

30-day readmission rate, % 15 9.1

In-hospital mortality, % 0 0

Upper and Lower GI Surgical Procedures Median Length of Stay, Inpatient Incisional/Ventral Hernia Repairs 2012 – 2014

Rectal Cancer Postoperative Outcomes 2013 – 2014

Ulcerative Colitis Postoperative Outcomes 2013 – 2014

6

0

N = 88 114 14526 35 36

4

2

Days

2012 2013 2014

OpenLaparoscopic

Outcomes 201490


97970_CCFBCH_Rev0_1-128.pdf 90 7/7/15 7:44 AM

91

Median Length of Stay, Laparoscopic Inpatient Cholecystectomy 2012 – 2014

Median Length of Stay, Pancreatectomy Proceduresa 2012 – 2014

aIncludes open Whipple, laparoscopic distal pancreatectomy, laparoscopic/robotic Whipple, and total pancreatectomy procedures

3

0

N = 113 113 69

2

1

Days

2012 2013 2014

10

0

N = 176 173 180

4

6

8

2

Days

2012 2013 2014


97970_CCFBCH_Rev0_1-128.pdf 91 7/7/15 7:44 AM

92

Liver Transplantation

In August 2012, the Agency for Health Care Administration approved Cleveland Clinic Florida’s Certificate of Need to provide liver and kidney transplanta services. In March 2013, the United Network for Organ Sharing granted approval to Cleveland Clinic Florida’s liver transplant program. The program was launched in April 2013 and received CMS (Medicare) approval in June 2014. A multidisciplinary team participates in the evaluation, management, treatment, and follow-up of the transplant patients.

Patients Referred, Evaluated, Listed, and Transplanted 2013 – 2014

Liver Transplantation, 1-Year Patient Survival (N = 9) July 2011 – December 2013

aExpected events based on risk adjustment model published by Scientific Registry of Transplant Recipients (SRTR).


200

0

N = 103 48 34160 64 41

80

120

160

40

Number of Patients

Referred Evaluated Listed

9 24

Transplanted

20132014

100

0

60

80

40

20

Percent

ObservedExpecteda

Outcomes 201492


97970_CCFBCH_Rev0_1-128.pdf 92 7/7/15 7:44 AM

93

Liver Transplantation, 1-Year Graft Survival (N = 9)July 2011 – December 2013

aExpected events based on risk adjustment model published by Scientific Registry of Transplant Recipients (SRTR).


100

0

60

80

40

20

Percent

ObservedExpecteda


97970_CCFBCH_Rev0_1-128.pdf 93 7/7/15 7:44 AM

94


The Bariatric and Metabolic Center (BMC) at Cleveland Clinic Florida is dedicated to the care and well being of surgical and morbidly obese patients. The American Society for Metabolic and Bariatric Surgeons, the American College of Surgeons, and the Fellowship Council have named BMC and the section of Minimally Invasive Surgery a Center of Excellence. For the past 14 years, BMC at Cleveland Clinic Florida has delivered high-quality care and research in the field of bariatric surgery.

Bariatric Surgery Cases 2012 – 2014

Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass, Median Length of Stay 2012 – 2014

6

0

N = 135 200 21187 46 33

4

2

Days

2012 2013 2014

Laparoscopic sleeve gastrectomyLaparoscopic Roux-en-Y

350

0

N = 267 310 297

250200

300

150100

50

Number of Cases

2012 2013 2014

BandBypassSleeveRevision

Outcomes 201494


97970_CCFBCH_Rev0_1-128.pdf 94 7/7/15 7:44 AM

95

30-Day Complication Rate for All Bariatric Cases (N = 874) 2012 – 2014

Reduction of Comorbidities 6 Months After Surgical Procedure 2014

GERD = gastroesophageal reflux disease

MBSC = Michigan Bariatric Surgery Collaborative

Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, Schram JL, Kole KL, Finks JF, Birkmeyer JD, Share D, Birkmeyer NJ; Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013 May;257(5):791-797.

4

00

2

3

1

Percent

RespiratoryFailure

Deep VeinThrombosis

Bleeding IntestinalObstruction

Wound Infection/Evisceration

AnastomoticLeak

Cleveland ClinicMBSC

80

0

40

60

20

Percent

Sleep Apnea GERD Hyperlipidemia Hypertension Diabetes

Laparoscopic sleeve gastrectomy (N = 116)Laparoscopic Roux-en-Y (N = 10)


97970_CCFBCH_Rev0_1-128.pdf 95 7/7/15 7:44 AM

96

Screening Mammograms Resulting in Callback 2012 – 2014

Breast Conservation Surgery for Breast Cancer (Lumpectomy) 2011 – 2013

Breast Disease

Cleveland Clinic Florida offers a diagnostic callback program for patients with abnormal screening mammograms.

75

0

N = 59 65 86

50

25

Percent

2011 2012 2013

20

0

N = 9865 11,756 13,379

15

10

5

Percent

2012 2013 2014

Outcomes 201496


97970_CCFBCH_Rev0_1-128.pdf 96 7/7/15 7:44 AM

97

Breast Surgery for Breast Cancer (Mastectomy) 2011 – 2013

Core Needle Biopsy Rate 2011 – 2013

aNational Quality Forum (NQF) qualityforum.org

75

0

N = 43 48 72

50

25

Percent

2011 2012 2013

100

0

N = 125 135 175

50

75

25

Percent

2011 2012 2013

Cleveland ClinicNational Quality Foruma benchmark


97970_CCFBCH_Rev0_1-128.pdf 97 7/7/15 7:44 AM

Breast cancer patients < 70 years of age who had lumpectomy also had radiation therapy within 1 year.

Radiation Therapy After Lumpectomy 2011 – 2013

aThe American College of Surgeons Commission on Cancer’s Cancer Program Practice Profile Report (ACoS/CoC CP3R) benchmark is 90%.

100

0

N = 31 29 42

50

75

25

Percent

2011 2012 2013

Cleveland ClinicACoS/CoC CP3Ra benchmark

98 Outcomes 2014


97970_CCFBCH_Rev0_1-128.pdf 98 7/7/15 7:44 AM

99

The ACoS/CoC CP3R combination chemotherapy was administered within 4 months for women < 70 years of age with AJCC T1c or stage II or III hormone receptor negative breast cancer.

Tamoxifen or third generation aromatase inhibitors were administered within 1 year of diagnosis for > 70% of women with AJCC T1c or stage II or III hormone receptor positive breast cancer.

aThe American College of Surgeons Commission on Cancer’s Cancer Program Practice Profile Report (ACoS/CoC CP3R) benchmark is 90%.

Combination Chemotherapy Within 4 Months of Diagnosis 2011 – 2013

Tamoxifen or Third Generation Aromatase Inhibitor Within 1 Year of Diagnosis 2011 – 2013

aThe ACoS/CoC CP3R benchmark is 90%.

100

0

N = 36 45 54

50

75

25

Percent

2011 2012 2013

Cleveland ClinicACoS/SoS CP3Ra benchmark

100

0

N = 9 11 10

50

75

25

Percent

2011 2012 2013

Cleveland ClinicACoS/SoS CP3Ra benchmark


97970_CCFBCH_Rev0_1-128.pdf 99 7/7/15 7:44 AM

100

Digestive Disease Institute Postoperative Hemorrhage or Hematoma (PSI 9) January 2010 – November 2014

PSI = Patient Safety Indicator

aThe Cleveland Clinic target is 4.64 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. (uhc.edu)

The Digestive Disease Institute’s postoperative hemorrhage or hematoma rate (AHRQ PSI 9) has steadily improved since 2010.

Digestive Disease Institute Patient Safety Indicators

The Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) are used to measure patient safety in hospitals. The Digestive Disease Institute has made great improvements in identifying potential complications or adverse events through efforts that align clinical care with documentation.

00

1616

88

1212

44

Rate per 1000 PatientsRate per 1000 Patients

2010 20122011 2013 2014

Digestive Disease Institute performanceCleveland Clinic targeta

Outcomes 2014100

Institute Quality Improvement

97970_CCFBCH_Rev0_1-128.pdf 100 7/7/15 7:44 AM

101

Digestive Disease Institute Postoperative Respiratory Failure (PSI 11) January 2010 – November 2014

Digestive Disease Institute Postoperative Pulmonary Embolism or Deep Vein Thrombosis (PSI 12) January 2010 – November 2014


Collaboration with the Intensive Care Unit staff has resulted in a 30% decrease in postoperative respiratory failure rate (AHRQ PSI 11).

aThe Cleveland Clinic target is 5.5 per 1000 patients. These data are prepared Data from the University HealthSystem Consortium (UHC) Clinical Database. (uhc.edu)

Reducing the incidence of postoperative pulmonary embolism or deep vein thrombosis (AHRQ PSI 12) continues to be an area of focus and a priority for improvement. There was a 27% decrease in the rate per 1000 patients from 2012 to 2014.

00

2020

1010

1515

55


2010 20122011 2013 2014


00

1616

88

1212

44


2010 20122011 2013 2014



97970_CCFBCH_Rev0_1-128.pdf 101 7/7/15 7:44 AM

102

Digestive Disease Institute Postoperative Sepsis (PSI 13) January 2010 – November 2014

Digestive Disease Institute Postoperative Wound Dehiscence (PSI 14) January 2010 – November 2014


aThe Cleveland Clinic target is 0 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. (uhc.edu)

The Digestive Disease Institute’s postoperative wound dehiscence rate (AHRQ PSI 14) is low at 1 per 1000 patients, despite performing complex primary and reoperative abdominal and colorectal surgical procedures.

00

3030

1212

1818

66


2010 20122011 2013 2014

2424


00

2.02.0

1.01.0

1.51.5

0.50.5


2010 20122011 2013 2014


Outcomes 2014102

Institute Quality Improvement

97970_CCFBCH_Rev0_1-128.pdf 102 7/7/15 7:44 AM

103

Readmission rates by department have been consistent since 2011. A process to review all unplanned readmissions was implemented to gain insight and identify improvement opportunities.

Digestive Disease Institute Accidental Puncture or Laceration (PSI 15) January 2010 – November 2014

Digestive Disease Institute All-Cause 30-Day Readmissions by Department 2011 – 2014


In spite of a large number of reoperative cases, the accidental puncture or laceration rate (AHRQ Patient Safety Indicator 15) has dramatically decreased since 2010 and remained below 5 per 1000 patients in 2014.

Digestive Disease Institute Readmissions

00

5050

2020

3030

1010


2010 20122011 2013 2014

4040


00

4040

2020

3030

1010

PercentPercent

20122011 2013 2014

BariatricsColorectal SurgeryGastroenterology & HepatologyGeneral Surgery


97970_CCFBCH_Rev0_1-128.pdf 103 7/7/15 7:44 AM

104

General Surgery Outcomes July 2013 – June 2014

American College of Surgeons National Surgical Quality Improvement Program

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. These outcomes data reflect Cleveland Clinic’s overall general surgery ACS NSQIP performance benchmarked against 458 participating sites and overall colorectal surgery benchmarked against 451 participating sites.

aIdentified as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model

Outcome N Observed Rate (%) Expected Rate (%)

30-day mortality 1145 1.31 1.82

30-day morbidity 1145 22.10a 18.30

Cardiac event 1145 1.22a 1.09

Pneumonia 1143 2.80 2.68

Unplanned intubation 1143 3.32a 2.40

Ventilator > 48 hours 1137 3.43a 2.44

Deep vein thrombosis/pulmonary embolism 1145 5.59a 2.16

Renal failure 1143 1.14 1.36

Urinary tract infection 1161 1.98 1.75

Surgical site infection 1138 13.44a 10.77

Sepsis 1102 10.89a 4.73

Return to operating room 1145 4.37 5.23

Readmission 1145 14.24a 11.99

Outcomes 2014104

Surgical Quality Improvement

97970_CCFBCH_Rev0_1-128.pdf 104 7/7/15 7:44 AM

105

Colorectal Surgery Outcomes July 2013 – June 2014



30-day mortality 693 1.59 2.00

30-day morbidity 693 21.36 19.10

Length of stay 511 29.94a 17.81

Pneumonia 691 2.17 1.97

Unplanned intubation 692 2.46 1.88

Ventilator > 48 hours 688 2.76 2.16



Urinary tract infection 692 3.76a 2.63

Surgical site infection 689 11.61 11.05

Sepsis 662 10.42a 4.63


Readmission 693 13.56 13.52


97970_CCFBCH_Rev0_1-128.pdf 105 7/7/15 7:44 AM

106

Pancreatectomy Outcomes July 2013 – June 2014




30-day morbidity 127 36.22 27.10


Hepatectomy Outcomes July 2013 – June 2014

In addition to overall general surgery and colorectal surgery ACS NSQIP outcomes data, data specific to the following procedures are provided (with number of sites participating in benchmarking outcomes shown in parentheses): hepatectomy (79), pancreatectomy (100), colectomy (451), and proctectomy (123).




30-day morbidity 73 32.88 19.60


Outcomes 2014106

Surgical Quality Improvement

97970_CCFBCH_Rev0_1-128.pdf 106 7/7/15 7:44 AM

107

Colectomy Outcomes July 2013 – June 2014




30-day morbidity 486 20.99a 16.76

Cardiac event 486 1.03 1.08

Pneumonia 484 2.27 1.89

Unplanned intubation 485 2.68 2.26

Ventilator > 48 hours 481 3.53 2.71



Urinary tract infection 485 2.47 2.45



Readmission 486 13.17 12.60

Anastomotic leak 486 5.14 3.14

Prolonged NPO/nasogastric tube use 486 24.90a 16.32

Proctectomy Outcomes July 2013 – June 2014

aIdentified as a low statistical outlier (lower than expected) by the ACS NSQIP hierarchical model


30-day morbidity 207 22.22 19.87



97970_CCFBCH_Rev0_1-128.pdf 107 7/7/15 7:44 AM

108 Outcomes 2014108

aIn 2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients’ perspectives of outpatient care.bBased on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 2013cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No

Source: Press Ganey, a national hospital survey vendor

100

80

0

60

40

20

Best Response (%)

CG-CAHPS 2013 database average(all practices)b

AppointmentAccess

(% Always)c

DoctorCommunication

(% Yes, Definitely)d

Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff


Test ResultsCommunication

(% Yes)e

2013 (N = 2981)2014 (N = 6843)

Patient Experience — Digestive Disease Institute

Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic’s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care.

Outpatient Office Visit Survey — Digestive Disease Institute

CG-CAHPS Assessmenta 2013 – 2014

97970_CCFBCH_Rev0_1-128.pdf 108 7/7/15 7:44 AM


HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Digestive Disease Institute

The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare.

HCAHPS Domains of Carea 2013 – 2014

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes

Doctor Communication

Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 1970)National average all patientsb

2013 (N = 1939)

aExcept for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013,from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no


2014 (N = 1970)

National averageall patientsa

2013 (N = 1939)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b

97970_CCFBCH_Rev0_1-128.pdf 109 7/7/15 7:44 AM


Cleveland Clinic — Implementing Value-Based Care

Cleveland Clinic Overall Mortality Observed/Expected Ratio

2013 – 2014


Cleveland Clinic’s observed/expected (O/E) mortality ratio outperformed its internal target derived from the University HealthSystem Consortium (UHC) 2014 risk model. Ratios less than 1.0 indicate mortality performance “better than expected” in UHC’s risk adjustment model.

Overview

Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing 3 goals: improving the patient experience of care (including quality and satisfaction), improving population health, and reducing the cost of healthcare. The following measures are examples of 2014 focus areas in pursuit of this 3-part aim. Throughout this section, “Cleveland Clinic” refers to the academic medical center or “main campus,” and those results are shown. Real-time dashboard data are leveraged in each Cleveland Clinic location to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels and support improved care in all clinical locations.

Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSI), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews of every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population.

Cleveland Clinic Central Line-Associated Bloodstream Infection — ICU Rate per 1000 Line Days

2013 – 2014

Improve the Patient Experience of Care

1.0

0.0Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

0.8

0.6

0.4

0.2

O/E Ratio

Cleveland ClinicCleveland Clinic target

2.5

0.0

2.0

1.5

1.0

0.5

Rate per 1000 Line Days


Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

97970_CCFBCH_Rev0_1-128.pdf 110 7/7/15 7:44 AM


Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1000 Eligible Patients

2013 – 2014

Improved screening, risk adjustment, and prevention strategies have supported Cleveland Clinic’s continued improvement with respect to perioperative pulmonary embolism and deep vein thrombosis (AHRQ Patient Safety Indicator 12). Embolism/thrombosis prevention remains a safety priority for Cleveland Clinic in 2015.

Source: Data reported from the National Database for Nursing Quality Indicators® (NDNQI®) with permission from Press Ganey.


A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing position on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning help while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur.

Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult)

2013 – 2014

Rate per 1000 Patients


10

0

8

6

4

2

Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

5

0

4

3

2

1

Percent

Cleveland ClinicNDNQI 50th percentile(academic medical centers)

Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

97970_CCFBCH_Rev0_1-128.pdf 111 7/7/15 7:44 AM


Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic’s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care.

Outpatient Office Visit Survey — Cleveland Clinic

CG-CAHPS Assessmenta 2013 – 2014

aIn 2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients’ perspectives of outpatient care.bBased on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 2013cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No


100

80

0

60

40

20

Best Response (%)

AppointmentAccess

(% Always)c

Primary Care

(% Always)c

Specialty Care


Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff


Test ResultsCommunication

(% Yes)e

2013 (N = 64,792)2014 (N = 124,521)

CG-CAHPS 2013 database average(all practices)b



97970_CCFBCH_Rev0_1-128.pdf 112 7/7/15 7:44 AM


HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Cleveland Clinic

The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare.

HCAHPS Domains of Carea 2013 – 2014

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no


2014 (N = 10,369)

National averageall patientsa

2013 (N = 10,730)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes


Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 10,369)National average all patientsb

2013 (N = 10,730)

aExcept for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

97970_CCFBCH_Rev0_1-128.pdf 113 7/7/15 7:44 AM



Cleveland Clinic is developing and implementing new models of care that focus on “Patients First” and aim to deliver on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new models of Value-Based Care is a strategic priority for Cleveland Clinic. As care delivery shifts from fee-for-service to a population health and bundled payment delivery system, Cleveland Clinic is focused on concurrently improving patient safety, outcomes, and experience.

What does this new model of care look like?

• The Cleveland Clinic Integrated Care Model (CCICM) is a value-based model of care, designed to improve outcomes while reducing cost. It is designed to deliver value in both population health and specialty care.

• The patient remains at the heart of the CCICM.

• The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in different settings. The care system represents integration of care across the continuum.

• Critical competencies are required to build this new care system. Cleveland Clinic is creating disease- and condition-specific care paths for a variety of procedures and chronic diseases. Another facet is implementing comprehensive care coordination for high-risk patients to prevent unnecessary hospitalizations and emergency department visits. Efforts include managing transitions in care, optimizing access and flow for patients through the CCICM, and developing novel tactics to engage patients and caregivers in this work.

• Measuring performance around quality, safety, utilization, cost, appropriateness of care, and patient and caregiver experience is an essential component of this work.

Focus on Value

HomeRetail Venues

Integrated Care Model

Outpatient Clinics

IndependentPhysicianOffices

Skilled NursingFacilities Rehabilitation

Facilities

Community-BasedOrganizations

Post-Acute(other)

AmbulatoryDiagnosis & Treatment

Hospitals

Emergency

Care System

MyChart

97970_CCFBCH_Rev0_1-128.pdf 114 7/7/15 7:44 AM


CMI = case mix index aTotal discharges Source: Data from the UHC Clinical Data Base/Resource ManagerTM

used by permission of UHC. All rights reserved.

a2015 ACO 90th percentile bLower is better

Cleveland Clinic All-Cause 30-Day Readmission Rate to Any Cleveland Clinic Hospital

2013 – 2014

Select Accountable Care Organization Performance Measures

Cleveland Clinic monitors 30-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Strategies associated with communication, education, and follow-up have been implemented for several high-risk conditions, including heart failure and pneumonia. These practices are being expanded and enhanced to reduce overall avoidable readmissions. Sicker, more complex patients are more susceptible to readmission. Case mix index (CMI) reflects patient severity of illness and resource utilization. Cleveland Clinic’s CMI remains one of the highest among American academic medical centers.

As part of Cleveland Clinic’s commitment to population health and in support of its newly certified Accountable Care Organization (ACO), these primary care ACO measures have been prioritized for monitoring and improvement. Cleveland Clinic is improving performance in these measures through enhanced care coordination, optimizing technology and information systems, and engaging primary care physicians and specialists directly in the improvement work. These pursuits are part of Cleveland Clinic’s overall strategy to transform care in order to improve health and make care more affordable.

Reduce the Cost of CareImprove Population Health

Percent of DischargesPercent of Discharges Case Mix Index

0.0

3.0

1.5

00

1818

99

1212

1515

66

33

Q1 Q2

201352,104Na =

201450,755

Q3 Q4 Q1 Q2 Q3 Q4

Cleveland Clinic rateCleveland Clinic CMIUHC academic medical centers CMI

Measure Cleveland Clinic 2014 Cleveland Clinic Performance (%) Goala (%)

Pneumococcal 84.9 100 vaccination

Colorectal 72.3 100 cancer screening

Mammography 77.5 ≥ 99.6 screening

Hemoglobin 20.5 ≤ 10b A1c > 9%

Hypertension 69.3 ≥ 79.7 control

97970_CCFBCH_Rev0_1-128.pdf 115 7/7/15 7:44 AM

ResultsTime to > 20 Polyps, > 2 mm on Single Colonoscopy

Subjects evaluated 106 97 73 51 28 11

Cumulative Event Rate (%)

Celecoxib Placebo

Time (y)

00 1 2 3 4 5 6

102030405060708090

100

116 Outcomes 2014

Innovations

Bariatric Surgery Provides Long-Term Control of Type 2 Diabetes

Cleveland Clinic researchers demonstrated that bariatric surgery is a highly effective and durable treatment for type 2 diabetes in obese patients, enabling nearly all surgical patients to be free of insulin, and many more to be free of all diabetic medications 3 years after surgery. The Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial also showed that bariatric surgery patients experienced an improvement in quality of life and a reduction in the need for cardiovascular medications to control blood pressure and cholesterol, compared with those receiving medical therapy.

Capnographic Monitoring in Colonoscopy Fails to Reduce Incidence of Hypoxemia

A randomized controlled trial of capnographic monitoring for the reduction of hypoxemia in patients undergoing routine colonoscopy with moderate sedation showed no statistical difference between the incidence of hypoxemia in patients titrated with capnography and patients who underwent standard care. The results of this trial were presented at the presidential plenary session of the American College of Gastroenterology’s annual meeting.

A worldwide trial conducted at Cleveland Clinic and directed in part by Cleveland Clinic staff assessed the impact of celecoxib, an anti-inflammatory drug, on colorectal polyp disease progression in children with familial adenomatous polyposis. The research showed that 13% of children receiving celecoxib met the end-point of developing more than 20 polyps larger than 2 mm at an annual colonoscopy, compared with 26% of the placebo group. The median time to the polyposis progression end-point was 2.1 years in the patients receiving celecoxib and 1.1 years in the patients receiving placebo. Although celecoxib is not a cure, the trial demonstrated that it is a reasonable adjunct to yearly colonoscopy to prevent polyp progression, and it may allow children to delay their surgery to a more suitable time.

Celecoxib Prevents Polyp Progression in Pediatric Familial Adenomatous Polyposis Patients

97970_CCFBCH_Rev0_1-128.pdf 116 7/7/15 7:44 AM


Cirrhotic Patients May Benefit From Routine Screening for Celiac Disease

Researchers at Cleveland Clinic found that celiac disease is more than twice as common in people with cirrhosis of the liver as it is in the general population, indicating that routine screening for celiac disease may be warranted for cirrhotic patients. They also found that patients who have levels of celiac serology antibodies at least 5 times higher than the upper levels of normal values may be diagnosed with celiac disease with no need for a small biopsy. Forgoing an upper endoscopy or small bowel biopsy would be more cost-effective and avoid risk of complications in the elderly or those with advanced cirrhosis.

Wakim-Fleming J, Pagadala MR, McCullough AJ, Lopez R, Bennett AE, Barnes DS, Carey WD. Prevalence of celiac disease in cirrhosis and outcome of cirrhosis on a gluten free diet: a prospective study. J Hepatol. 2014 Sep;61(3):558-563.

High-Definition Video Cholangioscopes Aid Diagnosis

Cleveland Clinic is optimizing evaluation of biliary disorders using high-definition video cholangioscopes with narrow-band imaging capability. It is among a handful of centers in the world with experience using this technology for various biliary disorders. High-definition endoscopes are now thin enough for insertion into the bile duct, allowing detection of smaller and more obscure lesions. Patients with biliary strictures will benefit from this new technology because it allows earlier detection of neovascularization and helps identify benign vs malignant lesions.

Direct Peroral Cholangioscopy for Difficult-to-Remove Biliary Stones

Cleveland Clinic gastroenterologists are utilizing direct peroral cholangioscopy for shockwave treatment of difficult-to-remove biliary stones. Direct visualization minimizes risk for damage to bile duct walls, including perforation, and can help patients avoid complicated surgeries. Many patients with difficult-to-remove stones are elderly with comorbidities that put them at greater risk for surgery.

97970_CCFBCH_Rev0_1-128.pdf 117 7/7/15 7:44 AM

Outcomes 2014

Innovations

118

Variable Width, Extreme Angulation Colonoscope May Prove Helpful

Cleveland Clinic Florida’s Digestive Disease Center staff conducted a study to assess the effectiveness of the PENTAX E-340TLi Video Colonoscope (RetroView™), the newly available variable-width colonoscope with extreme tip angulation capability. Based on colonoscopies of 16 patients, staff members found that the RetroView colonoscope may help complete colonoscopies made difficult by colon tortuosity and angulations. More data regarding the device’s performance, especially compared with other colonoscopes, are needed.

Lara LF, Erim T, Schneider A, Palekar N, Jimenez B, Murchie B, Pimentel RR, Charles RJ. Initial experience with a variable width and extreme tip angulation colonoscope. Tech Coloproctol. 2014 Dec;18(12):1173-1175.

Study of Overtube-Assisted Enteroscopy Adverse Events Prompts Change in Practice

A retrospective study conducted at Cleveland Clinic Florida’s Digestive Disease Center of 432 overtube-assisted enteroscopies identified 14 resulting in emergency resuscitation efforts. Based on the frequency of adverse events, and in consultation with anesthesia providers, endoscopists conducted all antegrade overtube-assisted enteroscopies with general anesthesia with no adverse events. The review prompted a change in practice. All patients undergoing antegrade overtube-assisted enteroscopy at Cleveland Clinic now have endotracheal intubation, which has dramatically decreased the rate of respiratory adverse events. The impact of endoscopic quality measurements on practices, procedures, and outcomes will be of further interest.

Lara LF, Ukleja A, Pimentel R, Charles RJ. Effect of a quality program with adverse events identification on airway management during overtube-assisted enteroscopy. Endoscopy. 2014 Nov;46(11):927-932.

97970_CCFBCH_Rev0_1-128.pdf 118 7/7/15 7:44 AM


Glucose Spray Used to Control Gastric Variceal, Peptic Ulcer Bleeding

Management of nonvariceal and nonulcerative bleeding in the gastrointestinal tract, such as that associated with radiation enteritis with active and extensive oozing, has been challenging. Conventional treatments, such as endoclips, electric cauterization, argon plasma coagulation, radiofrequency ablation, and epinephrine injection, may not be feasible or effective. Cleveland Clinic gastroenterologists reported the first case in the literature using hypertonic glucose spray in radiation enteritis-associated diffuse mucosal bleeding. The spray of hypertonic glucose (50% dextrose) was shown to be safe and effective in controlling bleeding from diffuse radiation enteritis. Cleveland Clinic gastroenterologists have also successfully used this technique as a single therapy or an adjuvant therapy to treat bleeding associated with radiation proctitis, postendoscopic dilation, Mallory-Weiss tears, and peptic ulcers.

Tian C, Mehta P, Shen B. Endoscopic therapy of bleeding from radiation enteritis with hypertonic glucose spray. ACG Case Rep J. 2014;1(4):181-183.

Metabolomics Studies Identify Novel Prognostic Indicators in Patients With End-Stage Liver Disease, Alcoholic Hepatitis

Cleveland Clinic’s hepatology staff, in collaboration with the Department of Cellular and Molecular Medicine, has developed a novel method to evaluate prognosis of patients with liver cirrhosis awaiting liver transplantation, as well as diagnosis of alcoholic hepatitis and the severity of liver disease in these patients. They conducted a study using mass spectrometry to identify and measure 29 metabolomics compounds in plasma samples. Using various statistical analyses to compare clinical characteristics and plasma levels of compounds among groups, the research group evaluated the correlation between levels of compounds and severity of liver disease. Specific plasma metabolomics compounds were found to be associated with transplant-free survival in patients with liver cirrhosis. Similarly, specific plasma metabolomics compounds were found to be associated with the presence of alcoholic hepatitis and severity of liver disease.

1-Specificity

AUC (95% CI)citrulline & betaine: 0.84 (0.75, 0.98)citrulline: 0.76 (0.61, 0.91)betaine: 0.73 (0.59, 0.88)

Sensitivity

0.00.0 0.2

0.2

0.4

0.6

0.8

1.0

0.4 0.6 0.8 1.0

1-Specificity

3-Month OLT-Free Survival

AUC (95% CI)MELD: 0.82 (0.69, 0.95)Tyrosine: 0.91 (0.74, 1.0)MELD & Tyrosine: 0.92 (0.76, 1.0)

Sensitivity

0.00.0 0.2

0.2

0.4

0.6

0.8

1.0

0.4 0.6 0.8 1.0

97970_CCFBCH_Rev0_1-128.pdf 119 7/7/15 7:44 AM

120 Outcomes 2014

Innovations

Multidisciplinary Clinic Uses Chromoendoscopy to Screen for Anal Dysplasia

Cleveland Clinic staff representing colorectal surgery, gastroenterology, and infectious disease have formed a multidisciplinary clinic to treat patients with anal dysplasia, a human papillomavirus-associated premalignant condition of the anal transitional zone and anal canal. The team uses chromoendoscopy to detect lesions that may become precancerous squamous intraepithelial lesions. Abnormalities such as punctuation (black arrow) and mosaicism (white arrow) suggest that squamous intraepithelial dysplasia may be present. These lesions are biopsied and ablated endoscopically or surgically.

Transanal Total Mesorectal Excision Offers Less Invasive Approach to Rectal Cancer

Surgical outcomes of rectal cancer are optimized by performance of high-quality total mesorectal excision (TME) including tumor-free circumferential radial margins (CRM)s. Thus far, despite evaluation of data on hundreds of thousands of patients worldwide, there are no significant differences in the quality of TME or tumor-free status after CRMs among open, laparoscopic, and robotic methods of surgery. To improve these outcomes, the Colorectal Surgery Department at Cleveland Clinic Florida’s Digestive Disease Center has started performing transanal TME. This “down to up” technique offers the potential for a less invasive procedure with ease of dissection in the most challenging cancer patients. A two-team approach facilitates the procedure with an abdominal team working concurrently with the pelvic team, potentially allowing for shorter operative times. The lower pelvic dissection is done transanally with improved visualization, which facilitates a more complete TME and the potential for improved oncologic outcomes. Increasing evidence demonstrates superior CRMs. Evidence from peer-reviewed publications has shown that transanal TME may be oncologically superior to all other commonly employed methods.

Endoscopic Full-Thickness Resection Reduces Complications

Endoscopic full-thickness resection (EFTR) reduces complications in resection of colonic lesions that require advanced endoscopic techniques. Currently, with few exceptions, gastroenterologists refer large, benign, sessile colonic polyps to surgeons for segmental colorectal resections. EFTR allows en bloc resection of polyps and large intraluminal lesions, permitting precise pathological assessments of resection. Digestive Disease Institute colorectal surgeons successfully performed EFTR in more than 12 patients, with insignificant complications. Initial experience proves that EFTR is feasible and effective and can avoid unnecessary oncologic segmental bowel resections.

97970_CCFBCH_Rev0_1-128.pdf 120 7/7/15 7:44 AM


Fluorescent Cholangiography Provides Effective Alternative to Intraoperative Cholangiography

Despite the standardization of laparoscopic cholecystectomy, the rate of bile duct injury (BDI) has risen from 0.2% to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. Staff at Cleveland Clinic Florida’s Digestive Disease Center prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. A total of 43 patients (21 males and 22 females) were analyzed during the study period. In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC and was perceived by the surgeons to be easier to perform and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.

Dip FD, Asbun D, Rosales-Velderrain A, Lo Menzo E, Simpfendorfer CH, Szomstein S, Rosenthal RJ. Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2014 Jun;28(6):1838-1843.

Gastric Bypass Effective Treatment for Refractory Gastroparesis

Cleveland Clinic staff conducted a study aimed at presenting their experience with laparoscopic gastric bypass and gastric electrical stimulation (GES) as a safe and efficacious procedure for gastroparesis patients. They retrospectively reviewed data from 72 medical records between 2003 and 2013, using descriptive analysis. Out of 72 patients, 68 patients underwent either a gastric bypass or GES. As a newer application of this technique, laparoscopic gastric bypass is a safe treatment option in this patient population. GES can also be safely employed to treat this cohort as previously established in literature. Though 54% of the combined group had symptom improvement in early follow-up, longer-term studies and postoperative gastric emptying studies are needed to objectively delineate efficacy of these procedures.

Barbed Sutures Offer Effective Alternative to Traditional Hiatal Hernia Repair

Hiatal hernia repair (HHR) is considered a technically challenging procedure in an anatomically difficult location. The method of hiatal hernia closure has a substantial impact on the course of postoperative recovery. Cleveland Clinic Florida’s Digestive Disease Center staff retrospectively reviewed the surgical cases of patients who had undergone HHR using unidirectional barbed sutures between January 2010 and December 2012. The researchers found that adopting continuous unidirectional barbed sutures provided a safe, efficient, and effective alternative to traditional techniques. The findings warrant further studies to establish the long-term efficacy of using barbed sutures during laparoscopic HHR.

97970_CCFBCH_Rev0_1-128.pdf 121 7/7/15 7:44 AM

Outcomes 2014122

Contact Information

Colorectal Surgery, Gastroenterology and Hepatology, and General Surgery Appointments/Referrals

800.223.2273, ext. 47000

Bariatric Surgery Appointments/Referrals

216.445.2224 or

800.223.2273, ext. 52224

Breast Center Appointments/Referrals

800.223.2273, ext. 43024

Center for Human Nutrition Appointments/Referrals

800.223.2273, ext. 43046

Cleveland Clinic Florida Appointments

877.463.2010

On the Web at clevelandclinic.org/digestive and clevelandclinic.org/bariatric

Staff Listing

For a complete listing of Cleveland Clinic’s Digestive Disease Institute staff, please visit clevelandclinic.org/staff.

Publications

Digestive Disease Institute staff authored 474 publications in 2014.

For a complete list, go to clevelandclinic.org/outcomes.

Locations

For a complete listing of Digestive Disease Institute locations, please visit clevelandclinic.org/digestive.

Outcomes 2014

97970_CCFBCH_Rev0_1-128.pdf 122 7/7/15 7:44 AM

http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/about-cleveland-clinic/quality-patient-safety/treatment-outcomes.aspx?utm_campaign=outcomes-url&utm_medium=offline&utm_source=redirect


http://my.clevelandclinic.org/services/digestive_diseases?utm_campaign=digestive-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/digestive_diseases?utm_campaign=digestive-url&utm_medium=offline&utm_source=redirect

http://weightloss.clevelandclinic.org/index.aspx?utm_campaign=bariatric-url&utm_medium=offline&utm_source=redirect


Additional Contact Information General Patient Referral

24/7 hospital transfers or physician consults

800.553.5056 General Information

216.444.2200 Hospital Patient Information

216.444.2000 General Patient Appointments

216.444.2273 or 800.223.2273 Referring Physician Center and Hotline

855.REFER.123 (855.733.3712)

Or email [email protected] or visit clevelandclinic.org/refer123 Request for Medical Records

216.444.2640 or 800.223.2273, ext. 42640 Same-Day Appointments

216.444.CARE (2273)

Global Patient Services/ International Center

Complimentary assistance for international patients and families

001.216.444.8184 or visit clevelandclinic.org/gps Medical Concierge

Complimentary assistance for out-of-state patients and families

800.223.2273, ext. 55580, or email [email protected] Cleveland Clinic Abu Dhabi

clevelandclinicabudhabi.ae Cleveland Clinic Canada

888.507.6885 Cleveland Clinic Florida

866.293.7866 Cleveland Clinic Nevada

702.483.6000 For address corrections or changes, please call

800.890.2467


97970_CCFBCH_Rev0_1-128.pdf 123 7/7/15 7:44 AM

http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/patients-visitors/international?utm_campaign=gps-url&utm_medium=offline&utm_source=redirect

https://www.clevelandclinicabudhabi.ae/en/pages/default.aspx

Overview

Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 3200 Cleveland Clinic staff physicians and scientists in 130 medical specialties and subspecialties care for more than 5.9 million patients across the system, performing more than 192,000 surgeries and conducting more than 497,000 emergency department visits. Patients come to Cleveland Clinic from all 50 states and more than 147 nations. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1400-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 42 buildings on 165 acres. Cleveland Clinic’s CMS case-mix index is the second highest in the nation. Cleveland Clinic encompasses more than 90 northern Ohio outpatient locations, including 18 full-service family health centers, 8 regional hospitals, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida; Cleveland Clinic Nevada, which includes the Lou Ruvo Center for Brain Health in Las Vegas, and urology and nephrology services; Cleveland Clinic Canada; and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu Dhabi is a full-service hospital and outpatient center in the United Arab Emirates (UAE), which began offering services in spring 2015. Cleveland Clinic is the second-largest employer in Ohio, with more than 42,500 employees. It generates $12.6 billion of economic activity a year. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Canada, China, the Dominican Republic, El Salvador, Guatemala, Honduras, Panama, Peru, Saudi Arabia, Turkey, UAE, and the United Kingdom.

The Cleveland Clinic Model

Cleveland Clinic was founded in 1921 by 4 physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education. The Cleveland Clinic health system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 1990s with the development of 18 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and 6 other regional hospitals have joined Cleveland Clinic over the past 2 decades, offering Cleveland Clinic institute services in heart and neurological care, physical rehabilitation, and more. Clinical and support services were reorganized into 27 patient-centered institutes beginning in 2007. Institutes combine medical and surgical specialists for specific diseases or organ systems under unified leadership and in a shared location to provide optimal team care for every patient. Institutes work with the Office of Patient Experience to give every patient the best outcome and experience. A Clinically Integrated Network

Cleveland Clinic is committed to providing value-based care, and it has grown the Cleveland Clinic Quality Alliance into the nation’s second-largest and Northeast Ohio’s largest clinically integrated network. The network comprises more than 5400 physician members, both employed and independent physicians from the community. Led by its physician members, the Quality Alliance strives to improve quality and consistency of care; reduce costs and increase efficiency; and provide access to expertise, data, and experience.

Outcomes 2014124

About Cleveland Clinic

97970_CCFBCH_Rev0_1-128.pdf 124 7/7/15 7:44 AM

Cleveland Clinic Lerner College of Medicine

Lerner College of Medicine is known for its small class sizes, unique curriculum, and full-tuition scholarships for all students. Each new class accepts 32 students who are preparing to be physician investigators. Cleveland Clinic is building a multidisciplinary Health Education Campus as the new home of the Case Western Reserve University (CWRU) School of Medicine and Cleveland Clinic’s Lerner College of Medicine, as well as the CWRU School of Dental Medicine, the Frances Payne Bolton School of Nursing, and physician assistant and allied health training programs.

Graduate Medical Education

In 2014, nearly 1800 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, which is part of a continuing upward trend.

U.S. News & World Report Ranking

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S. News & World Report. It is ranked No. 1 in urology and has ranked No. 1 in heart care and heart surgery since 1995. In 2014, 4 of its programs were ranked No. 2 in the nation: diabetes and endocrinology, gastroenterology and GI surgery, nephrology, and rheumatology.

For more information about Cleveland Clinic, please visit clevelandclinic.org.

Cleveland Clinic Physician Ratings

At Cleveland Clinic, we believe in transparency. We also believe in the positive influence of the physician-patient relationship on healthcare outcomes. To continue to meet the highest standards of patient satisfaction, we now publish Cleveland Clinic physician ratings, based on nationally recognized Press Ganey patient satisfaction surveys, online at clevelandclinic.org/staff.


97970_CCFBCH_Rev0_1-128.pdf 125 7/7/15 7:44 AM

http://my.clevelandclinic.org/


Referring Physician Center and Hotline

Call 24/7 for access to medical services or to schedule patient appointments: 855.REFER.123 (855.733.3712), email [email protected], or go to clevelandclinic.org/Refer123. The free Cleveland Clinic Physician Referral App, available for mobile devices, gives you 1-click access. Available at the App Store or Google Play. Remote Consults

Anybody anywhere can get an online second opinion from a Cleveland Clinic specialist through our MyConsult service. For more information, go to clevelandclinic.org/myconsult, email eclevelandclinic.org, or call 800.223.2273, ext. 43223. Request Medical Records

216.444.2640 or 800.223.2273, ext. 42640 Track Your Patients’ Care Online

Cleveland Clinic offers an array of secure online services that allow referring physicians to monitor their patients’ treatment while under Cleveland Clinic care, as well as access test results, medications, and treatment plans. my.clevelandclinic.org/online-services

DrConnect (online access to patients’ treatment progress while under referred care): 877.224.7367; [email protected]

MyPractice Community (affordable electronic medical records system for physicians in private practice): 866.320.4573

eRadiology (teleradiology consultation provided nationwide by board-certified radiologists with specialty training, within 24 hours or stat): 216.986.2915; [email protected]

Medical Records Online

Patients can view portions of their medical record, receive diagnostic images and test results, make appointments, and renew prescriptions through MyChart, a secure online portal. All new Cleveland Clinic patients are automatically registered for MyChart. clevelandclinic.org/mychart Critical Care Transport Worldwide

Cleveland Clinic’s fleet of ground and air transport vehicles is ready to transfer patients at any level of acuity anywhere on earth. Specially trained crews provide Cleveland Clinic care protocols from first contact. To arrange a transfer for STEMI (ST-elevation myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call 877.379.CODE (2633). For all other critical care transfers, call 216.444.8302 or 800.553.5056. CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education operates the largest CME program in the country. Live courses are offered in Cleveland and cities around the nation and the world. The center’s website (ccfcme.org) is an educational resource for healthcare providers and the public. It has a calendar of upcoming courses, online programs on topics in 30 areas, and the award-winning virtual textbook of medicine, The Disease Management Project. Clinical Trials

Cleveland Clinic is running more than 2100 clinical trials at any given time for conditions including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. Cancer Clinical Trials is a mobile app that provides information on the more than 100 active clinical trials available to cancer patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp.

Outcomes 2014126

Resources

97970_CCFBCH_Rev0_1-128.pdf 126 7/7/15 7:44 AM

http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services

http://my.clevelandclinic.org/online-services/mychart.aspx?utm_campaign=mychart-url&utm_medium=offline&utm_source=redirect

http://www.clevelandclinicmeded.com/

http://my.clevelandclinic.org/services/cancer/clinical-trials-research?utm_campaign=cancertrialapp-url&utm_medium=offline&utm_source=redirect

mailto:eclevelandclinic.org

mailto:[email protected]



Healthcare Executive Education

Cleveland Clinic has programs to teach people from outside the organization how it operates a major medical center. The Executive Visitors’ Program is an intensive 3-day behind-the-scenes view of the Cleveland Clinic organization for the busy executive. The Samson Global Leadership Academy is a 2-week immersion in challenges of leadership, management, and innovation taught by Cleveland Clinic leaders, administrators, and clinicians. Curriculum includes coaching and a personalized 3-year leadership development plan. Learn more at clevelandclinic.org/executiveeducation. Consult QD Physician Blog

A singular blog for physicians and healthcare professionals from Cleveland Clinic. Discover the latest research insights, innovations, treatment trends, and more for all specialties. Join the conversation: consultqd.clevelandclinic.org. Social Media

Cleveland Clinic uses social media to help caregivers everywhere provide better patient care. Millions of people currently like, friend, or link to Cleveland Clinic social media — including leaders in medicine.

Facebook for Medical Professionals facebook.com/CMEclevelandclinic

Follow us on Twitter @cleclinicMD

Connect with us on LinkedIn Clevelandclinic.org/Mdlinkedin


97970_CCFBCH_Rev0_1-128.pdf 127 7/7/15 7:44 AM

Notes

97970_CCFBCH_Rev0_1-128.pdf 128 7/7/15 7:44 AM

Measuring Outcomes Promotes Quality Improvement

This project would not have been possible without the commitment and expertise of a team led by Laura Buccini, DrPH, MPH; and Charmaine Jones, MBA.

Graphic design and photography were provided by Cleveland Clinic’s Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015


9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org

15-OUT-340


2014 Outcomes


Documents

Digestive Disease Institute - Cleveland Clinic · 9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org 15-OUT-340 Digestive Disease Institute 2014 Outcomes 97970_CCFBCH_15OUT340_Cover_ACG.indd