Digestive Disease Institute Outcomes

Transcription

1 Digestive Disease Institute 213 Outcomes

2 Measuring Outcomes Promotes Quality Improvement

3 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 data on patient volumes and outcomes 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) Ohio Department of Health (ohiohospitalcompare.ohio.gov) 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 to: OutcomesBooksFeedback@ccf.org or scan here. To view all our Outcomes books, please visit Cleveland Clinic s Quality and Patient Safety Institute website at clevelandclinic.org/outcomes.

4 Dear Colleague: Welcome to this 213 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 a summary 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 around 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 reports has received favorable notice from colleagues and healthcare observers. We appreciate your interest and hope you find this information useful and informative. Sincerely, Delos M. Cosgrove, MD CEO and President 2 Outcomes 213

5 what s inside Chairman s Letter 4 Institute Overview 5 Quality and Outcomes Measures Procedure Overview Digestive Disease Institute 6 Esophageal Disease 18 Small Bowel Disease and Intestinal Transplant 28 Nutrition 46 Large Bowel Disease 48 Trauma and Acute General Surgery 68 Pancreaticobiliary Disease 7 Liver Disease and Liver Transplant 76 Obesity 18 Breast Disease 118 Cleveland Clinic Florida 127 Institute Quality Improvement 14 Surgical Quality Improvement 146 Institute Patient Experience 148 Cleveland Clinic Implementing Value-Based Care 15 Prefer an e-version? Visit clevelandclinic.org/outcomesonline, and we ll remove you from the hard copy mailing list and you when next year s books are online. Innovations 156 Contact Information 164 About Cleveland Clinic 166 Resources 168 Digestive Disease Institute 3

6 Chairman s Letter I am pleased to present the 213 Outcomes book for Cleveland Clinic s Digestive Disease Institute. This is the 12th 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, our institute had many exciting achievements, including: Moving the Bariatric and Metabolic Center from the Endocrinology & Metabolism Institute to the Digestive Disease Institute. Under the leadership of Philip Schauer, MD, the program continues to expand and to be recognized as a leader in all aspects of bariatric surgery. Partnering with the Department of Thoracic Surgery and the Robert J. Tomsich Pathology & Laboratory Medicine Institute to create a new Center of Excellence for Barrett s Esophagus. The center provides a multidisciplinary approach to the diagnosis and innovative management of Barrett s dysplasia, a recognized risk factor for esophageal cancer. Performing the first liver and kidney transplants at our Weston, Fla., campus since the launch of the multiorgan transplant program in July 213. We welcome your feedback, questions, and ideas for collaboration. Please contact me via at OutcomesBooksFeedback@ccf.org and reference the Digestive Disease Institute book in your message. Sincerely, John Fung, MD, PhD Chairman, Digestive Disease Institute Medical Director, Allogen Laboratories Professor of Surgery, Lerner College of Medicine 4 Outcomes 213

7 Institute Overview Cleveland Clinic 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. Throughout the years, Digestive Disease Institute physicians have pioneered many new technologies and procedures for treating digestive disorders. This rich history of innovation continues today, whether through the development of new surgical techniques or participation in clinical trials and operating 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 23. The institute is located on Cleveland Clinic s main campus as well as 23 regional facilities and includes the departments of Gastroenterology and Hepatology, Colorectal Surgery and General Surgery (including hepatopancreato-biliary, liver and intestinal transplant surgery and breast surgery); the Bariatric and Metabolic Center; and the Center for Human Nutrition. The institute s 148 staff physicians, 138 residents and fellows, and 365 nurses offer the most advanced, safest and proven treatments performed in the most effective and patient-friendly way. 213 Statistics Evaluation & Management Visits 19,947 Locations 24 Research Studies 491 Publications 457 Presentations 59 Educational Events 134 Physicians 148 Inpatient Nurses 3 Ambulatory Nurses 65 Fellows 71 Residents 67 The Digestive Disease Institute staff authored more than 45 publications in 213. For a complete list, go to clevelandclinic.org/outcomes. Digestive Disease Institute 5

8 Procedure Overview-Digestive Disease Institute Surgical Overview Digestive Disease Institute: Surgical Procedures DDI Surgical Procedures: Inpatient/Outpatient Number of Procedures 12, 8 Inpatient Outpatient N = ,47 DDI Surgical Procedures: Inpatient/Outpatient, Practice Location Number of Procedures (N = 13,812) 212 (N = 15,675) 213 (N = 17,595) 2 Cleveland Clinic Main Campus Cleveland Clinic Community Hospitals Cleveland Clinic Main Campus Cleveland Clinic Community Hospitals Inpatient Outpatient 6 Outcomes 213

9 Breast Surgery: Procedures and Length of Stay Index Breast Surgical Procedures Number of Procedures N = Breast Surgery: Volume and LOS a Index b (N = 429) 213 Volume 5 LOS Index (O/E Ratio) Cleveland Clinic c A B C D E F G H I Top U.S. Hospitals a Length of Stay; b Surgical procedures include other skin, subcutaneous tissue breast procedures with cc and without cc/mcc and mastectomies for malignancy with and without cc/mcc. c Includes all Cleveland Clinic O/E = observed (actual) length of stay/expected (predicted) length of stay based on severity of illness. Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu Digestive Disease Institute 7

10 Procedure Overview-Digestive Disease Institute Bariatric Surgery: Procedures and Length of Stay Index Bariatric Surgical Procedures a : Inpatient/Outpatient Number of Procedures 8 6 Inpatient Outpatient N = a All bariatric and nonbariatric surgical procedures performed by bariatric surgeons Bariatric Surgery: Minimally Invasive Procedures Number of Procedures N = Outcomes 213

11 Bariatric Surgery: Robotic Procedures Number of Procedures N = Bariatric Surgery: Volume and LOS a Index b (N = 662) Volume LOS Index (O/E Ratio) Cleveland Clinic c A B C D E F G H I Top U.S. Hospitals a Length of Stay; b Surgical procedures include other skin, subcutaneous tissue breast procedures with cc and without cc/mcc and mastectomies for malignancy with and without cc/mcc. c Includes all Cleveland Clinic O/E = observed (actual) length of stay/expected (predicted) length of stay based on severity of illness. Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu Digestive Disease Institute 9

12 Procedure Overview-Digestive Disease Institute Colorectal Surgery: Procedures, Mortality Index, and Length of Stay Index Colorectal Surgical Procedures: Inpatient/Outpatient Number of Procedures 4 3 Inpatient Outpatient N = Colorectal Surgical Procedures: Inpatient/Outpatient, Practice Location Number of Procedures (N = 349) 212 (N = 3658) 213 (N = 425) 1 5 Cleveland Clinic Main Campus Cleveland Clinic Community Hospitals Cleveland Clinic Main Campus Cleveland Clinic Community Hospitals Inpatient Outpatient 1 Outcomes 213

13 Colorectal Surgery: Minimally Invasive Procedures Number of Procedures N = Colorectal Surgery: Volume and In-Hospital Mortality Index a (N = 272) Volume Mortality Index (O/E Ratio) Cleveland Clinic A B C D E F G H I Top U.S. Hospitals a Surgical procedures are defined as all major small/large bowel, minor small/large bowel, anal, and stomal procedures; rectal resection procedures; and other digestive system O.R. procedures. O/E = observed (actual) length of stay/expected (predicted) length of stay based on severity of illness. Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu Digestive Disease Institute 11

14 Procedure Overview-Digestive Disease Institute Colorectal Surgery: Volume and LOS a Index b (N = 272) 213 Volume LOS Index (O/E Ratio) Cleveland Clinic c A B C D E F G H I a Length of Stay; b Surgical procedures are defined as all major small/large bowel, minor small/large bowel, anal, and stomal procedures; rectal resection procedures; and other digestive system O.R. procedures. c Includes all Cleveland Clinic Top U.S. Hospitals O/E = observed (actual) length of stay/expected (predicted) length of stay based on severity of illness. Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu 12 Outcomes 213

15 General Surgery: Procedures, In-Hospital Mortality Index, and Length of Stay Index General Surgery, Surgical Procedures: Inpatient/Outpatient Number of Procedures 8 6 Inpatient Outpatient N = General Surgery, Surgical Procedures: Inpatient/Outpatient, Practice Location Number of Procedures (N = 8236) 212 (N = 9675) 213 (N = 1,714) 2 1 Cleveland Clinic Main Campus Cleveland Clinic Community Hospitals Cleveland Clinic Main Campus Cleveland Clinic Community Hospitals Inpatient Outpatient Digestive Disease Institute 13

16 Procedure Overview-Digestive Disease Institute General Surgery: Minimally Invasive Procedures Number of Procedures N = General Surgery: Volume and In-Hospital Mortality Index a (N = 159) 213 Volume Mortality Index (O/E Ratio) Cleveland Clinic b A B C D E F G H I Top U.S. Hospitals a Surgical procedures defined as all hernia, pancreas, and cholecystectomy procedures. b Includes all Cleveland Clinic community hospitals (with the exception of Cleveland Clinic Florida, Weston Campus) O/E = observed (actual) length of stay/expected (predicted) length of stay based on severity of illness Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu 14 Outcomes 213

17 General Surgery: Volume and LOS a Index b (N = 159) Volume LOS Index (O/E Ratio) Cleveland Clinic c A B C D E F G H I Top U.S. Hospitals a Length of Stay b Surgical procedures defined as all hernia, pancreas, and cholecystectomy procedures. c Includes all Cleveland Clinic community hospitals (with the exception of Cleveland Clinic Florida, Weston Campus) O/E = observed (actual) length of stay/expected (predicted) length of stay based on severity of illness Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu Digestive Disease Institute 15

18 Procedure Overview-Digestive Disease Institute Endoscopic Overview Digestive Disease Institute: Endoscopic Procedures, All Providers Total Endoscopic Procedures Number of Procedures 8, 6, 4, 2, N = 47,974 48,324 61,72 Colonoscopy and Esophagogastroduodenoscopy Number of Procedures 4, 3, Colonoscopy EGD a 2, 1, N = 24,4 16,54 3,915 18,783 32,519 2,397 a Esophagogastroduodenoscopy 16 Outcomes 213

19 Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound Number of Procedures ERCP a EUS b N = a Endoscopic retrograde cholangiopancreatography b Endoscopic ultrasound Sigmoidoscopy/Ileoscopy/Enteroscopy/Pouchoscopy Number of Procedures N = Sigmoidoscopy Ileoscopy/enteroscopy/pouchoscopy Digestive Disease Institute 17

20 Esophageal Disease Cleveland Clinic s Center for Swallowing and Esophageal Disorders features a multidisciplinary team that includes gastroenterologists; radiologists; thoracic surgeons; neurologists; lung specialists; swallowing therapists; and ear, nose, and throat specialists. The team sees nearly 2 patients annually. The Center is one of very few in the nation offering comprehensive services, including specialized teams for nutrition therapy, intestinal rehabilitation, and nutrition support. Diagnostic Procedures Esophagogastroduodenoscopy (EGD) is used to diagnose disorders of the esophagus, stomach, and first part of the small intestine. Esophagogastroduodenoscopies a Number of Procedures 2, 15, 1, a Performed by gastroenterology physicians N = 15,236 17,55 19,967 Indications for Esophagogastroduodenoscopy Indication Number Percent Epigastric pain/abdominal pain/dyspepsia GERD/heartburn/Barrett s esophagus GI bleeding/anemia Dysphagia/esophageal stricture/ulcer Nausea/vomiting/weight loss Establish/rule-out esophageal varices Other Total 25, Outcomes 213

21 Barrett s Esophagus Digestive Disease Institute staff have partnered with staff in Thoracic Surgery and Pathology to create a Center of Excellence for Barrett s esophagus. The center provides a multidisciplinary approach to the innovative management of Barrett s esophagus, in particular the early diagnosis of esophageal adenocarcinoma. It also facilitates research collaboration among these disciplines. Upper GI Endoscopy in Patients With a Diagnosis of Barrett s Esophagus Number of Procedures N = Endoscopic Mucosal Resection Endoscopic mucosal resection is a involving removal of the inner lining of the esophagus. The technique can be used for dysplasia (precancer) and some very early focal (single, small tumors) cancers of the esophagus. This procedure is not only used for therapeutic purposes, but it also provides tissue for staging esophageal cancer Number of Procedures N = Digestive Disease Institute 19

22 Esophageal Disease Radiofrequency ablation is a widely used procedure for treatment of dysplasia in Barrett s esophagus. It is associated with high eradication rates greater than 9% for dysplasia and greater than 8% for metaplasia. Patients will continue to require surveillance after successful eradication. Radiofrequency Ablations Number of Procedures N = Outcomes 213

23 Esophageal Motility and Reflux The Center for Swallowing and Esophageal Disorders has one of the largest esophageal motility laboratories in the country. The center performs high-resolution manometry and ph studies including conventional 24-hour ph studies and 48-hour Bravo ph capsule monitoring. Manometry Studies Number of Studies 1 8 Esophageal manometry only Esophageal manometry with ph monitoring N = ph Studies Number of Studies hour ph 48-hour Bravo N = Digestive Disease Institute 21

24 Esophageal Disease Hiatal Hernia Surgery Hiatal hernia is a common disorder that results from a defect in the diaphragm, leading to herniation of the stomach into the chest cavity. These hernias are graded according to severity and are often associated with gastroesophageal reflux disease. For patients with significant 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. Laparoscopic Hiatal Hernia Repair Number of Procedures Mean Length of Stay for Laparoscopic Hiatal Hernia Repair Days N = N = Day Readmission Rate for Laparoscopic Hiatal Hernia Repair Percent N = Outcomes 213

25 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. 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. Gastric Neurostimulator Surgery for Gastroparesis Number of Patients Mean Length of Stay Post Neurostimulator Surgery Days N = N = Day Readmission Rate Post Neurostimulator Surgery Percent N = Digestive Disease Institute 23

26 Esophageal Disease Median Arcuate Ligament Syndrome Median arcuate ligament (MAL) syndrome, also known as celiac artery compression syndrome, is a rare diagnosis 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 21, the yearly volumes of MAL release have tripled. Likewise, conversion to open procedure has decreased from 25% to < 1%. Median Arcuate Ligament Release Surgery Number of Surgeries N = Conversion From Minimally Invasive to Open MAL Release Surgical Procedure Percent Conversion 2 CCF Benchmark 15 a N = 5 12 a Benchmark: Jimenez JC, Harlander-Locke M, Dutson EP. Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc Surg. 212 Sep;56(3): Outcomes 213

27 Mean Length of Stay for MAL Release Surgery Days N = Celiac Artery Velocity (N = 14) Velocity (cm/s) Preoperative Postoperative Decreased celiac artery velocity is a marker for successful release of the ligament and occurred in 85% of DDI s patient population. Digestive Disease Institute 25

28 Esophageal Disease Esophageal Surgery Volume and Mortality Cleveland Clinic thoracic surgeons performed 26 esophageal procedures in 213. The in-hospital mortality rate was.9%. Volume Mortality (%) Observed Expected Source: These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Esophagectomy Mortality 1 Year After Surgery 213 Percent The 1-year mortality rate following esophagectomy was 1.2% among patients who had surgery at Cleveland Clinic. The expected rate was higher (3.5%). Observed Expected Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database Outcomes 213

29 Combined Morbidity/Mortality for Esophagectomy for Esophageal Cancer, July 21 June 213 Risk-adjusted Standardized incidence Eligible procedures Unadjusted rate rate (95% CI) ratio (95% CI) % 27.6% (2.5%-33.1%).94 ( ) Cleveland Clinic Min.45 25th.94 Median th 1.17 Max 1.7 = STS standardized incidence ratio Source: STS General Thoracic Surgery Database, July 21 June 213. Cleveland Clinic surgeons performed 149 esophageal surgeries from 21 to 213 with a risk-adjusted rate of morbidity and mortality better than the national median. Distribution of Esophageal Surgeries by Indication (N = 26) 213 1% 34% Paraesophageal hernia repair (N = 71) 33% Cancer (N = 68) 2% Achalasia (N = 41) 7% Other (N = 14) 3% Esophageal reconstruction (N = 6) 3% Reflux (N = 6) The majority of esophageal surgeries at Cleveland Clinic in 213 were to treat patients with paraesophageal hernias and esophageal cancer. Digestive Disease Institute 27

30 Small Bowel Disease and Intestinal Transplant Diagnostic Procedures The Digestive Disease Institute has an active device-assisted enteroscopy program and performs procedures for indications including obscure gastrointestinal bleeding, abnormal capsule endoscopy imaging, small bowel tumors, intestinal obstruction, and inflammatory bowel disease. Antegrade Balloon-Assisted Enteroscopy Number N = Retrograde Balloon-Assisted Enteroscopy Number N = Outcomes 213

31 The institute s Center for Capsule Endoscopy has extensive experience with the SmartPill, a novel ingestible medical device that assesses pressure, acid levels, and motility of the entire gastrointestinal tract. SmartPill Number of Procedures 6 The Center for Capsule Endoscopy also uses video capsules, an innovative method to detect and diagnose lesions of the small bowel in patients with suspected GI tract bleeding, inflammatory bowel disease, polyps, and masses. Video Capsule Number of Procedures N = N = The Center for Capsule Endoscopy implemented InteleCap, a distance medicine initiative that provides external centers with remote interpretation of their capsule endoscopy videos by a board-certified gastroenterologist. Remote Video Capsule Reads Number of Procedures N = Digestive Disease Institute 29

32 Small Bowel Disease and Intestinal Transplant Center for Inflammatory Bowel Disease Cleveland Clinic has an international reputation for excellence in treating inflammatory bowel disease (IBD), which includes Crohn s disease and ulcerative colitis. Over the years, its physicians have pioneered new technologies and procedures for treating IBD. Inflammatory Bowel Disease Outpatient Visits Number N = Outcomes 213

33 Crohn s Disease Medical Management Treatment for Crohn s disease is determined by severity and location. When Crohn s disease is active, treatment is aimed at controlling inflammation, correcting nutritional deficiencies, and relieving symptoms such as pain, diarrhea, and fever. Infliximab (Remicade ) is approved specifically for the treatment of moderate to severe Crohn s disease and for patients who are unresponsive to other treatments. Infliximab Infusions a Number of Infusions a Infliximab is used to treat ulcerative colitis as well, but most infliximab use (95%) is for the treatment of Crohn s disease. N = During the past 3 years, the number of infliximab infusions performed at Cleveland Clinic has increased, reflecting growing disease severity among Cleveland Clinic s patient population. Digestive Disease Institute 31

34 Small Bowel Disease and Intestinal Transplant Surgical Management 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. Crohn s Disease Surgical Cases Number of Surgeries 3 2 Laparoscopic Open N = Crohn s Disease Postoperative Outcomes Open Lap a Open Lap Open Lap Postoperative Outcomes (N = 295) (N = 51) (N = 296) (N = 6) (N = 295) (N = 82) Median length of stay, days day readmission rate 16% 18% 1% 8% 11% 2% In-hospital mortality rate 2% % % % % % Surgical site infection rate Superficial 7% 4% 5% 3% 7% 5% Deep 1% % 1% % 1% % Organ space 4% 12% 9% 8% 8% 5% Urinary tract infection rate 3% 2% 3% 7% 2% 1% Venous thromboembolism rate 4% 2% 4% 3% 4% 2% a Laparoscopic 32 Outcomes 213

35 Continent Ileostomy Cleveland Clinic s Department of Colorectal Surgery is one of the few sites in the world that performs this procedure. The continent ileostomy 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 Number Creation Revision N = Digestive Disease Institute 33

36 Small Bowel Disease and Intestinal Transplant 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 last 3 years. The section of Acute Care Surgery is developing an SBO clinical care path that will standardize nonoperative and operative SBO management. Small Bowel Obstruction Patients (Operative and Nonoperative) Number of Patients 3 2 Operative Nonoperative N = Mean Length of Stay of Small Bowel Obstruction Inpatients (Operative and Nonoperative) Days 2 15 Operative Nonoperative N = Outcomes 213

37 3-Day Readmission Rate of Small Bowel Obstruction, Inpatients (Operative and Nonoperative) Percent 3 2 Operative Nonoperative N = Digestive Disease Institute 35

38 Small Bowel Disease and Intestinal Transplant 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, ovaries, and pseudomyxoma peritonei and peritoneal mesothelioma. This is a two-step surgical procedure, which includes debulking of visible disease (tumor), followed by HIPEC. HIPEC delivers heated chemotherapy directly into the abdomen, which circulates for 9 minutes treating the microscopic disease that may remain. Patients Undergoing HIPEC a Procedure Number of Procedures Mean Length of Stay for HIPEC a Patients Days N = N = a Hyperthermic intraoperative peritoneal chemotherapy 36 Outcomes 213

39 Cancer Type for Patients Undergoing HIPEC a Procedure (N = 7) Cancer Type Patients Percent Colon cancer Appendix carcinoma Pseudomyxoma peritonei 7 1. Ovarian cancer Peritoneal mesothelioma Gastric cancer Peritoneal carcinomatosis Retroperitoneal cancer Undefined Cancer Type Patients Percent Adenocarcinoma unknown primary Breast carcinoma Cervical cancer Desmoplastic round cell tumor Gall bladder cancer Lung cancer Small bowel cancer Uterine cancer a Hyperthermic intraoperative peritoneal chemotherapy Digestive Disease Institute 37

40 Small Bowel Disease and Intestinal Transplant Hernia Center Surgeons from Cleveland Clinic s Hernia Center perform more than 17 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. Inguinal and Incisional/Ventral Hernia Repairs Number of Repairs Inguinal Incisional/ventral N = Inguinal Hernia Repairs: Open and Laparoscopic Number of Repairs 1 8 Open Laparoscopic N = Outcomes 213

41 Incisional/Ventral Hernia Repairs: Open and Laparoscopic Number of Repairs 5 4 Open Laparoscopic N = Digestive Disease Institute 39

42 Small Bowel Disease and Intestinal Transplant Mean Length of Stay of Inpatient Inguinal Hernia Repairs: Open and Laparoscopic Days Open Laparoscopic N = Mean Length of Stay, Inpatient Incisional/Ventral Hernia Repairs: Open and Laparoscopic Days 5 4 Open Laparoscopic N = Outcomes 213

43 Reoperation Rate, Post Hernia Repair: Open and Laparoscopic Inguinal 211 (N) 212 (N) 213 (N) Open.34% (3/884).32% (3/927).% (/96) Laparoscopic.% (/397).% (/397).% (/518) Incisional/Ventral Open 2.68% (11/411).85% (4/471).21% (1/472) Laparoscopic.59% (1/168).54% (1/184).% (/193) Digestive Disease Institute 41

44 Small Bowel Disease and Intestinal Transplant Center for Gut Rehabilitation and Transplantation The Center for Gut Rehabilitation and Transplantation (CGRT) 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 and complex abdominal pathology. The Intestinal Stroke Team (gut rehabilitation surgeons, infectious disease specialists, nutritionists, gastroenterologists, intestinal stroke surgeons, pharmacists, radiologists, nurses, social workers, and intensive care specialists) accepts all patients with acute intestinal ischemia with the intent to restore blood flow to the intestine and other abdominal organs utilizing combined radiologic and surgical techniques. With the recent inception of the Intestinal Stroke Program most patients were rescued with preservation of the gut organs that were viable on referral. Total CGRT Clinical Activities Number of Procedures 12 1 Number of Referrals N = Procedures Gut rehabilitation surgery Visceral transplantation Referrals Candidates referred Referrals have grown exponentially due to medical and surgical rehabilitative efforts including visceral transplantation. 42 Outcomes 213

45 The most commonly utilized surgical rehabilitation includes autologous reconstruction alone or combined with a bowel lengthening procedure. Gastric reconstruction with restoration of gut continuity has been increasingly required for patients who previously had gastric bypass surgery at other centers and subsequently developed intestinal failure after a catastrophic abdominal event. Nontransplant Intestinal Reconstruction (N = 98) 213 Percent Autologous Intestinal Reconstruction (Intention to Treat) Bowel Lengthening Procedure Foregut Gastric Reconstruction Fifty-six percent of patients undergoing intestinal surgical rehabilitation achieved nutritional autonomy with discontinuation of home parenteral nutrition. The remaining patients underwent continual gut rehabilitation with the recently FDA-approved agent Gattex (teduglutide) or received intestinal transplantation. Bowel Lengthening With Serial Transverse Enteroplasty Procedure Digestive Disease Institute 43

46 Small Bowel Disease and Intestinal Transplant Visceral Transplant Procedures (N = 9) 213 Number 1 8 Intestine alone Liver, intestine, and pancreas a Full multivisceral a The liver-intestine-pancreas recipient was a child who had Martinez-Frias syndrome, a rare hereditary disorder with neonatal diabetes, enterocyte failure, and end stage liver disease Types of Intestinal Transplant Intestine alone Multivisceral (liver, intestine, duodenum, pancreas) Full multivisceral Multivisceral without liver 44 Outcomes 213

47 Intestinal Transplant Patient Survival a (N = 9) 213 Percent Survival Days After Transplantation Intestinal Transplant Graft Survival a (N = 9) 213 Percent Survival Days After Transplantation a The first case of intestinal transplant was performed in July 213. Last follow-up date was April 25, 214. a The first case of intestinal transplant was performed in July 213. Last follow-up date was April 25, 214. Intestinal Transplant Patient Survival Compared With National Benchmark 213 Percent Survival Benchmark N = 9 Source: Based on data available as of April 25, 214, released at SRTR.org Digestive Disease Institute 45

48 Nutrition The Center for Human Nutrition provides evaluation, education, and treatment for disease-related nutrition problems as well as 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 nutrition needs of critically ill, organ transplant, and severe gastrointestinal failure patients. The goals of the center include intensive diet counseling, tube feeding, and oral rehydration techniques, along with medication, growth factor therapy, and restorative surgery. To support the continuum of care, hospital to home, the Center for Human Nutrition maintains outpatient services and clinics throughout a five-county area. Significant growth in the number of patients referred for outpatient consultation was observed in 213, especially those referred from the Cleveland Clinic Employee Health Plan. Successful implementation of MyConsult, an online nutrition service, helped accommodate the increased number of outpatient referrals in 213. Nutrition Service Volume Inpatient Services Hospital parenteral nutrition patients New home total parenteral nutrition patients Small-bowel feeding tube placement consults Feeding tubes placed Home enteral nutrition patients trained Outpatient Services Center for Gut Rehabilitation and Transplantation Clinic patients Outpatient clinic consultations 16,662 16,68 17,523 Eat Right at School Program a (no. of schools) Employee health plan b consultations MyConsult Nutrition c consultations 396 a Eat Right at School was developed in 211 by members of Outpatient Nutrition Therapy in collaboration with Cleveland Clinic s Public Health and Research team. Eat Right at School provides an award to schools that meet specific nutrition criteria (reduced fat, sugar, and salt, and increased fruits, vegetables, and fiber) that surpass the current USDA National School Lunch and National School Breakfast Programs. b Cleveland Clinic Employee Health Plan participants who receive weight reduction, hyperlipidemia, diabetes, or hypertension counseling c Online nutrition consult services for employees, consumers, and corporate clients 46 Outcomes 213

49 Readmissions for New Patients Discharged on Home Parenteral Nutrition Percent N a = a Total number of new home parenteral nutrition patients Complications of Home Parenteral Nutrition-Related Readmissions Percent N c = a CRBSI = catheter-related bloodstream infection b HPN = home parenteral nutrition c Total number of new home parenteral nutrition patients CRBSI a Dehydration Other HPN b reasons Home parenteral nutrition (HPN) frequently results in hospital readmission. In 213, a 4% increase from 212 was observed in the number of patients readmitted due to complications of HPN. The most common reasons for readmissions were CRBSI and other complications including noninfectious catheter complications, electrolyte disturbances, and venous thrombosis. Nutritional Assessment of Patients With Pressure Ulcers by Degree of Malnutrition Identified (N = 44) 213 Percent Severe Malnutrition Moderate Malnutrition Mild Malnutrition No Malnutrition Identified A sample of hospitalized patients with stage 2 or greater pressure ulcers were assessed for malnourishment. Twenty-five percent of patients were not found to be malnourished, while 35% were severely malnourished, 13% moderately malnourished, and 27% mildly malnourished. Digestive Disease Institute 47

50 Large Bowel Disease Diagnostic Procedures Colonoscopy Colonoscopy is an outpatient procedure commonly used to evaluate gastrointestinal symptoms or as a screening for colorectal polyps or cancer Number Performed 28, 22, 16, 1, N = 21,465 26,397 27,925 Cecal Intubation Rate for Colonoscopy Colonoscopy Complication Rate Percent Cleveland Clinic Benchmark * Rate/1, Procedures N a = 21,465 26,397 27,925 * Benchmark: Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR; United States Multi-Society Task Force on Colorectal Cancer. Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 212 Sep;143(3): a Total number of colonoscopies 48 Outcomes 213

51 Scope Withdrawal Time for Colonoscopy a Minutes 12 9 With maneuvers No maneuvers Benchmark * N = * Benchmark: Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR; United States Multi-Society Task Force on Colorectal Cancer.Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 212 Sep;143(3): Cleveland Clinic scope withdrawal times consistently exceed the national benchmark. a In pilot endoscopy areas where withdrawal time is measured Polyp Detection Rate During Colonoscopy Percent Flexible Sigmoidoscopy Number of Procedures N a = 21,465 26,397 27,925 N = a Total number of colonoscopies Digestive Disease Institute 49

52 Large Bowel Disease Colon and Rectal Cancer Cancer of the colon and rectum is the fourth most common type of cancer in the U.S., affecting over 136, patients annually. 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, patients pathology and radiologic images are reviewed for diagnosis and clinical staging; a treatment plan is then formulated. Colon Cancer Surgical Cases Number of Surgical Cases N= Laparoscopic Open In 213, more than 2 patients underwent surgery for tumors of the colon by the Department of Colorectal Surgery. Despite increasing patient acuity (average American Society of Anesthesiology score 2.9), surgeons in the Department of Colorectal Surgery achieved a 3-day mortality rate of % and the average lymph node harvest remained almost three times higher than the 12-node minimum that has become a national benchmark for quality of surgery and pathology assessment. 5 Outcomes 213

53 Colon Cancer Postoperative Outcomes Postoperative Outcomes Open Lap a Open Lap Open Lap N = Lymph nodes harvested b (mean) ASA c score d (mean) Median length of stay (days) day readmission rate 9% % 13% 1% 12% 16% In-hospital mortality rate 1% % 2% 1% 1% % Surgical site infection rate Superficial 5% 3% 5% 4% 6% 8% Deep % % % % 1% % Organ space 6% 7% 11% 3% 9% 3% Urinary tract infection rate 2% 3% 2% 3% 6% 8% Venous thromboembolism rate 2% % 8% 5% 4% 3% a Laparoscopic b Lymph nodes harvested The American Joint Committee on Cancer (AJCC) and a 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. c American Society of Anesthesiologists d ASA 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. Digestive Disease Institute 51

54 Large Bowel Disease Disease-Free Colon Cancer Survival by Stage Percent Survival Stage 1 (N = 17) Stage 2 (N = 1514) Stage 3 (N = 1117) Stage 4 (N = 748) Months After Surgery 6 Stage-specific, 5-year disease-free survival rates for Cleveland Clinic-treated patients with colon cancer continue to exceed national averages: stage 1 = 74%, stage 2 = 59%, stage 3 = 46%, and stage 4 = 6%. Rectal Cancer Surgical Cases Achieving high-quality outcomes in patients with rectal cancer requires a committed and multidisciplinary team of specialist surgeons, medical and radiation oncologists, pathologists, and radiologists. Cleveland Clinic s Rectal Cancer Multidisciplinary Team meets weekly to construct an individualized treatment plan for each newly referred patient Number 15 1 Laparoscopic Open N = Outcomes 213

55 Rectal Cancer Postoperative Outcomes Postoperative Outcomes Open Lap a Open Lap Open Lap N = ASA b score c (mean) Median length of stay (days) day readmission rate 1% % 9% 6% 15% 3% In-hospital mortality rate % % 1% % % % Surgical site infection rate Superficial 9% % 9% % 5% 2% Deep % % 1% % % % Organ space 5% % 1% 13% 8% 4% Urinary tract infection rate 7% 5% 4% % 6% 2% Venous thromboembolism rate 4% % 2% 3% 3% 2% a Laparoscopic b American Society of Anesthesiologists c ASA 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. Digestive Disease Institute 53

56 Large Bowel Disease Disease-Free Rectal Cancer Survival by Stage Percent Survival Months After Surgery 6 Stage 1 (N = 1666) Stage 2 (N = 995) Stage 3 (N = 1348) Stage 4 (N = 6) Stage-specific, 5-year, disease-free survival rates for Cleveland Clinic-treated patients with rectal cancer continue to exceed national averages: stage 1 = 74%, stage 2 = 52%, stage 3 = 45%, and stage 4 = 6%. 54 Outcomes 213

57 Hereditary Colon Cancer The Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia was established in 28. It is staffed by a multidisciplinary team dedicated to the care of patients with or at risk for hereditary colorectal cancer syndromes. It houses the David G. Jagelman Inherited Colon Cancer Registries, which were established in The mission of the Jagelman Registry and the Weiss Center is to prevent death from colorectal cancer or cancer of other organs involved in these syndromes by excellent patient care, effective education, and clinically relevant research. Weiss Center Registry Families Enrolled for Familial Adenomatous Polyposis and Hereditary Nonpolyposis Colorectal Cancer Cumulative Number N = The Weiss Center and the Digestive Disease Institute conduct multidisciplinary clinics that care for patients who are at high risk for developing colorectal and other cancers due to their syndromes. Specialties staffing the clinics include gastroenterology for evaluation of the stomach and small intestine, gynecology for uterine and ovarian screening, endocrinology for thyroid evaluation, urology for screening of the urinary tract, and dermatology for potential skin neoplasms. Biweekly clinics are held for patients with familial adenomatous polyposis and other polyposis syndromes, and monthly clinics for patients and families with hereditary nonpolyposis colorectal cancer. Digestive Disease Institute 55

58 Large Bowel Disease Consults Conducted on Enrolled Weiss Center Patients Number of Consults Gastroenterology Consult Surgical Consult N = Procedures Performed on Weiss Center Registry Patients Number of Procedures Thyroid/Renal Ultrasound EGD Sigmoidoscopy Colonoscopy N = Outcomes 213

59 Families Treated by the Weiss Center for Less Common Polyposis Syndromes (N = 1287) 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, MYHassociated polyposis, and serrated polyposis syndrome Number Treated 2 15 Peutz-Jeghers syndrome Juvenile polyposis syndrome MYH-associated polyposis Other a Serrated polyposis syndrome a Includes Cowden syndrome, Cronkhite-Canada syndrome, and oligopolyposis Digestive Disease Institute 57

60 Large Bowel Disease Genetic Counseling Cleveland Clinic is committed to identifying patients who may have Lynch syndrome by a routine screening process of patient tissues. Lynch syndrome, often called hereditary nonpolyposis colorectal cancer (HNPCC), is an inherited condition that causes an increased risk for colorectal cancer, endometrial cancer, stomach cancer, ovarian cancer, and cancer in certain other organs. The Digestive Disease Institute, Genomic Medicine Institute, Pathology and Laboratory Medicine Institute, and Ob/Gyn & Women s Health Institute have collaborated to screen all colorectal and endometrial cancers that are surgically removed at Cleveland Clinic for Lynch syndrome. Cleveland Clinic has been testing for Lynch syndrome since patients surgically resected colorectal cancer screened by MSI/IHC a 45 patients did not require further evaluation 25 patients required further evaluation for Lynch syndrome 12 patients did not have genetic counseling 13 patients underwent genetic counseling Five patients had no significant findings Eight patients b were found to have Lynch syndrome a microsatellite instability/immunohistochemistry b On average, each of these patients has three relatives who will also have Lynch syndrome. 58 Outcomes 213

61 Ulcerative Colitis Cleveland Clinic is a referral center for patients diagnosed with ulcerative colitis. Minimally invasive laparoscopic surgical approaches, J pouches, and salvaging problematic J pouches are available for those patients requiring surgery. Surgical Management of Ulcerative Colitis Number of Procedures 4 3 Laparoscopic Open N = Ulcerative Colitis Postoperative Outcomes Postoperative Outcomes Open Lap a Open Lap Open Lap N = Median length of stay (days) day readmission rate 14% 2% 14% 11% 14% 21% In-hospital mortality rate % % % % % % Surgical site infection rates Superficial 7% 5% 5% 6% 4% 7% Deep % % % % % % Organ space 5% 13% 9% 8% 5% 6% Urinary tract infection rate 3% 4% 3% 2% 5% 3% Venous thromboembolism rate 3% 2% 4% 7% 3% 6% a laparoscopic Collaborative efforts to enhance quality have resulted in consistently low surgical site infection and readmission rates. Digestive Disease Institute 59

62 Large Bowel Disease Center for Ileal Pouch Disorders The Ileal Pouch Center is the world s first and largest multidisciplinary pouch center and sees more than 12 patients each year. Pouch disorders are classified and managed based on the following categories: Surgical/mechanical Inflammatory/infectious Functional Neoplastic Systemic/metabolic Cleveland Clinic is one of the highest volume centers in the US for ileal J pouch surgery in the treatment of ulcerative colitis and familial adenomatous polyposis. For more than 3 decades, Cleveland Clinic has offered restorative proctocolectomy with ileal J pouch surgery as an alternative to permanent stoma, with successful outcomes and improved quality of life for thousands of patients. The Center for Ileal Pouch Disorders is a major referral center for dysfunctional ileal J pouches. It was the first of its kind established to treat pouch disorders and remains on the cutting edge in new approaches to the management of pouch complications. Surgical Pouch Construction 213 Number of Procedures N = Outcomes 213

63 Complete Healing Rate of Pouch Sinus Using Endoscopic Needle Knife Therapy Cleveland Clinic gastroenterologists have developed a novel needle knife technique to treat pouch complications such as the formation of sinuses, anastomotic leaks, and chronic abscesses. The technique uses a Doppler-ultrasound needle knife to perform sinusotomy to drain the sinus cavity and is a less invasive alternative to multistage surgical intervention. The Digestive Disease Institute is the only medical center in the US that treats pouch sinus using this technique Percent N a = a Total number of endoscopic needle-knife procedures Pouchoscopy A pouchoscopy is an endoscopic exam performed on patients who have undergone a total proctocolectomy with ileal pouch anal anastomosis. It is recommended that this be done annually to examine and biopsy the pouch (small bowel) and the anal transitional zone to rule out dysplasia. The exam can also reveal other problems, such as pouchitis, polyps, and ischemia, while allowing patients to continue their healthy living with a pouch Number of Procedures N = Digestive Disease Institute 61

64 Large Bowel Disease Diverticulitis Diverticulitis is a condition resulting from inflammation and infection in one 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 that were completed via a minimally invasive laparoscopic approach increased over the past 3 years. The colorectal department has a national and international referral base particularly for highly complex cases. Surgical Management of Diverticulitis Number of Surgeries Laparoscopic Open N = Outcomes 213

65 Diverticulitis Postoperative Outcomes Postoperative Outcomes Open Lap a Open Lap Open Lap N = Median length of stay (days) day readmission rate 17% 13% 11% 13% 15% 8% In-hospital mortality rate 4% % % % 3% % Surgical site infection rates Superficial 9% 4% 7% 4% 16% 5 Deep 1% % % 1% % % Organ space 5% 3% 7% 14% 11% 3% Urinary tract infection rate 3% 3% 7% 1% 6% 2% Venous thromboembolism rate 4% 6% 3% 3% 1% 1% a laparoscopic Digestive Disease Institute 63

66 Large Bowel Disease Stoma Therapy Some bowel diversion/ostomy surgeries divert the bowel to an opening in the abdomen where a stoma is created. Cleveland Clinic s R.B. Turnbull, Jr., MD, Wound, Ostomy, Continence Nursing (WOCN) Program was established as the first WOCN school in the world 5 years ago. The program prepares nurses to: Manage ostomies pre- and postoperatively Prevent and treat pressure ulcers, fistula, and other skin disorders Care for patients with urinary and fecal incontinence 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 boardcertified by their professional organization and care for patients each day in the inpatient setting and outpatient clinic. Total Inpatient and Outpatient Visits 213 Number of Patient Visits 12, Inpatient Outpatient N = 11, More than 3 WOCN specialists have graduated from the program and are practicing throughout the world. 64 Outcomes 213

67 Pelvic Floor Disorders The pelvic floor team is a multidisciplinary group of physicians with an emphasis 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 fistulae, 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. Sacral Nerve Stimulation Sacral nerve stimulation (SNS) is FDA-approved for the treatment of fecal incontinence, which in some patients may be impossible to control medically. This involves stimulation of the sacral nerves (S3 nerve root) and implantation of a pacemaker. Patients undergoing SNS at Cleveland Clinic are asked to complete preoperative and postoperative evaluations that assess a variety of patient-reported outcomes. Stage 1 and Stage 2 Sacral Nerve Stimulation Number of Patients Stage 1 Stage 2 a N = a Two patients were ineligible to progress on to stage 2. Stage 1 (the testing phase) is designed to determine if SNS treatment will improve symptoms. The test period may be as long as 3 weeks. If symptoms decrease by at least 5% during that time, patients may be considered ineligible to progress on to stage 2 permanent device implantation. Digestive Disease Institute 65

68 Large Bowel Disease Fecal Incontinence Severity Index Pre- and Postsacral Nerve Stimulation The Fecal Incontinence Severity Index (FISI) measures severity of incontinence by type and frequency of leakage and is assessed before and after (6 months 1 year) sacral nerve stimulation (SNS) surgery. FISI scores range from 61, with higher scores indicating more severe incontinence Mean FISI Score Pre SNS Post SNS N = Global Impression of Change After Sacral Nerve Stimulation a The Patient s Global Impression of Change (PGIC) is a single-item, self-reported question that assesses quality of life (QOL). Scores range from 7, with indicating no improvement and 7 indicating significant improvement in QOL Number of Patients Significantly Improved Somewhat Improved N = a PGIC scores of 5 7 = significantly improved; 3 4 = somewhat improved; 2 = limited to no improvement. Limited to No Improvement Therapeutic Improvement of Bowel Control After Sacral Nerve Stimulation a (N = 11) Percent of Patients Improvement No Improvement Complete continence achieved Therapeutic improvement No improvement Condition worsened a Therapeutic improvement of bowel control is defined as a decrease in bowel movements by more than 5%. It is measured by patient bowel diaries and the Fecal Incontinence Severity Index. 66 Outcomes 213

69 Ventral Rectopexy Ventral rectopexy (VR) is a procedure to correct internal and external rectal prolapse. VR is technically challenging, and even in expert hands, is not without complications. Ventral Rectopexy by Procedure Type Number of Procedures Robotic Lap a Open Converted b a laparoscopic b converted from laparoscopic/robotic to open procedures N = Complications of Ventral Rectopexy Number of Complications SBO a Ileus Respiratory Wound Urinary UTI b Other None N = a small bowel obstruction b urinary tract infection Digestive Disease Institute 67

70 Trauma and Acute General Surgery The Acute Care Surgery (ACS) Program provides coverage for acute general surgery and trauma at Cleveland Clinic main campus and at Hillcrest Hospital. The trauma service is a member of the Northeastern Ohio Trauma System. Created in 21, NOTS is a partnership between Cleveland Clinic health system and MetroHealth Medical Center, which provides integrated trauma care to the citizens of northeast Ohio. Since its inception, the collaboration has proven successful in controlling length-of-stay and mortality rates. Trauma Cases and Mean Length of Stay 213 Degree of Injury Hillcrest Hospital Mean Length Northeastern Ohio Mean Length N (%) of Stay Trauma System of Stay (Days) N (%) (Days) No injuries or noncodeable 99 (5.3%) (2.61%) 2.12 Minor (ISS a 1 9) 1538 (81.7%) (68.7%) 2.54 Moderate (ISS 1 15) 129 (6.9%) (13.9%) 4.82 Severe (ISS 16 24) 77 (4.1%) (9.%) 6.23 Critical (ISS 25) 4 (2.1%) (5.8%) 7.34 Total/mean 1883 (1%) (1%) 4.61 a Injury Severity Score 68 Outcomes 213

71 APR-DRG Severity of Illness at Admission a October 211 September 213 Percent N = Minor Moderate Major Extreme In 213, the ACS team was involved in the care of more than 12 patients. Most presented with moderate to major severity of illness. a APR-DRG severity of illness at admission is defined as the extent of physiologic decompensation or loss of organ system function. 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 Observed and Expected In-Hospital Mortality a October 21 September 213 Percent Observed Expected Despite severity of illness, patients actual mortality rate was substantially less than the expected rate based on presenting condition. N = a Expected mortality was determined using UHC risk-adjustment methodology. Source: These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Digestive Disease Institute 69

72 Pancreaticobiliary Disease Diagnostic Procedures Endoscopic Retrograde Cholangiopancreatography: Adult and Pediatric Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose and treat disorders of the bile and pancreatic ducts Number of Procedures N = ERCP: Pediatric Number of Procedures N = Post-ERCP Acute Pancreatitis: Adult and Pediatric Percent N = Outcomes 213

73 Pancreatic Stent Placement Placement of a prophylactic pancreatic duct stent in highrisk patients has been shown to reduce the risk for post- ERCP pancreatitis. The graph shows the percentage of ERCPs where a stent was placed Percent Cholangioscopy Cholangioscopy is a minimally invasive endoscopic method used for both direct visual diagnostic evaluation and simultaneous therapeutic intervention of the bile ducts. It is performed at the time of ERCP Number of Procedures N = N = Endoscopic Ultrasound Endoscopic ultrasound (EUS) is increasingly used to visualize details of abdominal and esophageal structures including lymph nodes, layers of the GI tract, and vessels. EUS can be used to facilitate biopsies of areas that are inaccessible percutaneously Number of Procedures N = Digestive Disease Institute 71

74 Pancreaticobiliary Disease Management of Gallbladder Disease Cholecystectomy 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 Number of Procedures 2 15 Open Laparoscopic N = Acute Cholecystitis Therapeutic Procedures Most patients with acute cholecystitis respond to conservative treatment and return for elective cholecystectomy at a later date. For the patients who do not respond to conservative treatment, the therapeutic options are urgent cholecystectomy, open or laparoscopic, or percutaneous aspiration of the gallbladder Number of Procedures Percutaneous aspiration Open cholecystectomy Laparoscopic cholecystectomy N = Outcomes 213

75 Median Length of Stay: Open and Laparoscopic Cholecystectomy for Acute Cholecystitis Days 1 8 Open Laparoscopic N = Day Readmission Rate: Open and Laparoscopic Cholecystectomy for Acute Cholecystitis Percent 25 2 Open Laparoscopic N = Day Mortality Rate: Open and Laparoscopic Cholecystectomy for Acute Cholecystitis (N) 212 (N) 213 (N) Open (%/N) % (/28) 3.7% (1/27) 4.5% (1/22) Laparoscopic (%/N) % (/65) 2.6% (2/76) 2.2% (2/91) Digestive Disease Institute 73

76 Pancreaticobiliary Disease Management of Pancreatic Disease Cleveland Clinic s Pancreas Disorder Clinic cares for patients with a spectrum of disease, both benign and malignant, and offers multidisciplinary care teams for pancreatic cancer and chronic pancreatitis. Pancreatectomy Procedures Several types of pancreatectomies are performed including pancreaticoduodenectomy (Whipple procedure), distal pancreatectomy, segmental pancreatectomy, and total pancreatectomy Number of Procedures Open Whipple Laparoscopic distal pancreatectomy Open distal pancreatectomy Laparoscopic/ robotic Whipple Total pancreatectomy N = Outcomes 213

77 Median Length of Stay: Pancreatectomy Procedures Days Open Whipple Laparoscopic distal pancreatectomy Open distal pancreatectomy Laparoscopic/ robotic Whipple Total pancreatectomy N = Day Readmission Rate: Pancreatectomy Procedures Percent N = Digestive Disease Institute 75

78 Liver Disease and Liver Transplant Diagnostic Procedures Liver Biopsies Liver biopsy is an important tool in the diagnosis and management of liver diseases Number of Biopsies 2 15 Outpatient Inpatient N = Severe Adverse Events Following Outpatient Liver Biopsy (N = 2984) The overall frequency of severe adverse events (SAEs) during outpatient liver biopsies was.8% (24 of 2984). This complication rate compares very favorably with the reported frequency of these events in the medical literature Type of SAE Number of SAEs SAE Rate Bleeding a 9.3% Severe pain 12.4% Hypotension 2.7% Pneumothorax 1.3% Total SAEs 24.8% a Includes hemoperitoneum (4), subcapsular hematoma (2), hemobilia (3) 1 Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD; American Association for the Study of Liver Diseases. Liver biopsy. Hepatology. 29 Mar;49(3): Outcomes 213

79 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 Number of Patients N = Paracentesis Patients Treated With Albumin Paracentesis patients receive intravenous albumin after large volume paracentesis (> 5 L) (8 g albumin/l of ascites removed) Number of Patients N = From , more than half of patients (55.5%) who underwent paracentesis received intravenous albumin therapy. Digestive Disease Institute 77

80 Liver Disease and Liver Transplant Spontaneous Bacterial Peritonitis Patients with community-acquired spontaneous bacterial peritonitis (SBP) have outpatient paracentesis with an ascitic fluid neutrophil count > 25 cells/mm 3. The prevalence of SBP in outpatients with ascites evaluated at Cleveland Clinic between 211 and 213 was 1.3%. This compares with previous reports of SBP in outpatients with ascites of 1.5% to 3.5% Percent 3 2 a Total number of patients with community-acquired SBP Evans LT, Kim WR, Poterucha JJ, Kamath PS. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology. 23 Apr;37(4): N a = 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. 78 Outcomes 213

81 Transjugular Intrahepatic Portosystemic Shunt Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat portal hypertension-related complications, such as bleeding esophageal 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. TIPS Procedures Admissions or Readmissions Within 3 Days of TIPS Number of Patients Percent N = N a = a Total number of patients with community-acquired SBP Indications for TIPS Number of Patients 6 4 Hepatic hydrothorax Ascites Variceal bleeding N = Digestive Disease Institute 79

82 Liver Disease and Liver Transplant Hepatology Service Cleveland Clinic has a very active inpatient and outpatient hepatology practice. Both inpatient and outpatient practices have continued to grow in recent years. Total Inpatient Visits Number of Patients Patients Transferred From Outside Institutions Percent N = N = Inpatient Consults Number of Patients N = Total Outpatient Visits Number of Patients N = Outcomes 213

83 Nonalcoholic Fatty Liver Disease The Fatty Liver Disease Clinic offers a specialized and multidisciplinary approach to care for patients with this common metabolic liver disease. Patients Treated for Nonalcoholic Fatty Liver Disease Number of Patients 6 4 Established New N = To the left is an illustration of a fatty liver that appears large and yellow in color with swollen, round edges. Digestive Disease Institute 81

84 Liver Disease and Liver Transplant Treatment Options The clinic has provided patients the opportunity to participate in multicentered clinical trials as part of the Nonalcoholic Steatohepatitis (NASH) Clinical Research Network funded by the NIH. Pioglitazone or Vitamin E for NASH Clinical Study Vitamin E 4 IU orally twice daily was associated with a significantly higher rate of improvement in NASH compared with placebo. There was no difference in progression of fibrosis among the study groups. 1 Outcome Vitamin E (N = 84) Placebo (N = 83) P Value NASH improvement 43% 19%.5 (via biopsy) 1 Sanyal AJ, Chalasani N, Kowdley KV, McCullough A, Diehl AM, Bass NM, Neuschwander-Tetri BA, Lavine JE, Tonascia J, Unalp A, Van Natta M, Clark J, Brunt EM, Kleiner DE, Hoofnagle JH, Robuck PR; NASH CRN. Pioglitazone, vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med. 21 May 6;362(18): Pentoxifylline for the Treatment of NASH Clinical Study Pentoxifylline 4 mg three times a day was associated with improved NASH histological scores in comparison with placebo. Although not statistically significant (P =.17), improvement in fibrosis was observed in a greater proportion of pentoxifylline-treated patients (35%) compared with placebo (15%). 1 Outcome Placebo (N = 29) Pentoxifylline (N = 26) P Value NASH score 15% 5% <.1 Fibrosis score 15% 35%.17 1 Zein CO, Yerian LM, Gogate P, Lopez R, Kirwan JP, Feldstein AE, McCullough AJ. Pentoxifylline improves nonalcoholic steatohepatitis: a randomized placebo-controlled trial. Hepatology. 211 Nov;54(5): Outcomes 213

85 Omega-3 Fatty Acids for the Treatment of NASH Patients With Diabetes Clinical Study (N=37) Polyunsaturated fatty acids (PUFA) provided no benefit over placebo in NASH patients with diabetes. The effects of PUFA on histology and insulin resistance were worse than placebo. These data provide no support for PUFA supplements in NASH Unit Change PUFA.5 Placebo Steatosis Inflammation Ballooning Fibrosis NAS a a NAS includes those patients with a diagnosis of NASH and a nonalcoholic fatty liver disease with an activity score > 4 on liver biopsy performed within 6 months of entry into the study. 1 Dasarathy S, Dasarathy J, Khiyami A, Yerian L, Hawkins C, Sargent R, McCullough AJ. Double-blind randomized placebocontrolled clinical trial of omega 3 fatty acids for the treatment of diabetic patients with nonalcoholic steatohepatitis. J Clin Gastroenterol. 214 Feb 27. [Epub ahead of print] Digestive Disease Institute 83

86 Liver Disease and Liver Transplant Pediatric Fatty Liver Disease Clinic The Be Well Kids Clinic provides multidisciplinary care for pediatric patients with a body mass index (BMI) > 85th percentile. In 213, 21 children were evaluated, of which 35% had fatty liver disease based on alanine transaminase elevation or increased echogenicity on liver ultrasound. Researchers are trying to identify biomarkers to noninvasively diagnose nonalcoholic fatty liver disease (NAFLD). A recent study investigated the association of breath volatile organic compounds with the diagnosis of NAFLD in children. Breath Volatile Organic Compounds as a Noninvasive Tool to Diagnose NAFLD in Children Clinical Study This study showed that different concentrations of chemicals were found in the breath of obese children with fatty liver disease compared with those without the condition. 1 Mean Volatile Organic Compound Levels (Adjusted for Race, Metabolic Syndrome, and ALT a ) Factor No Fatty Liver (N = 23) Fatty Liver (N = 37) P Value Acetaldehyde 26. (21.4, 31.6) 35.1 (29.4, 41.8).34 Acetone 36.9 (26.3, 51.9) 71.7 (52.8, 97.6).8 Isoprene 8.9 (6.6, 12.) 14.7 (11.2, 19.2).22 Pentane 8.8 (7.4, 1.6) 13.3 (11.3, 15.6).2 Trimethylamine 3.2 (2.6, 3.9) 5. (4.2, 6.).3 a alanine aminotransferase 1 Alkhouri N, Cikach F, Eng K, Moses J, Patel N, Yan C, Hanouneh I, Grove D, Lopez R, Dweik R. Analysis of breath volatile organic compounds as a noninvasive tool to diagnose nonalcoholic fatty liver disease in children. Eur J Gastroenterol Hepatol. 214 Jan;26(1): Outcomes 213

87 Hepatitis C There are 3, new cases of hepatitis C virus (HCV) in the US each year. It is the leading reason for liver transplantation. HCV Patients Treated With Antiviral Medications In 213 there was a significant reduction in the number of patients treated with antiviral medications. This reflects a practice change to reserve treatment while waiting for approval of more novel and effective therapies that were expected in December Number of Patients N = Sustained Virologic Response in Patients With and Without Cirrhosis Percent No Cirrhosis Cirrhosis N = HCV-treated patients (N = 282) had a liver biopsy or had clinical or radiologic evidence of cirrhosis prior to treatment. Approximately 42% of treated patients had cirrhosis. As expected, the sustained virologic response was better in patients without cirrhosis (54%) than in patients with cirrhosis (34%). Digestive Disease Institute 85

88 Liver Disease and Liver Transplant Sustained Virologic Response by Genotype for Nontransplant Patients The success of hepatitis C treatment is defined as an undetectable HCV viral load 6 months after completing a course of treatment, a sustained virologic response Percent All Genotypes Genotype 1 Genotype 2, 3, 4 N = Sustained Virologic Response by Genotype for Transplant Patients Percent All Genotypes Genotype 1 Genotype 2, 3, 4 N = Patients were treated with either combination therapy (peginterferon and ribavirin) or triple therapy (peginterferon, ribavirin, and protease inhibitors). 86 Outcomes 213

89 Sustained Virologic Response by Genotype 1 for Nontransplant Patients Treated With Triple Therapy Percent No Yes Triple Therapy N = Approximately 47% of nontransplant genotype 1 HCV patients (N = 27) treated with triple therapy (peginterferon, ribavirin, and protease inhibitors) achieved sustained virologic response. Sustained Virologic Response by Genotype 1 for Transplanted Patients Treated With Triple Therapy In May 211, the US Food and Drug Administration approved boceprevir and telaprevir (protease inhibitors) as add-on treatments to standard therapy with interferon and ribavirin for adult patients with genotype 1. Because of drug interactions with antirejection medications, universal use of protease inhibitors is not recommended in liver transplant recipients. Due to the complexity of the regimen and the need for close monitoring, a treatment protocol was developed at Cleveland Clinic to treat selected patients with clinically significant HCV recurrence after liver transplantation Percent No Yes Triple Therapy N = 2 12 Fifty percent of transplanted genotype 1 HCV patients treated with triple therapy (peginterferon, ribavirin, and protease inhibitors) achieved sustained virologic response. Digestive Disease Institute 87

90 Liver Disease and Liver Transplant Rifaximin Therapy and Liver Disease Complications Cleveland Clinic researchers conducted an observational study that reviewed the medical records of 44 adult patients (23 27) with cirrhosis and ascites justifying paracentesis. The study found that there was a 72% reduction in the rate of spontaneous bacterial peritonitis (SBP) among cirrhotic patients with ascites who were treated with rifaximin. 1 Rifaximin intestinal decontamination may also have a role in preventing other serious liver disease complications. Role of Rifaximin in the Primary Prophylaxis of Spontaneous Bacterial Peritonitis in Patients With Liver Cirrhosis SBP-Free (%) Rifaximin (N = 49) No rifaximin (N = 355) 12 9% ± 6% (19) 64% ± 3% (83) Months After Paracentesis 76% ± 11% (9) 55% ± 4% (49) 76% ± 11% (7) 48% ± 5% (29) 76% ± 11% (1) 47% ± 5% (11) NA 37% ± 7% (6) Rifaximin No rifaximin P Value =.1 1 Hanouneh MA, Hanouneh IA, Hashash JG, Law R, Esfeh JM, Lopez R, Hazratjee N, Smith T, Zein NN. The role of rifaximin in the primary prophylaxis of spontaneous bacterial peritonitis in patients with liver cirrhosis. J Clin Gastroenterol. 212 Sep;46(8): Outcomes 213

91 Celiac Disease in Patients With Cirrhosis Although considered primarily a malabsorptive disorder affecting the small bowel mucosa, celiac disease can be associated with damage to other organ systems including the liver. The prevalence of celiac disease in the cirrhotic population is not known. A recent prospective Cleveland Clinic study of patients with cirrhosis who received a screening upper endoscopy, human leukocyte antigen (HLA) typing, and celiac serological testing found that celiac disease was more than twice (2.5%) as common in patients with cirrhosis as in the general population. Treatment with a gluten-free diet resulted in improved liver function. 1 Additionally, the current criteria for diagnosing celiac disease requires a small bowel biopsy in patients who have abnormal levels of of human tissue transglutaminase (httg)> 2 IU/mL. The study found that httg > 118 IU is highly specific (98%) and can be used to diagnose celiac disease in patients who are not willing or are unable to have an upper endoscopy and a small bowel biopsy. This finding can help clinicians determine when celiac disease is present with a specific laboratory measure that may improve the diagnosis of celiac disease without the additional delay and costs of an upper endoscopy. 1 Prevalence of Celiac Disease Higher httg Cutoff Improved Specificity for Diagnosis of Celiac Disease Percent General Population Patients With Cirrhosis a N = Sensitivity TTG a > 2.4 TTG > Specificity.8 1. a Cleveland Clinic patients with cirrhosis from January 28 to November 212. a tissue transglutaminase 1 Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH, Guandalini S, Hill ID, Pietzak M, Ventura A, Thorpe M, Kryszak D, Fornaroli F, Wasserman SS, Murray JA, Horvath K. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 23 Feb 1;163(3): Digestive Disease Institute 89

92 Liver Disease and Liver Transplant Liver Tumor Clinic Cleveland Clinic s Liver Tumor Clinic uses a multidisciplinary approach to treat liver tumors, both benign and malignant. Treatment options include surgical resection (open, laparoscopic, and robotic) and nonsurgical treatment (chemoembolization, TheraSphere, radiofrequency ablation). The team includes medical and radiation oncologists, interventional radiologists, hepatologists, and transplant/hepatobiliary surgeons. Patients, New and Established Median Number of Days From Initial Visit to Intervention Number of Patients Established New Days N = N = Liver Malignancies Number of Malignancies Cholangiocarcinoma HCC a Metastatic liver tumor N = a hepatocellular carcinoma 9 Outcomes 213

93 Benign Liver Tumors Number of Benign Tumors 3 2 Cyst Hemangioma Adenoma FNH a N = a focal nodular hyperplasia CT scan shows a 2 cm hepatoma in the center of the liver (arrows). CT scan is the image of the liver post liver resection. Digestive Disease Institute 91

94 Liver Disease and Liver Transplant Liver Tumor Treatment Options Number of Cases 4 3 No treatment Surgical Nonsurgical N = Liver Tumor Surgical Procedures Number of Procedures Open Laparoscopic resection Laparoscopic RFA a Robotic N = a radiofrequency ablation 92 Outcomes 213

95 Liver Resections Number of Resections Left hepatectomy Right hepatectomy Segmentectomy Nonanatomic liver resection N = Liver Resection: Median Length of Stay Liver Resection: 3-Day Readmission Rate Days Percent N a = N a = a Data not available for all patients who underwent liver resection. a Data not available for all patients who underwent liver resection. Digestive Disease Institute 93

96 Liver Disease and Liver Transplant Recurrence of Malignant Tumors and Survival Following Laparoscopic Liver Resection for Various Tumor Types (N = 111) Type of Tumor Colorectal Hepatocellular Neuroendocrine Other a N Recurrence (%) a Breast (N = 3), cholangiocarcinoma (N = 3), renal (N = 2), sarcoma (N = 1), gastrointestinal stromal tumor (N = 1), ovary (N = 1), melanoma (N = 1), urothelial (N = 1), paraganglioma (N = 1), primary unknown (N = 1) Type of Tumor Neuroendocrine Hepatocellular Colorectal Other a Five-Year Disease-Free Survival (%) Five-Year Overall Survival (%) a Breast, cholangiocarcinoma, sarcoma, gastrointestinal tumor, ovary, melanoma, renal, urothelial, paraganglioma, primary unknown 94 Outcomes 213

97 Liver Tumor Nonsurgical Procedures Number of Procedures TheraSphere Transcatheter arterial chemoembolization Bland embolization Systemic inflammatory response syndrome Radiofrequency ablation N = Digestive Disease Institute 95

98 Liver Disease and Liver Transplant Liver Transplant Cleveland Clinic performed its first adult liver transplant on Nov. 8, 1984, and has completed 1962 liver transplants to date, including 1874 liver transplants alone and 87 multiorgan transplants: 7 liver/kidney, five liver/heart, four liver/lung, four liver/pancreas, and four liver/intestine/pancreas. Patients Referred, Evaluated, and Listed Number of Patients N = Referred Evaluated Listed Liver Transplantation Number of Transplants N = Patient Removals From the Wait List Number of Patients N = a includes all removals for reasons other than death and transplantation b patient deaths while on the liver transplant wait list Removals a Deaths b 96 Outcomes 213

99 Median Time to Transplant a Months Cleveland Clinic National median wait time N = Candidates wait-listed at Cleveland Clinic for a liver transplant are transplanted more than 8 months faster than the national median wait time. a Time determined by number on wait list at the start of each year Source: Scientific Registry of Transplant Recipients (SRTR). srtr.org Transplant Rate for Patients Waiting for Liver Transplantation 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, transplant, 6 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 Months Observed a Expected a Observed rates for 211 and 212 were both statistically significantly higher than the expected rate (P <.1). Source: Scientific Registry of Transplant Recipients (SRTR). srtr.org N = Digestive Disease Institute 97

100 Liver Disease and Liver Transplant Patient Survival Observed survival greater than the national average and greater than expected was seen in 213. One-Year Adult Patient Survival Three-Year Adult Patient Survival Percent 1 9 Observed Expected National average Percent Observed Expected National average N = N = Source: Scientific Registry of Transplant Recipients (SRTR). srtr.org Source: Scientific Registry of Transplant Recipients (SRTR). srtr.org Graft Survival One-Year Adult Graft Survival Three-Year Adult Graft Survival Percent 1 9 Observed Expected National average Percent Observed Expected National average N = N = Source: Scientific Registry of Transplant Recipients (SRTR). srtr.org Source: Scientific Registry of Transplant Recipients (SRTR). srtr.org 98 Outcomes 213

101 Donor Organs Transplanted The majority of organs utilized are standard organs donated after brain death. Other organ types used include organs donated after cardiac death, split liver grafts, and living donor grafts, which significantly expands the number of transplants performed annually Number of Transplants 15 1 Living donor Split donor DCD a DBD b 5 N = a donation after cardiac death b donation after brain death Donation After Cardiac Death Transplants Number of Transplants N = Digestive Disease Institute 99

102 Liver Disease and Liver Transplant Donation After Cardiac Death Patient Population and Biliary Stricture Rate (N = 81) The most significant problem with the use of DCD donors is increased rates of primary nonfunction and ischemic type biliary strictures. Due to better understanding of the recovery process, shorter cold ischemia time and greater use of tissue plasminogen activator, our biliary stricture rate (1.35% primary nonfunction and 3.7% ischemic type) is significantly less than the 9% to 33% 1 stricture rate that is reported in the literature Age (Years) MELD a Score Donor Age Cold Ischemia Warm Ischemia Primary Ischemic Type Time (Minutes) Time (Minutes) Nonfunction Biliary Stricture Biliary Stricture Rate Rate 57 ± 9 22 ± 6 39 ± ± ± % (1/74) 3.7% (3/81) a Model for End-Stage Liver Disease 1 DeOliveira ML, Jassem W, Valente R, Khorsandi SE, Santori G, Prachalias A, Srinivasan P, Rela M, Heaton N. Biliary complications after liver transplantation using grafts from donors after cardiac death: results from a matched control study in a single large volume center. Ann Surg. 211 Nov;254(5): Outcomes 213

103 Living Donor Transplants Number of Transplants N = Right lobe Left lobe Combined Liver/Kidney Transplants Number of Transplants N = Split Liver Transplants Number of Transplants Right lobe Left lobe N = Digestive Disease Institute 11

104 Liver Disease and Liver Transplant Patient Survival One-Year Patient Survival: Adult Primary Liver Transplant Only a Survival (%) DBD b (N = 253) DCD c (N = 47) Living donor (N = 2) Split (N = 24) Days After Transplantation a Scientific Registry of Transplant Recipients (SRTS) National Average for 1-Year Patient Survival = 9.18%. srtr.org b donation after brain death c donation after cardiac death Three-Year Patient Survival: Adult Primary Liver Transplant Only a Survival (%) a Scientific Registry of Transplant Recipients (SRTS) National Average for 3-Year Patient Survival = 8.8%. srtr.org b donation after brain death c donation after cardiac death DBD b (N = 253) DCD c (N = 47) Living donor (N = 2) Split (N = 24) Days After Transplantation 12 Outcomes 213

105 Graft Survival One-Year Graft Survival: Adult Primary Liver Transplant Only a Survival (%) DBD b (N = 253) DCD c (N = 47) Living donor (N = 2) Split (N = 24) Days After Transplantation a Scientific Registry of Transplant Recipients (SRTS) National Average for 1-Year Graft Survival = 87.62%. srtr.org b donation after brain death c donation after cardiac death Three-Year Graft Survival: Adult Primary Liver Transplant Only a Survival (%) Days After Transplantation a Scientific Registry of Transplant Recipients (SRTS) National Average for 3-Year Graft Survival = 76.48%. srtr.org b donation after brain death c donation after cardiac death DBD b (N = 253) DCD c (N = 47) Living donor (N = 2) Split (N = 24) Digestive Disease Institute 13

106 Liver Disease and Liver Transplant Liver Transplant Mean Length of Stay Cleveland Clinic s liver transplant team started a project to streamline the postoperative clinical care pathways in 21 that resulted in an immediate reduction in length of stay (LOS) from 16.9 days in 29 to 12 days in 21. The reduction in LOS was sustained in 211 and 212, and the Model for End-Stage Liver Disease (MELD) score remained stable, ranging from In 213 the mean MELD score increased from 19 to 26, and the mean LOS increased to 14.5 days. In 213, 1 patients had LOS > 3 days Days 18 MELD Score a Data not available for all liver transplant patients. N a = Day Liver Transplant Readmission Rate Monthly monitoring and review of readmissions has resulted in a reduction in the rate of readmissions from 5% in 21 to 3% in Percent a Data not available for all liver transplant patients. N a = Outcomes 213

107 Management of Postoperative Pain HCAHPS Survey for Liver Transplant Pain Management Pain management is difficult in the transplant population. A multidisciplinary team of surgeons, physician assistants, nurses, and a transplant pharmacist developed a pain protocol for liver transplant patients in 211. Based on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, there was an overall improvement in pain scores from 211 to Percent Best Response (Always) a Pain control b Pain management c Pain management domain d Benchmark N= a Response options: Always, Usually, Sometimes, Never b During this hospital stay, how often was your pain well controlled? c During this hospital stay, how often did the hospital staff do everything they could to control your pain? d Percentage of patients responding Always to both questions is averaged together Digestive Disease Institute 15

108 Liver Disease and Liver Transplant Liver Transplant for Hepatocellular Carcinoma Hepatocellular carcinoma (HCC) is the fifth most common cancer in men and the seventh 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. Liver Transplants for All Patients With Hepatocellular Carcinoma Patients With Hepatocellular Carcinoma Within and Beyond Milan Criteria Number of Transplants 6 4 Number of Patients 6 4 Beyond Milan Within Milan N = N = Adjuvant Therapies Prior to Transplantation a Patients are treated prior to transplant with the goal of downstaging or controlling cancer growth. Criteria for adjuvant treatment prior to transplant includes a single tumor 3 cm; two lesions < 2.5 cm each; two lesions either one > 2.5 cm; or α-fetoprotein > 1 ng/ml Number of Therapies Embolization: TACE b /bland Combined therapies c RFA Y-9 a In 212, there was one resection. b Transarterial chemoembolization c Combined therapies can include any combination of radiofrequency ablation (RFA), Y-9, or embolization. N = Outcomes 213

109 Three-Year Patient Survival: Within and Beyond Milan Criteria Survival (%) 1 Three-Year Graft Survival: Within and Beyond Milan Criteria Survival (%) Within Milan (N = 14) Beyond Milan (N = 31) Within Milan (N = 14) Beyond Milan (N = 31) Days After Transplantation Days After Transplantation Recurrence Outcomes, Within and Beyond Milan Criteria a Not applicable Recurrence rate (%) Within Milan criteria (N) % (/23) 11% (3/28) % (/32) Beyond Milan criteria (N) 33% (3/9) 29% (2/7) 11% (1/9) Time to recurrence (days) (mean ± SD) Within Milan criteria N/A a 353 ± 132 N/A Beyond Milan criteria 31 ± ± N/A 116 ± N/A Digestive Disease Institute 17

110 Obesity Bariatric Surgery In 213, Cleveland Clinic s Bariatric and Metabolic Center marked its eighth anniversary and continued to be accredited as a designated Bariatric Surgery Center of Excellence by the American Society for Metabolic and 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 Cases Other a Revision Banding Sleeve Bypass In 213, laparoscopic Roux-en-Y gastric bypass, with 419 cases (56%), was the most frequently performed bariatric procedure at Cleveland Clinic. Laparoscopic sleeve gastrectomy continued to grow and was the second most commonly performed procedure, with 23 cases (31%). Due to patient preference, laparoscopic adjustable gastric banding has shown large declines over the past several years. Forty-three cases were performed at Fairview Hospital, a Cleveland Clinic hospital. a Other includes other bariatric procedures such as gastric plication +/- band, duodenal switch, distal bypass, and band removal. IN 213, 57 BARIATRIC CASES WERE PERFORMED ROBOTICALLY Bypass Sleeve Banded Plication Gastric Plication Band Duodenal Switch 18 Outcomes 213

111 Comorbidities at Baseline Among Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Percent 8 6 Cleveland Clinic (N = 1156) MBSC* (N = 2949) 4 2 Hypertension Obstructive Sleep Apnea Hyperlipidemia Diabetes Mellitus Smoking Venous Thromboembolism 1..2 Renal Failure Comorbidities at Baseline Among Patients Undergoing Laparoscopic Sleeve Gastrectomy Percent 8 6 Cleveland Clinic (N = 353) MBSC* (N = 2949) 4 2 Hypertension Obstructive Sleep Apnea Hyperlipidemia Diabetes Mellitus Smoking Venous Thromboembolism.6.3 Renal Failure *MBSC = 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. 213;257(5): Digestive Disease Institute 19

112 Obesity Laparoscopic Sleeve Gastrectomy Length of Stay Laparoscopic Roux-en-Y Length of Stay Days 5 Days Cleveland Clinic UHC US NEWS Top 1* 3 2 Cleveland Clinic UHC US NEWS Top 1* N = N = N = N = *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu 3-Day Complication Rates for All Bariatric Cases Percent Cleveland Clinic a (N = 198) MBSC* (N = 2949) 1 Anastomotic Leak Bleeding Wound Infection/ Evisceration Intestinal Obstruction Deep Vein Thrombosis Respiratory Failure a Cleveland Clinic data are non-risk-adjusted. *MBSC = 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. 213;257(5): Outcomes 213

113 Percent of Patients Requiring Intensive Care Unit Admission: Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy Percent Cleveland Clinic UHC US NEWS Top 1* N = N = *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu 3-Day Mortality Rates for Bariatric Surgery Type All bariatric surgeries % (N) Laparoscopic Roux-en-Y gastric bypass % (N) Laparoscopic sleeve gastrectomy % (N) Cleveland Clinic (198).4 (1258). (434) BOLD*.1 (186,576).14 (136,36).8 (15,964) *BOLD = Bariatric Outcomes Longitudinal Database, a database of the American Society for Metabolic & Bariatric Surgery Source: National Comparisons of Bariatric Surgery Safety and Efficacy: Findings from the BOLD Database Paper presented at: 29th Annual Meeting of the American Society for Metabolic & Bariatric Surgery; June 17 22, 212; San Diego, CA. Abstract PL-14. 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. 212;214(4): Digestive Disease Institute 111

114 Obesity Mean Percent Weight Loss a Toward Ideal Body Mass Index at Follow-Up Percent N = Laparoscopic Roux-en-Y Laparoscopic Banding Year 2 Years 3 Years a Weight loss formula: (baseline BMI follow-up BMI) / (baseline BMI ideal BMI [25]) x 1 For cases followed up at 3 years, laparoscopic Roux-en-Y gastric bypass had the highest percentage of weight loss toward ideal body mass index, at 66%. Comorbidity Resolution at 3-Year Follow-Up for All Bariatric Surgery Cases Percent N = Sleep Apnea Diabetes Hyperlipidemia Hypertension Outcomes 213

115 Bariatric Behavioral Health Bariatric Surgery Clearance After Multidisciplinary Review of High-Risk Psychiatric Patients (N = 136) Percent N = Eligible for Surgery but Did Not Achieve Behavioral Requirements Not Cleared for Surgery Cleared for Surgery A bimonthly multidisciplinary committee composed of medical, surgical, nutritional, and psychological professionals meets to discuss high-risk patients seeking bariatric surgery. Both the medical and the psychiatric risks of bariatric surgery must be balanced with the medical and psychiatric risks of uncontrolled severe obesity and its complications. A retrospective chart review was completed on all patients discussed over a 2-year period from to assess patient surgery status. Patients cleared for and having bariatric surgery showed weight loss and comorbidity outcomes consistent with overall program outcomes. Digestive Disease Institute 113

116 Obesity Predictors From Preoperative Psychological Testing (N = 329) Postoperative Survey of Patient Complaints and Behaviors Somatic Problems Psychological Distress (e.g., grieving the loss of food) Maladaptive Eating (e.g., graze eating) Preoperative Psychological Testing a Somatic complaints (e.g., excessive pain and nausea) Internalizing emotional disorders (e.g., anxiety, demoralization) External behavioral dysfunction (e.g., impulsivity and disinhibition).3 (P <.5).43 (P <.1).3 (P <.5).36 (P <.5) a Minnesota Multiphasic Personality Inventory-2-Restructured Form R2 correlations are between MMPI-2-RF scale scores and postoperative concerns. Source: Marek RJ, Ben-Porath YS, Merrell J, Ashton K, Heinberg LJ. Predicting one and three month postoperative Somatic Concerns, Psychological Distress, and Maladaptive Eating Behaviors in bariatric surgery candidates with the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF). Obes Surg. 214;24(4): Preoperative psychological testing predicts some somatic complaints, psychological distress, and maladaptive eating behaviors at 3 months after bariatric surgery. Psychological evaluation of bariatric surgery candidates often includes standardized psychological testing. Preoperative scores on the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) were examined in the context of self-reported difficulties and behaviors at 3 months postsurgery. 114 Outcomes 213

117 Adherence to Bariatric Surgery Recommendations After Roux-en-Y Gastic Bypass at 4- to 6-Week Follow-Up (N = 37) 213 Percent Drink Before Thirsty Take 2 3 Min/Meal Daily Physical Activity Routine Drink 48 oz/day Exercise 5x/Week Protein 6 8 g/day Eat 5 Small Meals/Day Source: Spitznagel MB, Galioto R, Limbach K, Gunstad J, Heinberg LJ. Cognitive function is linked to adherence to bariatric postoperative guidelines. Surg Obes Rel Dis. 213;9(4): Preoperative screening may help identify and predict which patients will have a more challenging postoperative course. Recent research has demonstrated that clinically significant cognitive impairment is present in up to 23% of bariatric surgery patients and that these baseline preoperative impairments predict weight loss outcomes at 1 year. Such impairments could also contribute to poorer adherence. Cognitive testing and a self-report measure of adherence to postoperative bariatric guidelines were completed during a 4- to 6-week postoperative appointment for patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery. Early nonadherence to recommendations for eating small regular meals and exercising five times weekly were noted in these patients. Digestive Disease Institute 115

118 Obesity Nonsurgical Weight Management Appointment Compliance With Weight Management Programs (N = 1224) Sep 212 Dec 213 Percent 1 8 Completed One or More Appointments No Show/Canceled Appointments Weight Management Program Protein-Sparing Modified Fast N = During 16 months, there were 2944 appointments scheduled for 995 patients for the Weight Management Program (WMP) and 681 appointments for 229 patients for the Protein-Sparing Modified Fast (PSMF) program. The WMP is offered by registered dietitians and utilizes various lifestyle and nutrition strategies to assist patients with weight loss. Appointment Status Based on Type of Scheduled Weight Management Program (N = 1224) Sep 212 Dec 213 Percent No Show Canceled Completed 2 Weight Management Program Protein-Sparing Modified Fast N = Participants in both the WMP and the PSMF program are expected to attend regular and frequent appointments, which many are unable to do. Forty-four percent of PSMF program patients and 57% of WMP patients canceled or did not show up for appointments. 116 Outcomes 213

119 Body Mass Index Change Based on Program and Number of Completed Visits Sep 212 Dec 213 BMI Change a. 3 b. 4 c. 3 d. 4 e. 7 Visits Program a. WMP only b. WMP only c. PSMF w/ or w/o WMP d. PSMF w/ or w/o WMP e. PSMF w/ or w/o WMP N The Protein-Sparing Modified Fast (PSMF) program is monitored by a physician or nurse practitioner in collaboration with a registered dietitian who provides patient education for both the PSMF and Weight Management Programs (WMP). Patients completing four or more visits showed greater improvement in BMI, with PSMF patients having the greatest reduction in BMI. Baseline and Follow-Up Body Mass Index Based on Type of Weight Management Program and Completed Visits 213 BMI (kg/m 2 ) Baseline BMI Last BMI Program a. WMP only b. WMP only c. PSMF w/ or w/o WMP d. PSMF w/ or w/o WMP e. PSMF w/ or w/o WMP N Visits a. b. c. d. e. Weight Management Program Protein-Sparing Modified Fast Digestive Disease Institute 117

120 Breast Disease Cleveland Clinic s Breast Center 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 innovative breast cancer treatment and supportive counseling. The Breast Center at Cleveland Clinic s main campus was recently awarded a 3-year accreditation by the American College of Surgeons National Accreditation Program for Breast Centers (NAPBC). Percentage of Screening Mammograms Resulting in Callback Percent Cleveland Clinic offers a diagnostic callback program for patients with abnormal screening mammograms. The callback rate has been under 15% for several years. This is consistent with the National Comprehensive Cancer Network (NCCN) benchmark of 5% to 15%. N = 6,977 63,186 65,441 Surgery for Breast Cancer a Percent Mastectomy Lumpectomy The breast conservation rate is above 56% for all breast cancer surgeries. This exceeds the NAPBC ideal benchmark of 5% for breast conservation surgery in patients with stage, 1, or 2 breast cancer. a Includes all breast cancers plus prophylactic mastectomy with breast reconstruction N = Outcomes 213

121 Immediate Breast Reconstruction Percent More than 3% of breast cancer surgeries include immediate reconstruction performed by a plastic surgeon specializing in breast reconstruction. N = Digestive Disease Institute 119

122 Breast Disease Breast Cancer Cleveland Clinic s Breast Center is committed to providing patients with the best possible prevention, detection, and treatment options for breast disease. A multidisciplinary team comprising surgeons, medical oncologists, radiation oncologists, nurses, and social workers collaborate with each patient to develop a care plan. Cleveland Clinic main campus, Beachwood Family Health Center, and Fairview Hospital Breast Centers are accredited by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. Five-Year Relative Survival of Female Patients with All Stages of Breast Cancer (N = 4154) Percent Survival Years After Diagnosis CC Ref Percent Survival (Number at Risk) = 1 (375) 1 (2953) 99.6 (229) 99.2 (1546) 98.4 (97) American Joint Committee on Cancer (AJCC) stage I IV breast cancer. CC = Cleveland Clinic. Ref = Fast Stats: An interactive tool for access to SEER cancer statistics. Surveillance Research Program, National Cancer Institute. seer.cancer.gov/faststats. (Accessed on ) (SEER 13). 12 Outcomes 213

123 Five-Year Relative Survival of Patients with Breast Cancer by Stage at Diagnosis (N = 4154) Percent Survival Years After Diagnosis Stage I CC (N = 2174) Stage I Ref Stage II CC (N = 1354) Stage II Ref Stage III CC (N = 455) Stage III Ref Stage IV CC (N = 171) Stage IV Ref Percent Survival and (Number at Risk) by Stage Years After Diagnosis Stage I 1 (1973) 1 (158) 1 (1192) 1 (835) 1 (543) II 1 (1237) 1 (969) 1 (733) 1 (51) 98.5 (314) III 1 (414) 94.4 (318) 9.6 (231) 88.3 (167) 86.1 (95) IV 81.4 (126) 71.6 (86) 62.9 (51) 56. (33) 53.8 (18) American Joint Committee on Cancer (AJCC) stage I IV breast cancer. CC = Cleveland Clinic. Ref = Surveillance, Epidemiology and End Results (SEER). SEER (SEER , SEER 17-7). Software: Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version Data: Surveillance, Epidemiology, and End Results (SEER) Program (seer.cancer.gov) SEER*Stat Database: Incidence - SEER 17 Regs Research Data + Hurricane Katrina Impacted Louisiana Cases, Nov 21 Sub ( varying) - Linked To County Attributes - Total U.S., Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 211 (updated 1/28/211), based on the November 21 submission. Digestive Disease Institute 121

124 Breast Disease Five-Year Relative Survival of Patients with Breast Cancer by Race a (N = 425) Percent Survival Years After Diagnosis Black (N = 599) Black Ref White (N = 3426) White Ref Percent Survival and (Number at Risk) by Stage Years After Diagnosis Race Black 97 (524) 95.4 (412) 92.5 (295) 91.6 (189) 9.5 (16) White 99.2 (3116) 97.8 (2454) 97.5 (1847) 97.1 (1315) 96.4 (837) a Self-reported. American Joint Committee on Cancer (AJCC) stage I IV breast cancer. CC = Cleveland Clinic. Ref = Fast Stats: An interactive tool for access to SEER cancer statistics. Surveillance Research Program, National Cancer Institute. seer.cancer.gov/faststats. (Accessed on ). 122 Outcomes 213

125 Five-Year Overall Survival of Patients with Early-Stage Breast Cancer Treated with Radiation (N = 624) Percent Survival Years After Treatment Stage CC (N = 131) Stage Ref Stage I CC (N = 288) Stage I Ref Stage IIA CC (N = 132) Stage IIA Ref Stage IIB CC (N = 73) Stage IIB Ref Percent Survival and (Number at Risk) by Stage Years After Treatment Stage (114) 99.1 (97) 96.9 (81) 94.2 (61) 94.2 (41) I 99.3 (254) 98.4 (21) 97.4 (174) 97.4 (131) 93.9 (86) IIA 99.2 (114) 96.3 (88) 93.9 (71) 9.9 (51) 9.9 (36) IIB 95.7 (63) 89.1 (5) 89.1 (38) 86.5 (29) 86.5 (21) Patients who received radiation therapy at Cleveland Clinic main campus. CC = Cleveland Clinic. Ref = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) 21 22, as reported in: Edge SB, Byrd DR, Compton CC, et al. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 21. Digestive Disease Institute 123

126 Breast Disease Five-Year Overall Survival of Patients with Late-Stage Breast Cancer Treated with Radiation (N = 174) Percent Survival Years After Treatment Stage IIIA CC (N = 81) Stage IIIA Ref Stage IIIB CC (N = 15) Stage IIIB Ref Stage IIIC CC (N = 3) Stage IIIC Ref Stage IV CC (N = 48) Stage IV Ref Percent Survival and (Number at Risk) by Stage Years Since Treatment Stage IIIA 97.4 (71) 94.5 (59) 89.2 (46) 84.9 (35) 84.9 (27) IIIB 85.2 (1) 67.3 (7) 67.3 (3) 67.3 (2) 67.3 (2) IIIC 85.2 (2) 59.6 (14) 5.8 (11) 44.8 (5) 44.8 (3) IV 59.6 (23) 56.8 (19) 41.8 (14) 32.9 (11) 32.9 (5) Patients who received radiation therapy at Cleveland Clinic main campus. CC = Cleveland Clinic. Ref = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) 21 22, as reported in: Edge SB, Byrd DR, Compton CC, et al. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; Outcomes 213

127 Quality Measures Consideration or Administration of Tamoxifen or Third- Generation Aromatase Inhibitor Within 365 Days of Diagnosis for Women with Hormone Receptor-Positive Breast Cancer (N = 398) % (n = 12) Not considered or administered Combination Chemotherapy Considered or Administered Within 12 Days of Diagnosis for Women Under Age 7 with Hormone Receptor-Negative Breast Cancer (N = 11) % (n = 9) Not considered or administered 1% 97.2% (n = 38) Considered or administered 1% 91% (n = 92) Considered or administered Cleveland Clinic standard of care quality was 97.2% (387 of 398 patients) for , exceeding the 9% goal established by the Commission on Cancer. Twelve patients were not treated with either chemotherapy or endocrine therapy. Women diagnosed in ; 18 years of age at diagnosis; first or only cancer diagnosis; primary tumor of the breast; invasive solid tumors only; no clinical or pathological evidence of metastatic disease; all or part of first course of treatment performed at Cleveland Clinic; American Joint Commission on Cancer (AJCC) stage T1c, N, M or stage II or III hormone receptor-positive breast cancer. Cleveland Clinic met the Commission on Cancer care quality standard at 91% (92 of 11 patients) for , exceeding the 9% goal. Of the 9 patients where combination chemotherapy was not considered or administered, 8 patients received combination chemotherapy beyond the 12 days mark (median days; range days) and 1 patient was not offered chemotherapy (T1cNM) and not further documented. Women diagnosed in ; 18 years of age at diagnosis; first or only cancer diagnosis; primary tumor of the breast; invasive solid tumors only; no clinical or pathological evidence of metastatic disease; all or part of first course of treatment performed at Cleveland Clinic; American Joint Commission on Cancer (AJCC) stage T1c, N, M or stage II or III hormone receptor-negative breast cancer. Digestive Disease Institute 125

128 Breast Disease Radiation Therapy Administered Within 365 Days of Diagnosis for Women Under Age 7 Receiving Breast Conserving Surgery for Breast Cancer (N = 98) % (n = 17) Not administered 1% 98.3% (n = 963) Administered Cleveland Clinic care quality standard was 98.3.% (963 of 98 patients) for , exceeding the Commission on Cancer goal of 9%. For those receiving radiation therapy, mean time to treatment was 145 days; median time to treatment was 126 days (range, days). Of the 17 patients outside the quality of care goal, 3 patients received radiation therapy beyond 365 days from diagnosis and 14 were recommended to have radiation therapy but declined. Performance improvement opportunities include counseling and education for those declining treatment and identifying obstacles to timely treatment. Women diagnosed in ; < 7 years of age at diagnosis; first or only cancer diagnosis; primary tumor of the breast; invasive solid tumors only; no clinical or pathological evidence of metastatic disease; all or part of first course of treatment performed at Cleveland Clinic. 126 Outcomes 213

129 Cleveland Clinic Florida Upper and Lower GI Diagnostic Procedures Upper GI Diagnostic Procedures Esophagogastroduodenoscopy Esophagogastroduodenoscopy (EGD) is a test to examine the lining of the esophagus, stomach, and first part of the small intestine Number of Procedures N = Digestive Disease Institute 127

130 Cleveland Clinic Florida Endoscopic Ultrasound Endoscopic ultrasound (EUS) is increasingly used to visualize details of abdominal and esophageal structures including lymph nodes, layers of the GI tract, and vessels. EUS can be used to facilitate biopsies of areas that are inaccessible percutaneously Number of Procedures N = Double Balloon Enteroscopy Number of Procedures Endoscopic Retrograde Cholangiopancreatogram Number of Procedures N = N = Outcomes 213

131 Lower GI Diagnostic Procedure Colonoscopy Number of Procedures N = Digestive Disease Institute 129

132 Cleveland Clinic Florida Upper and Lower GI Surgical Procedures Overview Total Procedures Number of Procedures N = Upper GI Surgical Procedures Esophageal and Gastric Surgical Procedures Number of Procedures Duodenum, Small Intestine, and Appendix Procedures Number of Procedures N = N = Outcomes 213

133 Hepatic and Pancreaticobiliary Procedures Number of Procedures Oncologic Retroperitoneal Procedures Number of Procedures N = N = Abdominal Wall and Hernia Procedures Number of Procedures Soft Tissue Minor Procedures Number of Procedures N = N = Digestive Disease Institute 131

134 Cleveland Clinic Florida Lower GI Surgical Procedures Cleveland Clinic Florida Department of Colorectal Surgery diagnoses and treats a broad array of diseases including colon cancer, inflammatory bowel disease, and functional disorders such as fecal incontinence. Rectal Cancer Surgical Procedures 213 Rectal cancer surgical procedures 85 Minimally invasive procedures 35 Sphincter preservation procedures 66 Median length of stay (days) day readmission rate (%) 18.8 In-hospital mortality rate (%) Ulcerative Colitis Surgical Procedures 213 Ulcerative colitis surgical procedures 51 Minimally invasive procedures 31 Median length of stay (days) day readmission rate (%) 15.5 In-hospital mortality rate (%) 132 Outcomes 213

135 Liver Transplant In August 212, the Agency for Health Care Administration approved Cleveland Clinic Florida s Certificate of Need to provide liver and kidney transplantation services. In March 213, the United Network for Organ Sharing granted approval of Cleveland Clinic Florida s liver transplant program, and the program was launched in April 213. A multidisciplinary team participates in the evaluation, management, treatment, and follow-up of the transplant patients. Patients Referred, Evaluated, Listed, and Transplanted 213 Number of Patients Liver Transplant 1-Year Patient Survival (N = 9) July 213 December 213 Percent Referred Evaluated Listed Transplanted Observed Expected N = Transplants by Type of Donor Organ (N = 9) July 213 December 213 Percent DCD a ECD b SCD c Liver Transplant 1-Year Graft Survival (N = 9) July 213 December 213 Percent a Donation after cardiac death b Expanded criteria donors c Standard criteria donors Observed Expected Digestive Disease Institute 133

136 Cleveland Clinic Florida Obesity and Metabolic Disease The Bariatric and Metabolic Center (BMC) at Cleveland Clinic Florida has 17 full-time staff members 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. Bariatric Surgery Cases Number of Cases Revision Sleeve Bypass Band N = Comorbidities at Baseline Among Patients Undergoing Laparoscopic Roux-en-Y Bypass (N = 199) Percent CCF MBSC a 4 2 Venous Thromboembolism Current Smoker Hyperlipidemia Diabetes Mellitus Obstructive Sleep Apnea Hypertension a MBSC = 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; For the 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. 213 May;257(5): Outcomes 213

137 Comorbidities at Baseline Among Patients Undergoing Laparoscopic Sleeve Gastrectomy (N = 434) Percent CCF MBSC a 4 2 Venous Thromboembolism Smoking Hyperlipidemia Diabetes Mellitus Obstructive Sleep Apnea Hypertension a MBSC = 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; For the 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. 213 May;257(5): Laparoscopic Sleeve Gastrectomy Length of Stay Days 5 4 Cleveland Clinic UHC U.S. News Top N = Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu Digestive Disease Institute 135

138 Cleveland Clinic Florida Laparoscopic Roux-en-Y Length of Stay Days N = Cleveland Clinic UHC U.S. News Top 1 Source: These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 213 discharges. uhc.edu 3-Day Complication Rates for All Bariatric Cases (N = 848) 213 Percent 4 3 CCF MBSC a 2 1 Respiratory Failure Deep Vein Thrombosis Bleeding Intestinal Obstruction Wound Infection/ Evisceration Anastomotic Leak a MBSC = 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; For the 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. 213 May;257(5): Outcomes 213

139 Breast Disease Screening Mammograms Resulting in Callback Percent N = ,756 Cleveland Clinic Florida offers a diagnostic callback program for patients with abnormal screening mammograms. The callback rate has increased slightly during the past 2 years since digital mammography was introduced, but has been close to 15% for several years. This is consistent with the National Comprehensive Cancer Network benchmark of 5% to 15%. Surgery for Breast Cancer Percent 1 75 Mastectomy Lumpectomy N = The breast conservation rate is 57%. This exceeds the National Accreditation Program for Breast Centers ideal benchmark of 5% for breast conservation surgery in patients with stage, 1, or 2 breast cancer. Digestive Disease Institute 137

140 Cleveland Clinic Florida Biopsies Performed Percent 1 75 Excisional biopsy Core needle biopsy N = The core biopsy rate exceeds the National Quality Forum benchmark of 9%. Radiation Therapy After Lumpectomy Percent 1 75 Cleveland Clinic ACoS/CoC CP3R a N = a The American College of Surgeons Commission on Cancer s Cancer Program Practice Profile Report Breast cancer patients < 7 years of age who had lumpectomy also had radiation therapy within 1 year. The American College of Surgeons Commission on Cancer s Cancer Program Practice Profile Report (ACoS/ CoC CP3R) benchmark is 9%. 138 Outcomes 213

141 Tamoxifen or Third Generation Aromatase Inhibitor Within 1 Year of Diagnosis Percent 1 75 Cleveland Clinic ACoS/CoC CP3R a a The American College of Surgeons Commission on Cancer s Cancer Program Practice Profile Report N = Tamoxifen or third generation aromatase inhibitors were administered within 1 year of diagnosis for > 7% of women with American Joint Committee on Cancer (AJCC) stage T1c, or stage 2 or 3 hormone receptor positive breast cancer. ACoS/CoC CP3R benchmark is 9%. Combination Chemotherapy Within 4 Months Percent 1 75 Cleveland Clinic ACoS/CoC CP3R a a The American College of Surgeons Commission on Cancer s Cancer Program Practice Profile Report N = Combination chemotherapy was administered within 4 months for women < 7 years of age with AJCC stage T1c, or stage 2 or 3 hormone receptor negative breast cancer. ACoS/CoC CP3R benchmark is 9%. Digestive Disease Institute 139

142 Institute Quality Improvement Digestive Disease Institute Patient Safety Indicators The Agency for Healthcare Research and Quality s (AHRQ) Patient Safety Indicators (PSI) 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. Digestive Disease Institute Postoperative Hemorrhage or Hematoma (PSI 9) January 21 November 213 Rate per 1 Patients Digestive Disease Institute performance Cleveland Clinic target a a The Cleveland Clinic target is 1.8 per 1 patients (9th percentile). These data are prepared using the University Health System Consortium (UHC) Clinical Database. (uhc.edu) Despite performing complex abdominal and colorectal surgical procedures, the Digestive Disease Institute s postoperative hemorrhage or hematoma rates (AHRQ Patient Safety Indicator 9) have steadily improved since 21. Digestive Disease Institute Postoperative Respiratory Failure (PSI 11) January 21 November 213 Rate per 1 Patients Digestive Disease Institute performance Cleveland Clinic target a a The Cleveland Clinic target is 5.2 per 1 patients (9th percentile). These data are prepared using the University Health System Consortium (UHC) Clinical Database. (uhc.edu) Collaboration with the Intensive Care Unit staff has resulted in a 28% decrease in postoperative respiratory failure rates (AHRQ Patient Safety Indicator 11). 14 Outcomes 213

143 Digestive Disease Institute Postoperative Pulmonary Embolism or Deep Vein Thrombosis (PSI 12) January 21 November 213 Rate per 1 Patients Digestive Disease Institute performance Cleveland Clinic target a a The Cleveland Clinic target is 3.7 per 1 patients (9th percentile). These data are prepared using the University Health System Consortium (UHC) Clinical Database. (uhc.edu) Reducing the incidence of postoperative pulmonary embolism or deep vein thrombosis (AHRQ Patient Safety Indicator 12) continues to be an area of focus and priority for improvement. There was an 18% decrease in the rate per 1 patients from 212 to 213. Digestive Disease Institute Postoperative Sepsis (PSI 13) January 21 November 213 Rate per 1 Patients 28 Digestive Disease 24 Institute performance 2 Cleveland Clinic target a a The Cleveland Clinic target is 2.4 per 1 patients (9th percentile). These data are prepared using the University Health System Consortium (UHC) Clinical Database. (uhc.edu) Collaboration with the Intensive Care Unit staff resulted in a steady decrease of postoperative sepsis (AHRQ Patient Safety Indicator 13) since 21. Digestive Disease Institute 141

144 Institute Quality Improvement Digestive Disease Institute Postoperative Wound Dehiscence (PSI 14) January 21 November 213 Rate per 1 Patients Digestive Disease Institute performance Cleveland Clinic target a a The Cleveland Clinic target is per 1 patients (9th percentile). These data are prepared using the University Health System Consortium (UHC) Clinical Database. (uhc.edu) Despite performing complex primary and reoperative abdominal and colorectal surgical procedures, the Digestive Disease Institute s postoperative wound dehiscence rate the Agency for Healthcare Research and Quality s (AHRQ) Patient Safety Indicators (PSI) 14 is low at 1 per 1 patients. Digestive Disease Institute Accidental Puncture or Laceration (PSI 15) January 21 November 213 Rate per 1 Patients Digestive Disease Institute performance Cleveland Clinic target a a The Cleveland Clinic target is 1.1 per 1 patients (9th percentile). These data are prepared using the University Health System Consortium (UHC) Clinical Database. (uhc.edu) In spite of a large number of reoperative cases, the accidental puncture or laceration rates (AHRQ Patient Safety indicator 15) have dramatically decreased since 21 and were sustained at a rate below 5 per 1 patients in Outcomes 213

145 Digestive Disease Institute Readmissions Digestive Disease Institute All Cause 3-Day Readmissions by Department Percent Bariatrics Colorectal surgery Gastroenterology & Hepatology General surgery Readmission rates by department have been consistent since 211. A process to review all unplanned readmissions was implemented to gain insight and identify improvement opportunities. Digestive Disease Institute 143

146 Institute Quality Improvement Digestive Disease Institute Quality Initiatives to Improve Outcomes Deep Vein Thrombosis Prevention - Inpatient Intermittent Pneumatic Compression Boot To improve compliance with the use of intermittent pneumatic compression (IPC) patients usage of IPC was documented hourly. Hourly documentation resulted in increased compliance. Patient IPC Compliance 213 Percent Q1 Q2 (Pilot Implementation) Q3 Q4 1% hourly documentation compliance 8% IPC wear compliance a total number of patients taking part in the IPC quality initiative N a = Increasing Pain Assessments Using A Time Tracker Devise for Colorectal Patients To improve postoperative pain management on colorectal surgery units, a color-coded Time-Tracker device was implemented. The device is available to every nurse upon administration of narcotics/opioids and indicates when a patient last received pain medication and promps for reassessment and redosing of pain medication. The pilot resulted in an increase in the percentage of pain reassessments completed and improved HCAHPS scores. Patients Receiving Pain Assessments 213 Percent N a = 8/ /23 (Pilot Implementation) 82 9/3 68 1/7 44 1/ /4 11 a total number of colorectal patients taking part in the pain assessment quality initiative 144 Outcomes 213

147 Pain Management a HCAHPS Scores Following Pain Assessment Pilot Following the initiation of the pain assessment pilot, colorectal surgery patients responses to their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys reflected an increased sentiment that staff did everything to help with pain. 213 Percent Q1 Q2 Q3 (Pilot Implementation) Q4 Staff pain management Target a Pain Management refers to the HCAHPS question During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? b Response options: Always, Usually Sometimes, Never; Scores represent the percent of patients who responded Always. c total number of patients taking part in the pain management HCAHPS survey N c = Impact of Relaxation Therapy on Transplant Patients Postoperative Pain and Anxiety In July 213, a pilot relaxation therapy program was launched on the abdominal transplant nursing floor consisting of noninvasive stretching, breath work, and imagery. Patients showed a decrease in both pain and anxiety following therapy. A total of 76 patients have participated in the program to date. Pain scores and anxiety scores were recorded pre and postsession. The scales are 1 with 1 indicating no pain or anxiety and 1 indicating severe pain or anxiety. This is the first program of this type in the US. Pain Scale Pre- and Posttherapy (N = 76) 213 Anxiety Scale Pre- and Posttherapy (N = 32) 213 Pain Score Pretreatment Posttreatment Anxiety Score Pretreatment Posttreatment Digestive Disease Institute 145

148 Surgical Quality Improvement Surgical Care Improvement Program (SCIP) Appropriateness of Care This composite metric, based on a group of hospital surgical quality process measures developed by the Centers for Medicare & Medicaid Services, shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic Surgical Appropriateness of Care Percent Cleveland Clinic target Cleveland Clinic s goal is for all patients to receive all the recommended care that is appropriate. An aggregated all or nothing measurement approach to monitoring multiple publicly reported surgical measures trended positively in N = Source: medicare.gov/hospitalcompare 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 ACS NSQIP performance benchmarked against more than 4 participating hospitals. Cleveland Clinic Overall Multispecialty 3-Day Mortality and 3-Day Morbidity July 212 June 213 Outcome N Observed Rate (%) Expected Rate (%) Statistical Outlier a 3-day mortality day morbidity High a Identified as a statistical outlier by the ACS NSQIP hierarchical model 146 Outcomes 213

149 In addition to overall surgical performance, ACS NSQIP data specific to general surgery and to colorectal surgery are shown in the tables below. General Surgery Outcomes July 212 June 213 Outcome N Observed Rate (%) Expected Rate (%) Statistical Outlier a 3-day mortality day morbidity High Cardiac arrest/myocardial infarction Low Pneumonia Unplanned intubation Ventilator > 48 hours Deep vein thrombosis/pulmonary embolism High Renal failure Surgical site infection High Urinary tract infection Return to operating room a Identified as a statistical outlier by the ACS NSQIP hierarchical model Colorectal Surgery Outcomes July 212 June 213 Outcome N Observed Rate (%) Expected Rate (%) Statistical Outlier a 3-day mortality day morbidity Surgical site infection Urinary tract infection High Return to operating room a Identified as a statistical outlier by the ACS NSQIP hierarchical model Digestive Disease Institute 147

150 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 educational opportunities and training programs designed to help them provide the best possible experience in every patient encounter. Outpatient Office Visit Survey Digestive Disease Institute CG-CAHPS Assessment a (2981) 213 Percent Best Response 1 8 CAHPS Database Average (All Practices b ) Appointment Access Doctor Communication Doctor Rating Clerical Staff c Test Results Communication c a In 213, 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 and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the CAHPS database from 2399 medical practices in 212. c Data and benchmark based on results of the CG-CAHPS Visit-Specific survey submitted to the CAHPS database from 2399 medical practices in 212. Source: Press Ganey, a national hospital survey vendor 148 Outcomes 213

151 Inpatient Survey Digestive Disease Institute HCAHPS Overall Assessment Percent Best Response Hospital Rating (% 9 or 1) 1 Scale a Response options: Definitely Yes, Probably Yes, Probably No, Definitely No Source: Press Ganey, a national hospital survey vendor HCAHPS Domains of Care Percent Best Response a Recommend Hospital (% Definitely Yes) a 212 (N = 22) 213 (N = 1939) National Average All Patients b 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. 212 (N = 22) 213 (N = 1939) National Average All Patients b Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Quiet at Night Source: Press Ganey, a national hospital survey vendor b Based on national survey results of discharged patients, April 212 March 213, from 3938 US hospitals. medicare.gov/hospitalcompare Digestive Disease Institute 149

152 Cleveland Clinic Implementing Value-Based Care Overview Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing three 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 213 focus areas in pursuit of this three-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. Improve the Patient Experience of Care Cleveland Clinic Overall Mortality Observed/Expected Ratio O/E Ratio 1..8 Cleveland Clinic Central Line-Associated Bloodstream Infection ICU Rate per 1 Line Days Rate per 1 Line Days Cleveland Clinic UHC a Academic Medical Center 5 th Percentile (213) 1..5 Cleveland Clinic Performance Cleveland Clinic Target. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q a These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Cleveland Clinic s observed/expected (O/E) mortality ratio outperformed the University HealthSystem Consortium (UHC) academic medical center 5th percentile throughout 213 based on the UHC 213 risk model. Ratios less than 1. indicate mortality performance better than expected in UHC s risk adjustment model.. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSIs), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews for every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population. 15 Outcomes 213

153 Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1 Eligible Patients Rate per 1 Patients Cleveland Clinic UHC a Academic Medical Center 5 th Percentile Q3 Q4 Q1 Q2 Q3 Q a These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Improved screening and prevention strategies have supported Cleveland Clinic s continued improvement with respect to postoperative pulmonary embolism and deep vein thrombosis (AHRQ Patient Safety Indicator 12). Embolism/thrombosis prevention remains a safety priority for Cleveland Clinic in 214. Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult) Percent Q1 Cleveland Clinic NDNQI 5 th Percentile (academic medical centers) a Q2 Q3 Q4 Q1 Q2 Q3 Q a Data reported from the National Database for Nursing Quality Indicators (NDNQI ) with permission of the American Nurses Association A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. Cleveland Clinic caregivers have been trained to provide appropriate skin care preventive measures, which include patient repositioning and the use of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively identify hospital-acquired pressure ulcers through daily nursing assessments and, in collaboration with the multidisciplinary team, implement early treatment recommendations. Digestive Disease Institute 151

154 Cleveland Clinic Implementing Value-Based Care 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 educational opportunities and training programs designed to help them provide the best possible experience in every patient encounter. Outpatient Office Visit Survey Cleveland Clinic CG-CAHPS Assessment a (N = 64,463) 213 Percent Best Response 1 8 CAHPS Database Average (All Practices b ) Appointment Access Primary Care Specialty Care Doctor Communication Doctor Rating Clerical Staff Test Results Communication a In 213, 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 and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the CAHPS database from 2399 medical practices in 212. Source: Press Ganey, a national hospital survey vendor 152 Outcomes 213

155 Inpatient Survey Cleveland Clinic HCAHPS Overall Assessment Percent Best Response Hospital Rating (% 9 or 1) 1 Scale a Response options: Definitely Yes, Probably Yes, Probably No, Definitely No Source: Press Ganey, a national hospital survey vendor HCAHPS Domains of Care Percent Best Response a Recommend Hospital (% Definitely Yes) a 212 (N = 11,254) 213 (N = 1,671) National Average All Patients b 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. 212 (N = 11,254) 213 (N = 1,671) National Average All Patients b Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Quiet at Night Source: Press Ganey, a national hospital survey vendor b Based on national survey results of discharged patients, April 212 March 213, from 3938 US hospitals. medicare.gov/hospitalcompare Digestive Disease Institute 153

156 Cleveland Clinic Implementing Value-Based Care Focus on Value 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 top strategic priority for Cleveland Clinic as healthcare reform moves care delivery from fee-for-service to a population health and bundled payment delivery system, while concurrently improving patient safety, outcomes, and experience. What will our new model of care look like? Integrated Care Model Retail Venues Home Community-Based Organizations Care System Outpatient Clinics Post-Acute (other) Emergency Independent Physician Offices Skilled Nursing Facilities MyChart Rehabilitation Facilities Ambulatory Diagnosis & Treatment Hospitals The Cleveland Clinic Integrated Care Model is a value-based model of care, designed to improve outcomes while reducing cost. The patient remains at the heart of the Cleveland Clinic Integrated Care Model. The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in the different settings listed. The care system represents integration of care across the continuum. To build this new care system, critical competencies are care paths and care coordination. We have therefore begun to build disease and condition-specific care paths, and are implementing comprehensive care coordination. Care paths guide patient care both within a venue (e.g., a hospital) as well as along the care system (blue band) to appropriate care venues. Care paths will improve value by employing evidence and/or experience-based practice to reduce unnecessary variation in care, with the goal of achieving optimal outcomes at the lowest possible cost. Measurement of use and outcomes is integral to care paths. Care coordination identifies high-risk patients and risk points in transitions of care, and enhances communication and handoffs between providers and locations. 154 Outcomes 213

157 Improve Population Health In the future, value will be increasingly focused on measures such as the patient s functional status, rather than on traditional outcomes measures. The stroke care path measure below is an example. Improved Health-Related Quality of Life with Implementation of Stroke Care Path (N = 48) Mean Difference in EQ-5D a N b = Stroke Care Path A positive score indicates stable status or improvement a As measured between first and last visit in the same year and adjusted for age, gender, race, marital status, and socioeconomic status. b Patients with perfect self-reported health-related quality of life (EQ-5D index = 1.) were excluded from the analysis. The Ischemic Stroke Care Path, spanning the in-hospital and ambulatory settings, was implemented in 21. Health-related quality of life, defined by the EQ-5D and measured in the ambulatory setting, has shown greater improvements since implementation of the care path. Reduce the Cost of Care Cleveland Clinic All-Cause 3-Day Readmission Rate to Any Cleveland Clinic Hospital Percent of Discharges N b = Q1 Cleveland Clinic Rate Cleveland Clinic CMI UHC a Academic Medical Centers CMI Q ,991 a These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu b N = Total discharges ,14 Case Mix Index Q3 Q4 Q1 Q2 Q3 Q4 Cleveland Clinic monitors 3-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. Cleveland Clinic s CMI remains one the highest among American Academic Medical Centers Digestive Disease Institute 155

158 Innovations Classification System Improves Endoscopic Therapy of Inflammatory Bowel Disease Cleveland Clinic Digestive Disease Institute (DDI) gastroenterologists have developed a classification system and management algorithm for strictures and fistulae related to inflammatory bowel disease. Using several specific criteria, including stricture length, location, and etiology, the system classifies strictures and fistulae following their endoscopic or radiographic evaluations. The novel classification system was published in Paine E, Shen B. Endoscopic therapy in inflammatory bowel disease (with videos). Gastrointest Endosc. 213;78(6): Classification of Immune-Mediated Pouchitis Provides Insight Into Management, Prognosis Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require proctocolectomy; however, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. DDI gastroenterologists recently proposed a new disease category: immune-mediated pouchitis, as opposed to conventional dysbiosis- or pathogen-associated pouchitis. The subcategories of immune-mediated pouchitis are: Primary sclerosing cholangitis-associated pouchitis/enteritis IgG4-associated pouchitis Autoinflammatory-disorder-associated pouchitis Graft-vs-host-like pouchitis The description of immune-mediated pouchitis has clinical implications for management and prognosis. The disease classification was published in Seril DN, Yao Q, Shen B. The association between autoimmunity and pouchitis. Inflamm Bowel Dis. 214;2(2): Autoimmune Disorders Chronic Antibiotic- Refractory Pouchitis Autoinflammatory Disorders PSC a, IgG4 Diseases GVHD b -like a Primary sclerosing cholangitis b Graft vs host disease 156 Outcomes 213

159 Novel Bear Claw Approach Offers Nonsurgical Repair of J Pouch Leak Cleveland Clinic gastroenterologists have pioneered a novel endoscopic management of a leaking J pouch, using a bear claw closure instrument. Leaks from the tip of a J pouch are not unusual but may increase the risk for pouch failure as the symptoms are nonspecific and difficult to diagnose. Typically, J pouch leaks are managed surgically. This over-the-top clipping system may reduce medical costs and the risks of surgical procedures. The technique was reported in Lian L, Shen B. Closure of leak at the tip of the J after ileal pouch-anal anastomosis using a novel over-the-scope clipping system. J Coloproctol. In press. Three-Dimensional Liver Models Improve Surgical Planning Working with the Medical Device Unit, Cleveland Clinic hepatologists have built more than 2 liver models replicating individual patient livers using advanced three-dimensional (3D) printing technologies. The models are made of a flexible resin with internal lumen geometry generated from a reconstructed CT scan. The printed liver is made of transparent material for direct visualization of vascular and biliary anatomical structure, and thus allows for better planning of complex liver surgeries, including live-donor liver transplantation. The preoperative identification of the vascular and biliary tract anatomy with 3D printing can also prevent unnecessary surgery in patients with potentially unsuitable anatomy. These models were used to plan and provide real-time guidance during surgery for three living donors and their respective recipients who underwent living-donor liver transplantation. Online Tool Facilitates Personal Colon Cancer Risk Assessment In an effort to encourage those at risk for colon cancer to consider undergoing colonoscopy, Cleveland Clinic has developed clevelandclinic.org/score, an innovative online tool for the selfassessment of cancer risk. DDI markets the tool using social media channels, employee events, online articles, and a variety of educational materials. In 213, more than 45 people completed the assessment. Of those, 39 patients underwent at least one colonoscopy in the same year. Since the site s inception in March 21, nearly 2, visitors have completed the assessment. Digestive Disease Institute 157

160 Innovations ELAD Therapy May Affect Survival of Patients With Alcohol-Induced Liver Decompensation Cleveland Clinic hepatologists are participating in a multicenter study evaluating the safety and efficacy of modified extracorporeal liver assist device (ELAD ) therapy to determine overall survival of patients with a clinical diagnosis of alcohol-induced liver decompensation (AILD). ELAD is a biologic-device therapy, containing a blood pump and four metabolically active bioreactors through which a patient s plasma is circulated. Toxins found in the ultrafiltrate diffuse across the semipermeable membrane where they can be metabolized by C3A cells. These metabolites, along with albumin and other beneficial proteins synthesized by the cells, diffuse back across the membrane into the intracapillary space and are returned to the patient. Patients will be randomly assigned to: Standard of care treatment for AILD plus treatment with ELAD Standard of care treatment for AILD alone Endoscopic Device Improves Accuracy of Esophageal Disease Detection Cleveland Clinic is one of the few large centers employing the NvisionVLE Imaging System from NinePoint Medical to evaluate the esophageal microstructure using optical coherence tomography (OCT) during endoscopy. This technology captures a cross-sectional scan of the esophagus to 3 mm beneath the mucosa, at a resolution of 7 µm. Using high-speed OCT, the device incorporates rotation and pullback of the optics, scanning 6 cm of the esophagus in 9 seconds. Device Controls Upper GI Bleeding Hemospray is approved for control of upper GI bleeding in Europe and Canada but not in the United States. Cleveland Clinic gastroenterologists are currently using the agent off-label for compassionate care in patients with upper GI bleeding not amenable to other endoscopic therapies. Hemospray is a powder, sprayed through a catheter that is passed through an endoscope. The mechanism of action is thought to occur by: Physical adherence to the damaged tissue and sealing injured blood vessels to prevent further blood loss Rapid absorption of water from blood, which concentrates all clotting elements on the injured tissue A chemical reaction that activates platelets and the intrinsic coagulation pathway to promote clot formation 158 Outcomes 213

161 Breathprints Identify Novel Biomarkers in Alcoholic Hepatitis Selected-ion flow-tube mass spectrometry (SIFT-MS) can achieve precise identification of trace gases in the human breath in the parts per billion range. Cleveland Clinic hepatologists, in collaboration with the pulmonary team, identified six volatile organic compounds in the breath in patients with liver disease compared with healthy subjects. Of those compounds, trimethylamine (TMA), acetone, and pentane in the exhaled breath were remarkably higher in patients with alcoholic hepatitis (AH) in particular. The hepatology team developed a model for the diagnosis of AH that includes the breath levels of TMA, acetone, and pentane. The breathprint may provide a noninvasive method for the diagnosis of AH as well as have independent prognostic value in these patients. Sensitivity z-specificity TMA + Acetone + Pentane (.93) TMA (.89) Acetone (.78) Pentane (.72).8 1. Digestive Disease Institute 159

162 Innovations Collaborative Developmental Endoscopy Group Works on Device Development, Training Initiatives, Less Invasive Techniques The Developmental Endoscopy Group formed this past year. Three initiatives are described below. Stent placement allows for a minimally invasive endoscopic repair of anastomotic complications following bariatric surgery. This technique avoids revisional surgery, which often results in significant morbidity. A recent Cleveland Clinic study assessed 18 patients who underwent endoscopic stent placement for surgical anastomotic complications including leaks, strictures, and fistulae. All but two patients showed symptomatic improvement, and stent placement was successful in definitively managing the anastomotic complication in 13 of the 18 patients. Five patients required additional surgical or endoscopic intervention. Stent migration occurred in four patients, who were treated successfully with endoscopic management. The group also completed the first endoscopic, fullthickness, gastric tumor excision and endoscopic submucosal dissection for gastric adenocarcinoma, providing a less invasive way of removing gastric tumors. Both tumors were resected completely. The patients are now disease-free and were discharged within 23 hours. In December 213, the Developmental Endoscopy Group completed its first peroral endoscopic myotomy (POEM) procedure, a new surgical treatment for achalasia and other esophageal disorders. Typically, achalasia is treated using a minimally invasive technique that requires several small cuts in the abdomen. POEM obviates the need for incision by using a small knife passed through an endoscope that makes a small slit in the lining of the esophagus to reach the sphincter muscle. Once the blockage is cleared, the endoscope is removed, and the slit is repaired. Patients experience little-to-no pain, resulting in faster recovery. 16 Outcomes 213

163 Novel Intestinal Stroke Program Aims to Preserve Patients Intestines The intestinal stroke program is a multidisciplinary approach to treating patients with intestinal ischemia by a team of gastroenterologists, hematologists, radiologists, and surgeons with the goal of preserving patients intestines. The program, led by the Center for Gut Rehabilitation and Transplantation, is establishing an algorithmic protocol for managing patients and working closely with the Acute Care Surgery team to triage intestinal stroke patients who arrive through the Emergency Department. Multi-Institution Registry Offers Analysis of Intraoperative Radiation Therapy for Breast Cancer Cleveland Clinic has recently established and currently maintains the largest retrospective data collection registry for patients treated with intraoperative radiation therapy (IORT) in North America. IORT is an alternative form of radiation for early stage breast cancer patients with a favorable prognosis. A single dose of radiation is delivered to the lumpectomy site at the time of surgery, rather than the traditional treatment of daily radiation to the whole breast for 6 weeks. Patients undergoing this therapy have their surgical and radiation treatment completed with a single trip to the operating room. The registry includes more than 2 centers across the country and is a collaborative effort aimed at documenting long-term recurrence outcomes and safety. MyFamily Collects Family Health History Prior to Appointment MyFamily, a clinical decision support application built by Cleveland Clinic, enables collection of patient-entered personal and family health history through a MyChart invitation before a scheduled encounter. MyFamily then integrates a disease risk reference document into the electronic medical record at the point-of-care, which represents stratified disease-risk scores along with evidence-based, clinically actionable recommendations. MyFamily facilitates clinicians optimizing their encounter time, allowing them to focus on creating personalized preventive care plans and maximizing the quality of care for patients. In collaboration with the Genomic Medicine Institute, DDI is using the program for the first time with breast cancer and colon cancer patients. Digestive Disease Institute 161

164 Innovations Data Warehouse Enhances Quality Analysis DDI has developed a data warehouse storing electronic medical records (EMR) on more than 7, patients. These data provide information on laboratory reports, medications, admissions and discharges, operative reports, all encounter notes, diagnoses, and patient demographics. Natural language processing parses textual notes into discrete parameters, capitalizing on the use of Epic SmartSets and other structured text within the EMR. Users are able to query data across the population; integrated architecture aligns data into more usable and intuitive results. The warehouse will provide information on quality-of-care measures and monitoring for adherence to clinical pathways. Eventually, the data warehouse will be used to guide clinical decisions, building on the collective knowledge gained from the EMR. Combination Technique Reduces Complications in Resection of Colonic Lesions Endoscopic mucosal resection/endoscopic submucosal dissection (EMR/ESD) reduces complications in resection of challenging colonic lesions, which require advanced endoscopic techniques. Currently, with few exceptions, gastroenterologists refer large, benign, sessile colonic polyps to surgeons for segmental colorectal resections. ESD technique allows the intact removal of polyps and large intraluminal lesions ( en bloc ), which permits precise pathological assessments of resection. DDI colorectal surgeons successfully performed the EMR/ESD technique in more than 26 patients with insignificant complications. Initial experience proves that ESD is feasible and effective and can avoid unnecessary oncologic segmental bowel resections. 162 Outcomes 213

165 Combined Endoscopic and Laparoscopic Surgery Avoids Bowel Resection For difficult colonic lesions, Cleveland Clinic colorectal surgeons perform laparoscopic mobilization of the colon with combined intraoperative CO 2 colonoscopy. A new combined laparoendoscopic approach allows removal of difficult colonic lesions that avoids formal bowel resection. Combined endoscopic and laparoscopic surgery is safely offered to selected patients with benign polyps or early colonic neoplasms that could not be removed by colonoscopy alone. DDI Pioneers Techniques to Prevent Anastomotic Leaks Following Colorectal, Bariatric Surgeries Good blood perfusion at the anastomotic site is the key factor in decreasing clinically apparent, anastomotic problems, which can occur in up to 2% of patients after all colorectal resections. Cleveland Clinic colorectal surgeons have been using objective measurement of tissue perfusion with a near infrared (NIR) endoscopic imaging system, instead of macroscopic appraisal of the tissue. A specialized endoscopic camera and light source capable of acquiring high-definition, white light images and NIR angiographic images constitute this system. Transanal imaging with direct evaluation of the anastomosis is also achieved by using this new technology through a rigid rectoscope. Enhanced robotic visualization developed at Cleveland Clinic can also identify potential anastomotic leaks following bariatric surgery. Using contrast injected into a patient s bloodstream, the robot views the blood supply in any organ with contrast via infrared light, allowing the surgeon to see inconsistencies and treat the anastomosis before it leaks. Digestive Disease Institute 163

166 Contact Information Colorectal Surgery, Gastroenterology and Hepatology, and General Surgery Appointments/Referrals , ext. 47 Bariatric Surgery Appointments/Referrals or , ext Breast Center Appointments/Referrals , ext 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 495 publications in 213. For a complete list, go to clevelandclinic.org/outcomes. Center for Human Nutrition Appointments/Referrals , ext Cleveland Clinic Florida Appointments On the Web at clevelandclinic.org/digestive and clevelandclinic.org/bariatric Locations For a complete listing of Digestive Disease Institute locations, please visit clevelandclinic.org/digestive. 164 Outcomes 213

167 Additional Contact Information General Patient Referral 24/7 hospital transfers or physician consults General Information Hospital Patient Information General Patient Appointments or Referring Physician Center and Hotline 855.REFER.123 ( ) Or or visit clevelandclinic.org/refer123 Request for Medical Records or , ext Same-Day Appointments CARE (2273) Global Patient Services/ International Center Complimentary assistance for international patients and families or visit clevelandclinic.org/gps Medical Concierge Complimentary assistance for out-of-state patients and families , ext. 5558, or Cleveland Clinic Abu Dhabi clevelandclinicabudhabi.ae Cleveland Clinic Canada Cleveland Clinic Florida Cleveland Clinic Nevada For address corrections or changes, please call Digestive Disease Institute 165

168 About Cleveland Clinic 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 3,2 Cleveland Clinic staff physicians and scientists in 13 medical specialties and subspecialties care for more than 5.5 million patients across the system, performing more than 22, surgeries and conducting more than 476, emergency department visits. Patients come to Cleveland Clinic from all 5 states and more than 13 nations around the world. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1,44-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 44 buildings on 167 acres. Cleveland Clinic patients represent the highest CMS case-mix index in the nation. Cleveland Clinic encompasses 75 northern Ohio outpatient locations, including 16 full-service family health centers, eight community 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) scheduled to begin offering services in the spring of 215. Cleveland Clinic is the secondlargest employer in Ohio, with more than 43,4 employees. It generates $1.95 billion of economic activity a year. The Cleveland Clinic Model Cleveland Clinic was founded in 1921 by four 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 system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 199s with the development of 16 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and six other community hospitals joined Cleveland Clinic over the past decade and a half, 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 27. Institutes combine medical and surgical specialists around specific diseases or body systems under single 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. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Riyadh, Saudi Arabia; London, England; Istanbul, Turkey; and Dubai, UAE, as well as El Salvador, Panama, Guatemala, Honduras, the Dominican Republic, and other Caribbean nations. 166 Outcomes 213

169 Cleveland Clinic Lerner Research Institute At the Lerner Research Institute, hundreds of principal investigators, project scientists, research associates, and postdoctoral fellows are involved in laboratory-based translational and clinical research. Total research expenditures from external and internal sources exceeded $248 million in 213. Research programs include cardiovascular, oncology, neurology, musculoskeletal, allergy and immunology, ophthalmology, metabolism, and infectious diseases. Cleveland Clinic Lerner College of Medicine Lerner College of Medicine of Case Western Reserve University is known for its small class size, unique curriculum, and fulltuition scholarships for all students. The program is open to 32 students who are preparing to be physician investigators. Cleveland Clinic is building a new Health Education Campus as the new home for the college and for its partner Case Western Reserve University s schools of medicine, dental medicine, and nursing. Graduate Medical Education In 213, nearly 1,8 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, and its heart and heart surgery program has been ranked No. 1 in the nation since In 213, five programs were ranked No. 2 in the nation diabetes and endocrinology, gastroenterology and GI surgery, nephrology, rheumatology, and urology. For more information about Cleveland Clinic, please visit clevelandclinic.org. Digestive Disease Institute 167

170 Resources Referring Physician Center and Hotline For the 24/7 hotline to streamline access to an array of medical services and schedule patient appointments, call 855.REFER.123 ( ), org, or visit clevelandclinic.org/refer123. A free Physician Referral App is now available so you can get in touch immediately with one click of your iphone, ipad, or Android phone or tablet. Remote Consults Online medical second opinions from Cleveland Clinic s MyConsult are particularly valuable for patients who wish to avoid the time and expense of travel. Cleveland Clinic offers online medical second opinions for more than 1,2 life-threatening and life-altering diagnoses. For more information, visit clevelandclinic.org/myconsult, eclevelandclinic@ccf.org, or call , ext Request Medical Records or , ext Medical Records Online Cleveland Clinic continues to expand and improve electronic medical records (EMRs) to provide faster, more efficient, and more accurate care by sharing patient data through a highly secure network. Patients using MyChart can renew prescriptions and review test results and medications from their personal computers. MyChart provides a link to Microsoft HealthVault, a free online service that helps patients securely gather and store health information. It connects to Cleveland Clinic s social media and Internet site, currently the most visited hospital website in America. For more information, visit clevelandclinic.org/mychart. Critical Care Transport Worldwide Cleveland Clinic s critical care transport team and fleet of mobile ICU vehicles, helicopters, and fixed-wing aircraft serve critically ill and highly complex patients across the globe. To arrange a transfer for STEMI (ST elevation myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call CODE (2633). For all other critical care transfers, call or Track Your Patients Care Online DrConnect offers referring physicians secure access to their patients treatment progress while at Cleveland Clinic. To establish a DrConnect account, visit clevelandclinic.org/drconnect or drconnect@ccf. org. MyPractice Community gives referring physicians online access to their patients test results, medications, and treatment plans during Cleveland Clinic care. Cleveland Clinic s eradiology system offers teleradiology consultation for physicians nationwide. CME Opportunities: Live and Online Cleveland Clinic s Center for Continuing Education operates one of the largest and most successful CME programs in the country. The center s website (ccfcme.org) is an educational resource for healthcare providers and the public. Available 24/7, it houses programs that cover topics in 3 areas. Among other resources, the website contains a virtual textbook of medicine (Disease Management Project) and mycme, a system for physicians to manage their CME portfolios. Live courses, however, remain the backbone of the center s CME operation. Most live courses are held in Cleveland, but outreach plans are underway. 168 Outcomes 213

171 Clinical Trials Cleveland Clinic has promoted research from its earliest days, and has since participated in historic, large, multicenter clinical trials. Today, Cleveland Clinic is running more than 2,2 clinical trials of various types. Researchers are focused on an array of 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. To learn more, go to clevelandclinic.org/research. Cancer Clinical Trials is a new mobile app that provides up-to-date information on the more than 1 active clinical trials available for cancer patients. Download the free Cancer Clinical Trials App at clevelandclinic.org/ cancertrialapp. Healthcare Executive Education Cleveland Clinic s executive education program offers its programs to caregivers worldwide seeking insights into the business, operations, and logistics of a major medical center. The Executive Visitors Program is an intensive three-day behind-the-scenes view of Cleveland Clinic s organization for the busy executive. The Samson Global Leadership Academy is a two-week immersion into the challenges of leadership, management, and innovation. The curriculum includes coaching and a personalized three-year leadership development plan. Learn more at clevelandclinic.org/execed. Digestive Disease Institute 169