Digestive Disease Institute Outcomes

Transcription

1 Digestive Disease Institute 212 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 disease-based 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 techniques. In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives: Joint Commission Performance Measurement Initiative (qualitycheck.org) Centers for Medicare & Medicaid Services (CMS) Hospital Compare (hospitalcompare.hhs.gov) 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 website at clevelandclinic.org/outcomes.

4 Dear Colleague: Welcome to this 212 Cleveland Clinic Outcomes book. We distribute Outcomes books for more than 14 specialties. These publications are unique in healthcare. Each one provides a summary overview of medical or surgical trends, innovations, and clinical data for a Cleveland Clinic specialty over the past year. Cleveland Clinic uses data to manage outcomes across the full continuum of care. Clinical services are delivered through patient-centered institutes, each based around a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. The individual institute defines quality benchmarks for its specialty services and reports 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, media, 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 212

5 what s inside Chairman s Letter 4 Institute Overview 5 Quality and Outcomes Measures Barrett s Metaplasia and Esophageal Cancer 1 Colon Cancer 16 Crohn s Disease 24 Ulcerative Colitis 26 Diverticulitis 27 Small Bowel Disease 28 Liver Disease 31 Pancreaticobiliary Disease 41 Acute Care Surgery 42 Motility Disorders 44 Inpatient Quality and Safety Measures 48 Nutrition 58 Cleveland Clinic Florida Colorectal Surgery 6 Obesity 62 Surgical Quality Improvement 7 Institute Patient Experience 72 Cleveland Clinic Improving Quality, Safety, and the Patient Experience 74 Innovations 8 Selected Publications 84 Staff Listing 9 Contact Information 94 Institute Locations 96 About Cleveland Clinic 98 Resources 1 Breast Disease 53 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. Digestive Disease Institute 3

6 Chairman s Letter I am pleased to present the 212 Outcomes book for Cleveland Clinic s Digestive Disease Institute. This is the 11th year that we have shared our clinical outcomes and innovations with referring physicians, alumni, potential 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. In 212, we experienced continued growth in our clinical programs, research funding, and use of innovative technologies. This past year, there also were many exciting achievements for our institute, including: Continuing to rank No. 2 in the nation for digestive disease care, according to U.S. News & World Report s America s Best Hospitals Survey Receiving a state of Florida Certificate of Need for liver transplant services at Cleveland Clinic Florida, as well as certificates for kidney and heart transplantation Welcoming Kareem Abu-Elmagd, MD, PhD, as Director, Transplant Center, and Director, Center for Gut Rehabilitation and Transplantation Receiving a three-year accreditation by the National Accreditation Program for Breast Centers of the American College of Surgeons for our Breast Center at Cleveland Clinic main campus Receiving the designation of Center of Excellence: Continence Care for Women for Female Pelvic Medicine and Reconstructive Surgery Receiving $8.3 million in research funding, participating in 182 IRB-approved research studies, and publishing more than 425 publications Providing 24,9 Category 1 AMA continuing medical education credit hours to nearly 3, attendees at numerous educational events Training 68 residents and 64 fellows through programs accredited by the Accreditation Council for Graduate Medical Education On behalf of my colleagues, I hope that you find this edition of the Digestive Disease Institute Outcomes book useful. We are grateful for the opportunity to work with you to help our patients lead full lives unencumbered by disease. I value your input and would enjoy hearing from you. I can be reached at Sincerely, John Fung, MD, PhD Chairman, Digestive Disease Institute Medical Director, Allogen Laboratories 4 Outcomes 212

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 patient experience. Departments include Gastroenterology and Hepatology, Colorectal Surgery, General Surgery (including hepato-pancreato-biliary, transplant surgery, and breast surgery), and Human Nutrition. This innovative model of care helps the institute offer the most advanced, safest, and proven treatments performed in the most effective and patient-friendly way, including shorter waits for appointments and more seamless interaction with all specialists. In addition, the institute model enhances opportunities for cuttingedge research and physician education. Throughout the years, Digestive Disease Institute physicians have pioneered many new technologies and procedures for treating digestive disorders, such as continent ileostomy/stapled pouch procedures; advancement flaps/sleeves for perianal fistulas and Crohn s disease; innovative and advanced endoscopic, laparoscopic, and robotic procedures; multiorgan and living donor transplants; multimodality approaches to abdominal malignancies; and the most current medical therapies for a wide variety of gastrointestinal 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. In 212, Digestive Disease Institute faculty produced more than 42 publications. Also in 212, the Digestive Disease Institute offered more than 24, Category 1 AMA continuing medical education credits to nearly 3, attendees at numerous educational events around the world. The Digestive Disease Institute is committed to educating the next generation of specialists and has one of the largest accredited graduate medical education programs in the field, encompassing gastroenterology, general surgery, colorectal surgery, breast surgery, surgical oncology, advanced therapeutic endoscopy, advanced laparoscopic surgery, hepatology, inflammatory bowel disease, and nutrition. In addition, the Wound, Ostomy, Continence Nursing (WOCN) program celebrated its 5th anniversary in 212. To date, it has graduated more than 3, WOCN specialists practicing throughout the world. U.S. News & World Report s America s Best Hospitals survey has ranked the institute s gastroenterology services as No. 2 in the nation every year since Statistics Surgical Cases 18,13 Endoscopic Procedures 59,638 Total Admissions 7,966 Patient Days 57,9 Evaluation & Management Visits 89,26 Digestive Disease Institute 5

8 Institute Overview Digestive Disease Institute Key Specialties Swallowing and Motility Cleveland Clinic s Center for Swallowing and Esophageal Disorders offers a comprehensive program. The center s multidisciplinary team which includes gastroenterologists; radiologists; thoracic surgeons; neurologists; lung specialists; swallowing therapists; and ear, nose, and throat specialists sees about 1,5 patients annually. This center has extensive experience with the SmartPill (Given Imaging Ltd., Yoqneam, Israel), a novel capsule that assesses pressure, acid levels, and motility of the entire gastrointestinal tract. Endoscopy The advanced endoscopy team performs more than 24, endoscopic procedures annually to diagnose and treat intestinal disorders in a new, leading-edge, 15,-squarefoot endoscopy facility. The team offers endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, endoscopic mucosal resection and ablation of dysplastic Barrett s epithelium, and balloon enteroscopy and percutaneous endoscopic gastrostomy, with complication rates at or below the national average. Highly specialized techniques to remove precancerous and early cancerous polyps and other lesions, such as endoscopic mucosal resection and endoscopic submucosal dissection, are also available. A referral service for interpreting images from the pill endoscopy camera, based on the extensive experience of Digestive Disease Institute gastroenterologists, is expanding. Nutrition The institute s Center for Human Nutrition is the most comprehensive and largest center in the nation and includes specialized teams for nutrition therapy, intestinal rehabilitation and transplant nutrition, and nutrition support. The nutrition support team, which was established in 1975, set the national standard for inpatient and outpatient PIC? 6 Outcomes 212

9 intravenous nutrition support. The center is also a leader in intestinal rehabilitation and transplant nutrition, having one of the few such programs in the world. This group collaborates with the newly Medicare-certified intestinal transplant program and the certified bariatric surgery programs of the Endocrinology & Metabolism Institute to provide a variety of bariatric procedure options and support programs. Comprehensive GI The Comprehensive GI Section provides specialized care for digestive disorders with a special focus on rare conditions, including complex celiac disease and small-bowel diseases. Its staff collaborates with the Center for Human Nutrition and other Cleveland Clinic specialists to manage symptoms affecting other organ systems, such as osteoporosis, infertility, skin rashes, low energy, and fatigue. Pelvic Floor This team, led by a multidisciplinary group of physicians with an emphasis on female pelvic floor disorders, is the most experienced group of such specialists in the region. Specialists treat the entire spectrum of bowel disorders, including fecal incontinence, chronic constipation, and other difficulties; anal pain; hemorrhoids; fissures; anal and rectovaginal fistula; and rectal prolapse. Applying leading-edge diagnostics and decades of experience, physicians determine the cause of patients problems and then tailor the most appropriate treatment. 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: Continence Care in Women. Hernia At Cleveland Clinic s Hernia Center, surgeons perform more than 1,7 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, which helps avoid recurrent hernias and complications. Pancreas The Pancreas Disorder Clinic is one of the few centers in the nation specializing in multidisciplinary treatments and frontline research for every type of pancreatic disease and disorder. Together with Cleveland Clinic s Pain Management Department, the clinic helps patients with chronic pancreatitis who struggle with debilitating pain. Auto-islet transplantation is available for select chronic pancreatitis patients who have not responded to medical and alternative surgical management. Liver Digestive Disease Institute liver specialists have the experience and expertise to accurately diagnose and treat all forms of liver disease. This multidisciplinary team works with patients to develop the appropriate treatment plan aimed at preserving liver function and quality of life. Surgeons have extensive experience in major resectional techniques and employ minimally invasive liver resection approaches when feasible. In addition, Cleveland Clinic is a national leader in caring for both adult and pediatric patients with cirrhosis and its complications and has one of the most innovative, experienced, and largest transplant programs in the country. Patients on the wait list receive transplants nearly twice as fast as the average expected national rate, and the institute s one-year survival rate of 91.2 percent exceeds the national average for expected one-year survival rate. Living donor liver transplantation is also an option for selected patients. In 212, a Florida Certificate of Need was approved for liver transplant services at Cleveland Clinic Florida, in addition to certificates for kidney and heart transplantation. Digestive Disease Institute 7

10 Institute Overview Inflammatory Bowel Disease Cleveland Clinic has an international reputation for excellence in treating inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn s disease. Over the years, its physicians have pioneered new technologies and procedures for treating IBD. In addition, they consult on complex cases with colleagues from other disciplines through IBD boards. Cleveland Clinic performs the most operations for IBD, especially the bowel-conserving strictureplasty. It also performs the world s highest volume of J-pouch surgeries and is the nation s largest referral center for repairing failed pelvic pouches. Pouch Disorders The Digestive Disease Institute has developed a center designed to evaluate and treat pouch disorders. Innovative endoscopic approaches are available to treat conditions such as inflammation (pouchitis), strictures, and fistulas. The Pouchitis Clinic was the first such clinic established to treat pouch-associated disorders and remains on the cutting edge in new approaches to management of pouch complications. Gut Rehabilitation and Transplantation The Center for Gut Rehabilitation and Transplantation is one of the few programs in the nation that offers a full spectrum of comprehensive services. Medical and surgical specialists in gastrointestinal diseases, total parenteral nutrition experts, and transplant surgeons evaluate, support, and treat patients all under one roof. Colorectal Cancer The Digestive Disease Institute is at the forefront of colon polyp and cancer prevention through patient screening, education, detection, and treatment. The team has one of the highest volumes of colorectal surgeries in the nation and regularly holds tumor boards to discuss cases with colleagues from other disciplines. The institute s experience allows it to offer treatment options to save the sphincter and minimize the need for an ostomy. The institute also achieves some of the world s lowest recurrence rates. It is one of only a few programs in the country offering hyperthermic intraoperative peritoneal chemotherapy to treat cancers that have spread to the abdominal cavity s lining. The institute is home to the largest institutional registries for inherited colon cancer in the nation and the second-largest in the world the David G. Jagelman Inherited Colorectal Cancer Registries. Acute Care Surgery Program The Acute Care Surgery Program on Cleveland Clinic main campus ensures that a board-certified general surgery staff member is on-site 24 hours a day to provide timely consults in the Emergency Department and inpatient units, and to oversee and teach general surgery residents. The team also provides trauma coverage and surgical intensive care at Cleveland Clinic main campus and at Hillcrest Hospital. Specialty Clinics Streamline Multidisciplinary Care The Digestive Disease Institute also includes a variety of specialty clinics that help physicians collaborate to provide dynamic solutions for their patients. These include the following: Liver Tumor Clinic The Liver Tumor Clinic uses a multidisciplinary approach to treat liver tumors, including surgical resection (open, laparoscopic, robotic). Its team includes medical and radiation oncologists, interventional radiologists, hepatologists, and transplant/hepatobiliary surgeons. The clinic streamlines appointments and provides referring physicians with a central contact point. 8 Outcomes 212

11 Pancreas Disorder Clinic The Pancreas Disorder Clinic unites pancreatic surgeons, gastroenterologists, radiologists, medical oncologists, anesthesiologists, and psychologists to deliver optimal treatments and follow-up care. Patients can see a pancreatologist and surgeon in one visit, and services include endoscopic, minimally invasive, and radiographic imaging to diagnose and treat patients with acute pancreatic inflammation. It is one of a handful of institutions nationwide offering endoscopic pancreatic function testing to help diagnose early-stage pancreatitis. Chronic pancreatitis patients also have been successfully treated with pancreatic resection and auto-islet transplantation to minimize the risk of developing diabetes mellitus. The clinic is one of the few sites in the nation using robotic surgery for certain pancreatic cancers. HNPCC Clinic The Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia has established a multidisciplinary clinic for patients and families affected by hereditary nonpolyposis colorectal cancer, or Lynch syndrome. The Weiss Center has brought together experts from various medical specialties, including gastroenterology, colorectal surgery, gynecology, urology, and genetic counseling, to coordinate care for patients and their families. Breast Center 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 three-year accreditation by the American College of Surgeons National Accreditation Program for Breast Centers. Digestive Disease Institute 9

12 Barrett s Metaplasia and Esophageal Cancer Barrett s Esophagus Cleveland Clinic has a multidisciplinary clinical care and research program dedicated to the management of Barrett s esophagus and early esophageal adenocarcinoma. The program, which offers a number of therapeutic options, grew considerably in 212 due to increased referrals. Endoscopic mucosal resection is performed for removal of intramucosal adenocarcinomas of the esophagus. This procedure is not only used for therapeutic purposes, but it also provides tissue for staging. Number of Endoscopic Mucosal Resections Number N = Outcomes 212

13 Radiofrequency ablation (RFA) 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. Number of Radiofrequency Ablations Number From 211 to 212, the number of RFAs performed increased from 26 to 238. Digestive Disease Institute 11

14 Barrett s Metaplasia and Esophageal Cancer Endoscopic Therapy Endoscopic therapy is playing an increasingly important role in the management of patients with Barrett s esophagus with dysplasia or early cancer. Endoscopic mucosal resection of any nodular lesions followed by RFA of the remaining diseased cells is becoming the standard of care. Cryotherapy is an emerging technique that is being successfully used for treatment of high-grade dysplasia or early cancer. Cleveland Clinic s Center of Excellence for Barrett s Esophagus compared the eradication rates of metaplasia and dysplasia for both these modalities. Mean Number of Sessions and Treatment Duration Required for Radiofrequency Ablation (RFA) vs. Cryotherapy for Treatment of Barrett s Esophagus With Dysplasia or Early Cancer Number 3 2 RFA (N = 49) Cryotherapy (N = 53) 1 Number of Sessions Treatment Duration (Months) Patients who underwent cryotherapy required a greater number of sessions and longer treatment duration to achieve treatment response compared with patients treated with RFA. 12 Outcomes 212

15 Metaplasia and Dysplasia Eradication Rates After Radiofrequency Ablation (RFA) or Cryotherapy for Treatment of Barrett s Esophagus With Dysplasia or Early Cancer Percent 6 4 RFA (N = 49) Cryotherapy (N = 53) 2 Metaplasia Dysplasia No substantial differences between RFA and cryotherapy were seen in the eradication rates for dysplastic Barrett s esophagus or intramucosal carcinoma. Digestive Disease Institute 13

16 Barrett s Metaplasia and Esophageal Cancer Esophageal Adenocarcinoma Number of Endoscopic Procedures Performed in Patients Diagnosed With Esophageal Adenocarcinoma Number Number of Esophageal Surgeries Number N = Major esophageal surgery includes cancer resections and reoperative surgery for motility and reflux disorders. In 212, the center performed 189 esophageal operations with a low one-year mortality rate of 1.5%. 14 Outcomes 212

17 One-Year Mortality Rate for Esophagectomy (N = 189) 212 Percent Observed Expected* *Expected mortality was determined using UHC risk-adjustment methodology. Source: These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Distribution of Esophageal Surgeries by Indication (N = 189) 212 Percent Esophageal Reconstruction Paraesophageal Hernia Repair Cancer Reflux Achalasia N = Other* 23 *Includes abnormal radiologic findings, acquired absence of esophagus (post-esophagectomy), esophageal foreign body, stricture and stenosis of esophagus, tracheoesophageal fistula, and Zenker s diverticulum The surgical staff manages high volumes of both benign and malignant esophageal conditions. Digestive Disease Institute 15

18 Colon Cancer Colon Cancer Screening and Surveillance Cleveland Clinic s cecal intubation rate and mean withdrawal time for colonoscopy equaled or exceeded established benchmarks in 211 and 212. Cecal Intubation Rate for Colonoscopy (N = 24,158) Percent Scope Withdrawal Time for Colonoscopy (N = 6,951 ) Minutes Cleveland Clinic Benchmark* Cleveland Clinic Benchmark* In pilot endoscopy areas where withdrawal time is measured *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): Outcomes 212

19 Polyp Detection Rate During Colonoscopy (N = 9,88) Percent The overall polyp detection rate during colonoscopy has remained stable over the past two years. Digestive Disease Institute 17

20 Colon Cancer Surgical Oncology Colon Cancer Surgical Cases Type of Surgery Major colon surgery, N Laparoscopic approach 46% 63% Patient Characteristics Age, years, mean ± SD 64 ± ± 15 Sex Female 5% 38% Male 5% 62% Body mass index, mean ± SD 3 ± 8 28 ± 6 Postoperative Outcomes Postoperative median length of stay, days 7 7 Surgical site infection rate Superficial 6% 4% Deep % % Organ space 5% 6% Urinary tract infection rate 3% 2% Venous thromboembolism rate 3% 5% 3-day readmission rate 7% 1% In-hospital mortality rate % 1.6% The percentage of patients who benefited from undergoing laparoscopic colon surgery for the surgical treatment of colon cancer greatly increased from 211 to 212. Sixty-three percent of these surgeries were performed laparoscopically in 212, which is double the national average of 31%.* *Bardakcioglu O, Khan A, Aldridge C, Chen J. Growth of laparoscopic colectomy in the United States: Analysis of regional and socioeconomic factors over time. Ann Surg. 213 Aug;258(2): Outcomes 212

21 Five-Year Disease-Free Colon Cancer Survival by Stage Percent Disease-Free Survival Stage I (N = 738) Stage II (N = 1,114) Stage III (N = 935) Stage IV (N = 675) Months After Surgery Digestive Disease Institute 19

22 Colon Cancer Surgical Oncology Rectal Cancer Surgical Cases Type of Surgery Major rectal surgery, N Laparoscopic approach 2% 29% Patient Characteristics Age, years, mean ± SD 62 ± 12 6 ± 13 Sex Female 4% 37% Male 6% 63% Body mass index, mean ± SD 24 ± 6 28 ± 6 Postoperative Outcomes Median length of stay, days 7 7 Surgical site infection rate Superficial 1% 8% Deep %.6% Organ space 5% 12% Urinary tract infection rate 5% 4% Venous thromboembolism rate 4% 3% 3-day readmission rate 14% 8% In-hospital mortality rate %.6% Of the 163 rectal cancer surgeries performed in 212, 134 (82%) were sphincter-saving procedures. This high rate of ostomy avoidance was achieved even though many patients presented with locally advanced disease. The readmission rate substantially dropped in Outcomes 212

23 Disease-Free Rectal Cancer Survival by Stage Percent Disease-Free Survival Stage I (N = 1,348) Stage II (N = 753) Stage III (N = 1,8) Stage IV (N = 476) Months After Surgery Digestive Disease Institute 21

24 Colon Cancer Hereditary Colon Cancer The Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia houses the David G. Jagelman Inherited Colorectal Cancer Registries, the world s most comprehensive listing of patients with hereditary colon cancer. Number of Weiss Center Registry Families Enrolled for Familial Adenomatous Polyposis and Hereditary Nonpolyposis Colorectal Cancer (N = 1,849) Cumulative Number 2, 1,6 1, Inherited colorectal polyps and cancer syndromes often involve organs other than the colon and rectum. The Weiss Center s comprehensive approach to these syndromes includes screening and surveillance of all potentially affected organs. Number of Procedures Performed and Consults Conducted at the Weiss Center The number of families enrolled has steadily increased since the registry s inception in Number (N = 855) 212 (N = 1,115) Colonoscopy Sigmoidoscopy EGD* Thyroid/Renal Ultrasound Gastroenterology Consult Surgical Consult *Esophagogastroduodenoscopy Among the patients in the registry in 212, 21 underwent a sigmoidoscopy, 192 had an esophagogastroduodenoscopy, and 198 underwent a colonoscopy. Patients had the following consults: 16 in endocrine surgery and 14 in medical genetics in the Digestive Disease Institute. Nonpolyposis patients had 25 consults in dermatology, 23 consults in gynecology, and 1 consults in urology. 22 Outcomes 212

25 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. Families Treated by the Weiss Center for Less Common Polyposis Syndromes Number of Families Peutz-Jeghers Syndrome Juvenile Polyposis Syndrome MYH-Associated Polyposis Other* Serrated Polyposis Syndrome N = *Includes Cowden syndrome, Cronkhite-Canada syndrome, and oligopolyposis Digestive Disease Institute 23

26 Crohn s Disease Medical Management Cleveland Clinic s Digestive Disease Institute is the only medical center in the United States that treats pouch sinus with the endoscopic needle knife technique. This is a less invasive alternative therapy to multistage surgical intervention. Endoscopic Needle Knife Therapy Volume Number Pouch Sinus Healing Percent Complete Healing Partial Healing Complete or Partial Healing N = In 212, the institute achieved partial or complete healing of pouch sinus in 1% of patients who underwent the endoscopic needle knife procedure. 24 Outcomes 212

27 Surgical Management Crohn s Disease Surgical Cases Type of Surgery Major small bowel, colon, or rectal surgery, N Laparoscopic approach 36% 34% Patient Characteristics Age, years, mean ± SD 43 ± ± 14 Sex Female 54% 53% Male 46% 47% Body mass index, mean ± SD 25 ± 5 24 ± 6 Postoperative Outcomes Median length of stay, days 7 7 Surgical site infection rate Superficial 7% 6% Deep.4%.4% Organ space 8% 11% Urinary tract infection rate 3% 2% Venous thromboembolism rate 3% 3% 3-day readmission rate 12% 12% In-hospital mortality rate.4% % The Digestive Disease Institute s surgical volumes for Crohn s disease remain the highest in the United States. Through ongoing quality efforts, the surgical team has maintained low 3-day readmission and surgical site infection rates in these often-complex cases. Digestive Disease Institute 25

28 Ulcerative Colitis Surgical Management of Ulcerative Colitis Surgical Cases Major colon and rectal surgeries, N Laparoscopic approach 37% 48% Patient Characteristics Age, years, mean ± SD 42 ± ± 16 Sex Female 42% 46% Male 58% 54% Body mass index, mean ± SD 27 ± 6 26 ± 6 Postoperative Outcomes Median length of stay, days 6 6 Surgical site infection rates Superficial 7% 7% Deep.4% % Organ space 8% 8% Urinary tract infection rate 3% 3% Venous thromboembolism rate 4% 6% 3-day readmission rate 15% 15% In-hospital mortality rate.4% % Cleveland Clinic colorectal surgeons are often able to preserve a problematic J-pouch or revise the J-pouch, when needed, to allow patients with ulcerative colitis to avoid a permanent ostomy. The surgical team has the highest volume in the world of reoperative J-pouch surgeries. Through continued quality improvement efforts, the group has maintained low surgical site infection, urinary tract infection, and readmission rates in this group of patients. 26 Outcomes 212

29 Diverticulitis Surgical Management of Diverticulitis Surgical Cases Major colon surgeries, N Laparoscopic approach 58% 6% Patient Characteristics Age, years, mean ± SD 59 ± ± 13 Sex Female 59% 6% Male 41% 4% Body mass index, mean ± SD 3 ± 9 29 ± 7 Postoperative Outcomes Median length of stay, days 6 6 Surgical site infection rates Superficial 5% 8% Deep 1%.6% Organ space 6% 14% Urinary tract infection rate 3% 4% Venous thromboembolism rate 4% 4% 3-day readmission rate 13% 13% In-hospital mortality rate 2% % The percentage of diverticulitis surgical cases that were completed via a minimally invasive laparoscopic approach increased in the past year. The Digestive Disease Institute s colorectal surgery team is well-equipped to handle these more complex cases, many of which are referred from other surgeons across the United States as well as internationally. A decrease in the readmission rate for these patients is one of the team s goals for the coming year. Digestive Disease Institute 27

30 Small Bowel Disease Balloon Enteroscopy The Digestive Disease Institute has an active enteroscopy program and performs the procedure for various indications. These include obscure bleeding, abnormal capsule endoscopy imaging, ruling out possible small bowel lesions, and inflammatory bowel disease. Antegrade and retrograde numbers are shown below. Antegrade Enteroscopy Number of Procedures N = Retrograde Enteroscopy Number of Procedures N = Outcomes 212

31 Breath Testing Breath Testing Volume Number of Procedures Glucose Lactose Fructose H. Pylori N = Digestive Disease Institute volumes for various breath tests are among the highest in the United States. The volume for each type of test fluctuates from year to year depending on patient population and physician preferences. Increases in breath testing as well as outside referrals and patient volume are anticipated in the coming year. Digestive Disease Institute 29

32 Small Bowel Disease Gut Rehabilitation and Transplant Cumulative Intestinal Transplant Volume Number of Patients The Center for Gut Rehabilitation and Transplantation has performed 22 transplants since the program began in June 28. As a result, the program received Centers for Medicare & Medicaid Services certification in 21 for adult intestinal and multivisceral transplantation. Cumulative Gut Rehabilitation and Transplant Program Growth Number of New Consults 2, Number of Follow-Up Encounters 8, 1,5 6, 1, 5 4, 2, N = ,256 2,488 5,267 7,3 The center had 1,256 new consults and completed 7,3 follow-up encounters for either medical or surgical management in 212. While transplant volume has increased, staff members are frequently able to use less drastic medical and surgical therapies to alleviate nutritional failure. 3 Outcomes 212

33 Liver Disease Medical Management New Outpatient Visits Hepatology Service* (N = 1,573) Number of Patients 3,5 3, 2,5 2, 1,5 1, *Includes new patients and new hepatology consults Initial Inpatient Visits Hepatology Service (N = 2,915) Number of Patients 1, Cleveland Clinic has a very active inpatient and outpatient hepatology practice. Digestive Disease Institute 31

34 Liver Disease Liver Biopsies Performed (N = 1,497) Number of Biopsies N = Liver biopsy is an important tool in the diagnosis and management of liver diseases. From 28 to 212, a total of 1,497 ultrasound-guided percutaneous liver biopsies were performed at Cleveland Clinic. Severe Adverse Events Severe Adverse Events (SAEs) Following Liver Biopsy (N = 18) 212 Type of SAE Number of SAEs SAE Rate Bleeding* 8.53% Severe pain 6.4% Punctured gallbladder 1.7% Hypotension 2.13% Pneumothorax 1.7% *Includes hemoperitoneum (3), subcapsular hematoma (2), hemobilia (2), hemothorax (1) The overall frequency of severe adverse events during 212 was 1.2% (18 of 1,497). This complication rate compares favorably with the reported frequency of these events in the medical literature. 32 Outcomes 212

35 Transplantation and Oncology Liver Transplant Cleveland Clinic performed its first adult liver transplant on Nov. 8, 1984, and has completed 1,834 liver transplants to date. Long-term survival rates exceed national benchmarks, as published in the OPTN/SRTR (Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients) annual report. 1-Year Primary Liver Transplant Patient Survival Percent Survival Cleveland Clinic Benchmark* Years After Transplant N at risk 1,182 1, Cleveland Clinic % = 89.9% 78.% 67.5% Benchmark % = 89.7% 74.3% 61.% Source: Cleveland Clinic transplant database (patients transplanted with a primary liver graft from a deceased donor from 2 212) *Benchmark: 211 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients from Deceased Donors: Transplant Data U.S. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD. Digestive Disease Institute 33

36 Liver Disease Number of Liver Transplants Performed and One-Year Survival Rates Number of Transplants 1,2 1, Percent Survival Outcomes 212

37 Five-Year Survival of Pediatric Primary Liver Transplant Recipients August 1986 December 212 Percent Survival Years After Transplant N at risk Cleveland Clinic performed its first pediatric liver transplant on Aug. 26, 1986, and has completed 75 pediatric liver transplants to date. Digestive Disease Institute 35

38 Liver Disease Innovative Techniques to Increase the Liver Transplant Donor Pool Cleveland Clinic has increased the donor pool for liver transplants while maintaining positive outcomes by utilizing alternative techniques to traditional deceased donor transplants. These techniques include live donor transplant, liver donation after cardiac death, and split liver transplant (a deceased donor liver is divided for two recipients). Patients being transplanted with innovative liver donor techniques tend to have higher Model for End-stage Liver Disease (MELD) scores or liver cancer, making the need for transplantation more urgent. The following graphs show one-year survival outcomes for primary liver patients, donor techniques, and the overall shift in the percentage of innovative vs. standard transplants. One-Year Survival of Live Donor Primary Liver Transplant Recipients October 1999 December 212 Percent Survival Months After Transplant N at risk = Cleveland Clinic performed its first live donor liver transplant on Oct. 5, 1999, and has completed 57 of these transplants to date. 36 Outcomes 212

39 One-Year Survival of Primary Liver Transplant Recipients, Based on Innovative Donor Technique Percent Survival Donation After Cardiac Death Living Donor Split Liver Months After Transplant N at risk = 73/86% 41/85% 47/89% Percentage of Innovative and Standard Liver Donor Techniques Used Percent 1 8 Innovative Standard N = In 212, 31% of the 143 transplants were from the following donor types: living donors (N = 12), split livers (N = 16), and donation after cardiac death (N = 16). Digestive Disease Institute 37

40 Liver Disease Time to Transplant and Transplant Rate Median Time to Transplant for Liver Patients on Wait List January 26 June 211 Months Cleveland Clinic United States* *Source: Based on data available as of April 3, 211, released at srtr.org on July 13, 212 Cleveland Clinic s median time to transplant is nearly half the median time to transplant for the nation, based on data released by the Scientific Registry of Transplant Recipients. Liver Transplant Rate (N = 214) Percent 8 6 Observed Expected 4 2 Cleveland Clinic United States* *Source: Based on data available as of April 3, 211, released at srtr.org on July 13, 212 Cleveland Clinic s transplant rate is 72% greater than its expected rate (P <.1), far exceeding the national average. 38 Outcomes 212

41 3-Day Post-Liver Transplant Readmissions Percent N = Thirty-day liver transplant readmissions decreased from 43% in 211 to 32% in 212. Hepatocellular Carcinoma Five-Year Survival Rate for Hepatocellular Carcinoma (HCC) Patients After Liver Transplant Compared With Those Without HCC Percent Survival No HCC HCC Years After Transplant N at risk = 768/76% 355/75% Digestive Disease Institute 39

42 Liver Disease Liver Tumor Clinic The multidisciplinary Liver Tumor Clinic offers leading-edge medical care to patients with hepatic tumors. In a single visit, patients may be seen by a hepatologist, oncologist, surgeon, and interventional radiologist. The number of patients seen in the clinic has increased each year since 21. Number of Patients Seen in Liver Tumor Clinic Number Total Patients New Patients Median Number of Days From Initial Liver Tumor Clinic Visit to Intervention or First Treatment Days N = Outcomes 212

43 Pancreaticobiliary Disease Various types of pancreatic resections are performed for a variety of indications at Cleveland Clinic. They range from laparoscopic pancreaticoduodenectomy for periampullary neoplasms to total pancreatectomy and islet autotransplant for chronic pancreatitis. Pancreatectomy Cases Variable Surgical cases, N Mean observed length of stay, days Medicare case mix index Non-Medicare case mix index day same hospital readmission rate, % (N) 13.8% (17) 16.% (21) In-hospital mortality rate, % (N) Observed 2.4% (3) 1.5% (2) Expected* 2.4% 1.49% Mortality ratio (observed/expected) *Expected values determined using UHC risk-adjustment methodology Source: These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu From 211 to 212, Cleveland Clinic s mortality rate decreased from 2.4% to 1.5%, which is below the national mean of 4.7%. Source: HCUP Databases. Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality, Rockville, MD. hcup-us.ahrq.gov/databases.jsp Digestive Disease Institute 41

44 Acute Care Surgery The Department of General Surgery implemented an Acute Care Surgery (ACS) program on Cleveland Clinic s main campus in July 21. The core ACS team is made up of six experienced, board-certified general surgeons (each with additional certification in surgical critical care) and a physician assistant. A staff surgeon is dedicated 24 hours per day to attend to the urgent needs of the Emergency Department, inpatients, and transfers to the main campus. These physicians also supervise and educate general surgery residents, anesthesia residents, and critical care fellows. The ACS team provides trauma coverage at Hillcrest Hospital, a Cleveland Clinic hospital. The trauma service is a member of the Northeastern Ohio Trauma System (NOTS). 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 reducing length-of-stay and mortality rates. Trauma Cases and Mean Length of Stay 212 Degree of Injury Hillcrest Hospital Length of Stay Northeastern Ohio Length of Stay N (%) (Days) Trauma System (Days) N (%) No Injury 53 (5.5) 1.43 Injury Unable to Score 7 (.7) 1 Minor (ISS* 1 9) 78 (8.7) ,663 (72) 2.24 Moderate (ISS 1 15) 87 (9) (14.7) 4.49 Severe (ISS 16 24) 2 (2.1) (8.5) 7.91 Critical (ISS 25) 19 (2) (4.8) 1.41 Total/Average 966 (1) ,475 (1) 3.45 *ISS = Injury Severity Score 42 Outcomes 212

45 Acute Care Surgery APR-DRG Severity of Illness at Admission* October 21 November 212 Percent (N = 877) 212 (N = 1,55) Minor Moderate Major Extreme In 212, the ACS team was involved in the care of more than 1, patients. Well over 5% of patients referred to the ACS team suffered from major or extreme physiologic derangement. *APR-DRG severity of illness at admission is defined as the extent of physiologic decompensation or loss of organ system function. Source: These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Observed and Expected In-Hospital Mortality* October 21 November 212 Percent (N = 877) 212 (N = 1,55) Observed Expected* Despite their severity of illness, patients actual mortality rate was substantially less than the expected rate, based on presenting condition. *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 43

46 Motility Disorders Esophageal Motility The Center for Swallowing and Esophageal Disorders has one of the largest esophageal motility laboratories in the country by volume. The center performs high-resolution manometry, traditional 24-hour ph probe studies, 48-hour Bravo ph capsule monitoring, and esophageal impedance manometry and ph impedance studies. Motility Studies Number 8 6 Esophageal Manometry Only Esophageal Manometry With ph Pelvic Floor Total Abdominal Colectomy/Ileorectal Anastomosis for Slow-Transit Constipation Total abdominal colectomy is a surgical option for patients with chronic constipation who have failed medical therapy. Patient satisfaction after colectomy for constipation ranges from 39% to 1% in the medical literature. However, few studies have evaluated changes in validated symptom severity scores after total abdominal colectomy and ileorectal anastomosis (TAC/IRA) for constipation. The Colorectal Center for Functional Bowel Disorders reviewed constipation scores and quality-of-life indices to assess the impact of surgery on the individual. 44 Outcomes 212

47 In the outcomes below, the following scoring systems were used: Constipation Severity Instrument (CSI). Scores range from (no constipation) to 73 (severe constipation). Patient s Global Impression of Change (PGIC) scale. Scores range from to 7, with values of 5 to 7 indicating significant improvement after surgery. Cleveland Clinic s experience in 212: Thirty-three patients had minor postoperative complications (no intervention required). Eighteen patients had major postoperative complications (intervention required). Patients had between one and 15 spontaneous bowel movements per day after surgery. Constipation Severity Index scores improved significantly after TAC/IRA. Patients reported a considerable improvement in quality of life after surgery (PGIC score, 6.3). Data of Patients Who Underwent Total Abdominal Colectomy and Ileorectal Anastomosis for Slow-Transit Constipation 212 Total patients, N 39 Female/Male, N 38/1 Mean age, years 42 Mean length of follow-up, months ± SD 8.21 ± 9.68 Mean interquartile range, months 3 Laparoscopic cases, N 32 Mean operative time, hours ± SD 4. ± 1.48 CSI* and PGIC* Scores of Patients Who Underwent Total Abdominal Colectomy and Ileorectal Anastomosis for Slow-Transit Constipation 212 Score Mean Preoperative Score ± SD Mean Postoperative Score ± SD P Value CSI ± ± PGIC 6.32 ± 1.42 *CSI = Constipation Severity Instrument, PGIC = Patient s Global Impression of Change scale A lower postoperative CSI score or a higher postoperative PGIC score indicates an improved constipation index. Digestive Disease Institute 45

48 Motility Disorders OnabotulinumtoxinA for Posterior Pelvic Floor Issues The ability of onabotulinumtoxina (Botox ) to produce reversible muscle paralysis merits its use in the treatment of anorectal pain disorders secondary to anal muscle spasm. These disorders may include anal fissure or levator spasm. Every year 235, new cases of anal fissure are reported in the United States, and approximately 4% of these cases persist for months or even years. Levator ani syndrome has a prevalence of 6.6% in the general population, occurring predominantly in women. In the outcomes below, the pain visual analog scale scores range from to 1, with 1 being the most severe pain. Cleveland Clinic s experience in 212: Injection of onabotulinumtoxina has been shown to be effective for relaxing anal spasm. Pre- and post-treatment pain scores for anal fissure were 5.4 and 2. (P <.1), respectively. Pre- and post-treatment pain scores for levator ani syndrome were 6. and 4. (P =.2), respectively. Seventy-one percent of patients were happy with the results of their treatment. Seventy-five percent stated that they would recommend the treatment to others. OnabotulinumtoxinA is an effective treatment in patients with anal pain due to anal fissure and levator ani syndrome. Data of Patients Treated With OnabotulinumtoxinA for Anal Fissure or Levator Ani Syndrome 212 Variable Anal Fissure Levator Ani Syndrome Overall (N = 66) (N = 37) (N = 13) Sex Male Female Mean age, years OnabotulinumtoxinA injection > 1, N (%) 17 (25%) 21 (56%) 38 (36%) Mean follow-up, months Outcome, N (%) Resolved 39 (59%) 16 (43%) 55 (53%) Unresolved 2 (3%) 16 (43%) 36 (35%) Recurrence 7 (11%) 5 (13%) 12 (12%) 46 Outcomes 212

49 Neuromodulation via Sacral Nerve Stimulation Neuromodulation via sacral nerve stimulation (SNS) is FDA-approved for the treatment of fecal incontinence. Diarrhea is a common etiology of fecal incontinence and, in some patients, may be impossible to control medically. Cleveland Clinic s experience in 212: Six female patients with severe diarrhea refractory to medical therapy and fecal incontinence underwent SNS device implantation. The etiology of diarrhea/fecal incontinence was idiopathic in three patients; one patient developed irritable bowel syndrome after gastric bypass, and two patients experienced diarrhea/fecal incontinence after total abdominal colectomy. The total number of preoperative bowel movements ranged from six to 25 per day. After SNS device implantation, all patients reported a reduction in the number of daily bowel movements to two to four per day, with no daily accidents. Fecal accidents decreased from multiple daily episodes to one to two times per week. Preoperative Fecal Incontinence Severity Index (FISI) scores ranged between 2 and 61. Postoperative FISI scores ranged from to 1. The average Patient s Global Impression of Change score was 6.6 at follow-up, showing significant improvement in quality of life as a result of the surgical intervention. SNS appeared to control the symptoms of diarrhea, leading to a decrease in symptoms of fecal incontinence. Digestive Disease Institute 47

50 Inpatient Quality and Safety Measures Inpatient Quality and Safety Measures Patient Safety Indicators The Agency for Healthcare Research and Quality s Patient Safety Indicators 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. Accidental Puncture or Laceration Rate per 1, Patients Rate Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q N = 2,217 2,326 2,432 2,32 4,53 4,422 4,644 4,557 4,679 4,861 4,674 3,47 Accidental puncture or laceration rates have decreased since 21 and were sustained at a rate below 1 per 1, patients in Outcomes 212

51 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate per 1, Patients Rate Q1 Reducing the incidence of postoperative pulmonary embolism or deep vein thrombosis remains an area of focus and priority for improvement. A three-hour education session on deep vein thrombosis prevention and prophylaxis was created for residents. The postoperative units implemented a program to improve compliance with the use of intermittent pneumatic compression devices. Central Venous Catheter-Related Bloodstream Infection Rate per 1, Patients Rate 5 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q N = 1,213 1,263 1,344 1,278 2,418 2,338 2,518 2,438 2,38 2,561 2,369 1, Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q N = Implementation of a standard set of interventions for line insertion and line maintenance resulted in improved central venous catheter-related bloodstream infection rates in 211 and 212. Digestive Disease Institute 49

52 Inpatient Quality and Safety Measures Postoperative Hemorrhage or Hematoma Rate per 1, Patients Rate Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q N = 1,27 1,256 1,338 1,271 2,42 2,342 2,56 2,435 2,39 2,553 2,375 1,786 Despite performing complex abdominal and colorectal surgical procedures, the Digestive Disease Institute s postoperative hemorrhage or hematoma rate has steadily improved since 21. Postoperative Respiratory Failure Rate per 1, Patients Rate Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q N = ,572 1,592 1,552 1,486 1,354 1,455 1,485 1,26 Collaboration with the Intensive Care Unit staff has been essential in improving the rate of postoperative respiratory failure. 5 Outcomes 212

53 Colorectal Surgery Pain Management Pain management is important in the clinical care of perioperative colorectal surgery patients. Through the collaborative effort of nurses and physicians, pain management via a patient-controlled analgesia method resulted in an improved patient experience, reduced postoperative pain, and improved clinical outcomes. Patients Requiring PCA* Medication Changes Due to Postoperative Pain September 21 September 212 Percent Sept 211 Mar 211 Sept 212 Mar 212 Sept N = A 64% reduction was seen from 21 to 212 in the need for patient-controlled analgesia narcotic changes due to poor postoperative pain control. *PCA = patient-controlled analgesia Data were collected on 1 colorectal surgery patients every six months. Digestive Disease Institute 51

54 Inpatient Quality and Safety Measures Mean Length of Stay of Colorectal Surgery Inpatients Days Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Percentage of Colorectal Surgery Patients Who Said Their Pain Was Well-Controlled 212 Percent Q1 Q2 Q3 Q4 Cleveland Clinic Benchmark*: 9th Percentile Pain management remains a priority. There was marked improvement in 212. N= *Benchmark: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. hcahpsonline.org 52 Outcomes 212

55 Breast Disease Percentage of Screening Mammograms Resulting in Callback Percent N = ,657 6, ,186 65, ,959 Cleveland Clinic performs a very large number of screening mammograms and has a diagnostic callback program for patients with abnormal screening mammograms. The callback rate has been around 13% since 28, with some variation in 21 due to changes in technology and staffing. Type of Biopsies Performed Percent Excisional Biopsies Core Needle Biopsies Most breast biopsies were nonsurgical, consistent with Cleveland Clinic s minimally invasive approach to breast cancer diagnosis. 2 N = ,257 3, , , ,494 Surgery for Breast Cancer Percent Mastectomy* Lumpectomy 2 N = , ,273 *Includes prophylactic mastectomy with breast reconstruction Digestive Disease Institute 53

56 Breast Disease Breast Cancer Patients newly diagnosed with breast cancer are seen in the multidisciplinary Breast Center, a single location staffed with surgeons, medical oncologists, and radiation oncologists specializing in breast cancer. This arrangement is convenient for patients and allows the closest possible collaboration among physicians in order to develop an integrated treatment plan. Five-Year Relative Survival of Female Patients With All Stages of Breast Cancer (N = 7,646) Percent Survival 1 8 CC Ref Years Since Diagnosis Percent Survival = American Joint Committee on Cancer (AJCC) Stage I IV breast cancer CC = Cleveland Clinic Ref = Fast Stats: An interactive tool for access to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. seer.cancer.gov/faststats (accessed on ) (SEER 13) 54 Outcomes 212

57 Five-Year Relative Survival of Patients With Breast Cancer by Stage at Diagnosis (N = 7,646) Percent Survival Stage I CC (N = 3,835) Stage I Ref Stage II CC (N = 2,755) Stage II Ref Stage III CC (N = 752) Stage III Ref Stage IV CC (N = 34) Stage IV Ref Years Since Diagnosis Percent Survival by Stage Years Since Diagnosis Stage I II III IV 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 55

58 Breast Disease Overall Survival of Patients With Early-Stage Breast Cancer Treated With Radiation (N = 2,13) Percent Survival Stage CC (N = 38) Stage Ref Stage I CC (N = 1,34) Stage I Ref Stage IIA CC (N = 54) Stage IIA Ref Stage IIB CC (N = 284) Stage IIB Ref Years Since Treatment Percent Survival and (Number at Risk) by Stage Years Since Treatment Stage (286) (265) (237) (29) (194) I (977) (927) (87) (83) (763) IIA (468) (437) (392) (361) (335) IIB (261) (233) (214) (197) (174) 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 212

59 Overall Survival of Patients With Late-Stage Breast Cancer Treated With Radiation (N = 466) Percent Survival Stage IIIA CC (N = 166) Stage IIIA Ref Stage IIIB CC (N = 9) Stage IIIB Ref Stage IIIC CC (N = 31) Stage IIIC Ref Stage IV CC (N = 179) Stage IV Ref Years Since Treatment Percent Survival and (Number at Risk) by Stage Years Since Treatment Stage IIIA (148) (127) (11) (94) (82) IIIB (76) (59) (54) (49) (45) IIIC (27) (18) (1) (7) (4) IV (15) (81) (63) (36) (23) 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 57

60 Nutrition The Center for Human Nutrition provides evaluation, education, and treatment to people who have disease-related nutrition problems. With one of the largest multidisciplinary teams in the nation, the center offers a variety of services, including nutrition support, intestinal rehabilitation, and transplant for patients with severe gastrointestinal dysfunction or failure. Ongoing nutrition research supports these areas, making the center an internationally recognized leader in the field of specialized nutrition support. Several outpatient nutrition programs provide services at family health centers throughout a five-county area, and community-related programs are also available. Nutrition Service Volume Service Hospital parenteral nutrition patients 1,324 1,348 1,585 1,823 Small-bowel feeding tube placement consults N/A* 2,899 2,579 2,222 Feeding tubes placed 2,149 2,136 1,754 1,542 New home total parenteral nutrition patients Outpatient consults 12,353 14,454 16,662 16,68 Center for Gut Rehabilitation and Transplant Clinic patients Home enteral nutrition patients Eat Right at School Program (no. of schools participating) Media events and health fairs Employee health consults 1,433 2,368 *Data not available 58 Outcomes 212

61 Home Parenteral Nutrition-Related Readmissions Percent Readmitted per Complication (N = 88) 29 (N = 123) 21 (N = 135) 211 (N = 115) 212 (N = 19) 1 HPN* Complications CRBSI Dehydration Other HPN Reasons Complication *HPN = home parenteral nutrition CRBSI = catheter-related bloodstream infection Home parenteral nutrition frequently results in hospital readmission. In 212, a 6% decrease from 211 was seen in the number of patients readmitted due to complications of home parenteral nutrition. Of those readmissions, the most common reason was catheter-related bloodstream infection, which decreased to 9% in 212. Other complications, such as noninfectious catheter complications, electrolyte disturbances, and venous thrombosis, also caused home parenteral nutrition-related readmissions. Digestive Disease Institute 59

62 Cleveland Clinic Florida Colorectal Surgery As the largest colorectal surgery center in Florida, Cleveland Clinic s Department of Colorectal Surgery diagnoses and treats a broad array of diseases of the colon, rectum, and anus. The staff has pioneered improvements in patient care for rectal cancer, ulcerative colitis, familial adenomatous polyposis, Crohn s disease, fecal incontinence, and hemorrhoids. Additionally, the surgical team has developed or helped develop numerous techniques, including stimulated graciloplasty, sacral nerve stimulation, artificial bowel sphincter, adhesion barriers, reconstruction with a colonic J-pouch following rectal cancer removal, and laparoscopic management of colorectal disorders. U.S. News & World Report has repeatedly cited the center as being among the top 5 colorectal programs in the country. Colorectal Surgery Case Volume Number of Procedures 1,6 1,2 Anorectal Abdominal The Department of Colorectal Surgery performed more than 1,5 surgical procedures in 212, including both inpatient abdominal surgeries and outpatient anorectal operations. The majority of abdominal colorectal surgeries were performed in a minimally invasive manner using a laparoscopic or robot-assisted technique, and the percentage of cases performed annually with these techniques continues to rise. 6 Outcomes 212

63 Colorectal Surgery Cases by Type 212 Number of Procedures J-Pouch Anorectal Laparoscopic Abdominal Open Abdominal The department continues to act as a tertiary referral center for patients with complex inflammatory bowel disease. In 212, more than 2 patients underwent surgical intervention for ulcerative colitis and Crohn s disease, and 87 patients underwent total proctocolectomy with creation of an ileal reservoir, making Cleveland Clinic Florida one of the busiest centers in the nation for this procedure. More than 15 patients underwent surgery for rectal cancer, the majority via a minimally invasive approach. The department also continues to be a leader in the treatment of fecal incontinence, with one of the largest series of patients treated with sacral nerve stimulation and other advanced treatments such as the artificial bowel sphincter. Colorectal Surgery Cases by Disorder or Disease 212 Number of Procedures Rectal Prolapse Constipation Fecal Incontinence Rectal Cancer Irritable Bowel Disease Digestive Disease Institute 61

64 Obesity Bariatric Surgery In 212, Cleveland Clinic Bariatric and Metabolic Institute marked its seventh anniversary and continued to be accredited as a designated Bariatric Surgery Center of Excellence by the American Society for Metabolic & Bariatric Surgery and the American College of Surgeons. This designation is awarded to programs that meet high quality standards and perform a minimum of 125 procedures annually. Bariatric Surgery Cases by Type Cases Other Duodenal Switch Gastric Plication Banded Plication Revision Band Sleeve Bypass 212 Laparoscopic Roux-en-Y gastric bypass, with 429 cases, continues to be the most frequently performed bariatric procedure at Cleveland Clinic. Laparoscopic sleeve gastrectomy was the second most commonly performed procedure in 212, with 117 cases. Due to patient preference, laparoscopic adjustable gastric banding has declined over the past three years. Bypass Sleeve Banded Plication Gastric Plication Band Duodenal Switch 75% 2% 3% < 1% < 1% < 1% 212 Percentage of Cases 62 Outcomes 212

65 Comorbidities at Baseline Among Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Percent 8 6 Cleveland Clinic (N = 1,244) MBSC* (N = 2,949) 4 2 Hypertension Obstructive Sleep Apnea Hyperlipidemia Diabetes Mellitus Smoking Venous Thromboembolism.9.2 Renal Failure Comorbidities at Baseline Among Patients Undergoing Laparoscopic Sleeve Gastrectomy Percent 8 6 Cleveland Clinic (N = 221) MBSC* (N = 2,949) 4 2 Hypertension Obstructive Sleep Apnea Hyperlipidemia Diabetes Mellitus Smoking Venous Thromboembolism.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; 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): Digestive Disease Institute 63

66 Obesity Bariatric Surgery Length of Stay Readmission Rates for Laparoscopic Sleeve Gastrectomy Days 8 6 Cleveland Clinic UHC U.S. News Top 1* Percent 8 6 Cleveland Clinic (N = 186) UHC U.S. News Top 1* (N = 645) Laparoscopic Laparoscopic Roux-en-Y Sleeve Gastrectomy N = 1,299 2, Days 14 Days 7 Days Time After Discharge Readmission Rates for Laparoscopic Roux-en-Y Gastric Bypass Percent 8 6 Cleveland Clinic (N = 1,299) UHC U.S. News Top 1* (N = 2,256) Days 14 Days 7 Days Time After Discharge *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu 64 Outcomes 212

67 The Bariatric and Metabolic Institute has focused on reducing the 3-day readmission rate for nausea, fluid and electrolyte issues, and dehydration, with an emphasis on patients readmitted for one day or less. To ensure patients receive intravenous therapy for dehydration in the most appropriate setting, in late 21 the institute implemented an ambulatory hydration clinic. 3-Day Readmission Rates for All Bariatric Surgery Types (N = 2,696) Percent Day Complication Rates* for Laparoscopic Roux-en-Y Gastric Bypass Readmission Rates Linear Rate Trend Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Percent 5 4 Cleveland Clinic (N = 1,223) MBSC (N = 2,949) Bleeding Wound Infection/ Evisceration Intestinal Obstruction Anastomotic Leak Deep Vein Thrombosis Respiratory Complications *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; 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): Digestive Disease Institute 65

68 Obesity Percentage of ICU Cases Based on Revenue Code Data: Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy Percent Cleveland Clinic UHC U.S. News Top 1* UHC AAMC Teaching N = 1,457 2,91 28,23 *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu AAMC Teaching = Association of American Medical Colleges Teaching Hospitals 3-Day Mortality Rates for Bariatric Surgery Type Cleveland Clinic BOLD* % (N) % (N) All bariatric surgeries.3 (1,716).1 (186,576) Laparoscopic Roux-en-Y gastric bypass.4 (1,239).14 (136,36) Laparoscopic sleeve gastrectomy. (219).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; San Diego, CA. Abstract P-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 Apr;214(4): Outcomes 212

69 Mean Percent Weight Loss* Toward Ideal Body Mass Index at Follow-Up Percent Year 2 Years 3 Years 4 Years 2 All Cases Laparoscopic Laparoscopic Laparoscopic Roux-en-Y Sleeve Banding N = 1, N/A N/A *Weight loss formula: (baseline BMI follow-up BMI) / (baseline BMI ideal BMI [25]) x 1 For cases followed up at four years, laparoscopic Roux-en-Y gastric bypass had the highest percentage of weight loss toward ideal body mass index at 64%. Body Mass Index (BMI) Reduction at Four Years BMI (kg/m 2 ) Baseline 4 Years All Cases Laparoscopic Laparoscopic Roux en Y Banding N = Digestive Disease Institute 67

70 Obesity Comorbidity Resolution at One-Year Follow-Up for Laparoscopic Roux-en-Y Percent Cleveland Clinic MBSC* Diabetes Sleep Apnea Hyperlipidemia Hypertension N = , , ,533 *MBSC = Michigan Bariatric Surgery Collaborative Diabetes includes only non-insulin type for MBSC, insulin and non-insulin types for Cleveland Clinic. 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 212

71 Medical Weight Loss In 212, the Diabetes Center offered group or individual appointments for weight loss, provided by registered dietitians. Thirty-five patients had an initial visit, 23 (66%) had at least one follow-up visit, and 12 patients were lost to follow-up. The average follow-up duration was five months. At the initial visit, 33 patients (94%) were female (average age, 47 years; range, 24 61). Of this group, nearly half (17) attended group sessions. Body Mass Index (BMI) of Patients Who Had at Least One Follow-Up Visit for Weight Loss (N = 23) 212 BMI (kg/m 2 ) Initial Visit P <.1 Last Visit In the 23 patients who had at least one follow-up visit for weight loss, a significant reduction in body mass index was seen at the patients last visit vs. the initial visit (P <.1). Average Weight Loss by Appointment Type (N = 23) 212 Pounds Lost Group Individual N = 8 15 Patients showed successful weight loss whether they attended group or individual sessions. Those in the group setting lost an average of 17 lbs, whereas those attending individual sessions lost an average of 26 lbs. Weight Loss by Gain/Loss Category (N = 23) 212 Number of Patients Gained Lost Weight 1 1 lbs Lost 11 2 lbs Lost > 2 lbs Of the 23 patients who had at least one follow-up visit for weight loss, 13 lost more than 2 lbs. Of the 18 patients who lost weight, seven patients (38%) changed from a higher to a lower body mass index category five from obese ( 3) to overweight (25 29) and two from severely obese (4+) to obese (3 39). Digestive Disease Institute 69

72 Surgical Quality Improvement National Surgical Quality Improvement Program The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. The outcomes data below reflect Cleveland Clinic s performance benchmarked against more than 35 participating hospitals. Cleveland Clinic Overall Multispecialty Surgery July 211 June 212 Outcome N Observed Rate (%) Expected Rate (%) Performance* 3-Day Mortality 4, Low 3-Day Morbidity 4, High In addition to the overall Cleveland Clinic performance above, NSQIP data specific to the Digestive Disease Institute is summarized in the following table. General Surgery July 211 June 212 Outcome N Observed Rate (%) Expected Rate (%) Performance* 3-Day Mortality 1, NS 3-Day Morbidity 1, High Cardiac Arrest/Myocardial Infarction 1, NS Pneumonia 1, NS Unplanned Intubation 1, NS Ventilator > 48 hours 1, NS Deep Vein Thrombosis/Pulmonary Embolism 1, NS Renal Failure 1, NS Surgical Site Infection 1, High Urinary Tract Infection 1, NS Colorectal Surgery July 211 June Day Mortality NS 3-Day Morbidity NS Length of Stay High Surgical Site Infection NS Urinary Tract Infection NS *Low = signficantly better than expected, High = significantly worse than expected, NS = no significant difference 7 Outcomes 212

73 Surgical Care Improvement Program (SCIP) Appropriateness of Care This composite metric, based on 1 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 UHC 9th Percentile, 212* N = 1,51 1,293 *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Cleveland Clinic has set a target of UHC s 9th percentile, and results are trending positively. Digestive Disease Institute 71

74 Patient Experience Digestive Disease Institute Cleveland Clinic is dedicated to delivering excellent clinical outcomes and the best possible experience for our patients and their families. Patient feedback is critical in driving priorities and assessing results. Based on this feedback, Cleveland Clinic s Office of Patient Experience implements training programs to improve service and communication as well as educational initiatives to help patients understand what to expect when they are in our care. Outpatient Office Survey Digestive Disease Institute Percent Best Response* (N = 2,291) (N = 2,538) Appt Access/ Check-In Clinic Wait Times and Comfort Nurse and Assistant *Response options: Very Good, Good, Fair, Poor, Very Poor Each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendor Physician Concern for Needs and Privacy Overall Assessment 72 Outcomes 212

75 Inpatient Survey Digestive Disease Institute HCAHPS Overall Assessment Percent Best Response* 1 8.2% 82.5% Recommend Hospital (% Definitely Yes)* 211 (N = 1,95) 212 (N = 1,998) 74.5% 77.3% Hospital Rating (% 9 or 1) 1 Scale *Response options: Definitely Yes, Probably Yes, Probably No, Definitely No Source: Press Ganey, a national hospital survey vendor 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. The guiding principle of Cleveland Clinic is Patients First, and improving the patient experience is a major strategic organizational goal. The Office of Patient Experience collaborates with physician and nursing leadership to establish best practices and implement standardized protocols that ensure delivery of patientcentered care. HCAHPS Domains of Care Percent Best Response* (N = 1,95) 212 (N = 1,998) Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs *Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendor Quiet at Night Digestive Disease Institute 73

76 Cleveland Clinic Improving Quality, Safety, and the Patient Experience Overview Cleveland Clinic health system uses a scorecard approach to measure and monitor quality, safety, and patient experience. Real-time dashboard data are leveraged in each 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. The following measures are examples of health system 212 quality and safety focus areas. Throughout this section, Cleveland Clinic refers to the academic medical center or main campus, and those results are shown. Cleveland Clinic Core Measures Appropriateness of Care All-Cause 3-Day Readmission Rate to Any Cleveland Clinic Hospital Percent of Patients Q1 Cleveland Clinic Performance Cleveland Clinic Target Q2 Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic s goal is for all patients to receive all the recommended care for their condition. An aggregated all or nothing measurement approach to monitoring multiple publicly reported process-of-care measures for heart failure, acute myocardial infarction, pneumonia, and surgery patients yields results consistently above 94%. Percent of Discharges Cleveland Clinic Performance 4 2 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q 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. 74 Outcomes 212

77 Cleveland Clinic Overall In-Hospital Mortality Observed/Expected Ratio O/E Ratio Q1 Q2 Cleveland Clinic Performance UHC* 5th Percentile (Academic Medical Center) Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic s observed/expected (O/E) mortality ratio outperformed the University HealthSystem Consortium (UHC) academic medical center 5th percentile throughout 212 based on the UHC 212 risk model. Ratios less than 1. indicate mortality performance better than expected in UHC s risk adjustment model. Cleveland Clinic Deaths Among Surgical Patients With Serious Treatable Complications (PSI 4) Rate per 1, Eligible Patients Rate per 1, Patients Cleveland Clinic Performance 6 UHC* 5th Percentile 4 (Academic Medical Center) 2 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q The Agency for Healthcare Research and Quality s Patient Safety Indicator 4 (AHRQ PSI 4) reports deaths among patients with serious treatable complications. Cleveland Clinic performs in the top third of UHC s academic medical centers for this measure. *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu Digestive Disease Institute 75

78 Cleveland Clinic Improving Quality, Safety, and the Patient Experience Cleveland Clinic Postoperative Blood Clot Rate (PSI 12) per 1, Eligible Patients Cleveland Clinic Central Line-Associated Bloodstream Infection ICU Rate per 1, Line Days Rate per 1, Patients Cleveland Clinic Performance UHC* 5th Percentile (Academic Medical Center) Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic continues to improve its performance with respect to postoperative blood clots (AHRQ Patient Safety Indicator 12). Improved screening and prevention strategies have led to a 45% reduction in these events over the past two years. Rate per 1, Line Days Cleveland Clinic Performance Cleveland Clinic Target Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSI), including a central-line bundle of insertion, maintenance, and removal best practices. In 212, Cleveland Clinic initiated focused reviews of every CLABSI occurrence and is introducing equipment and technology to support reductions in CLABSI rates in its high-risk critical care population. *These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu 76 Outcomes 212

79 Cleveland Clinic Hospital-Acquired Pressure Ulcers Prevalence Cleveland Clinic Falls Rate per 1, Patient Days Percent Q1 Q2 Cleveland Clinic Performance NDNQI * 5th Percentile (Academic Medical Center) Q3 Q4 Q1 Q2 Q3 Q Rate per 1, Patient Days Q1 Q2 Cleveland Clinic Performance NDNQI * 5th Percentile (Academic Medical Center) Q3 Q4 Q1 Q2 Q3 Q A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing positions on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning help while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur. Nationally, falls are a leading cause of hospital patient injury. Cleveland Clinic fall prevention efforts include identifying patients who are at risk for falls, checking on them frequently, assisting them to the bathroom, and providing nonskid footwear. Caregivers make sure patients have all necessary items, including a call light, within easy reach. *The National Database of Nursing Quality Indicators (NDNQI ) is owned by the American Nurses Association. The database collects and evaluates unit-specific nurse-sensitive data from hospitals domestically and globally, with > 19 hospitals participating. The comparison data represented here are based on a third of all hospitals in the U.S. participating. 212, American Nurses Association, All Rights Reserved. nursingquality.org Digestive Disease Institute 77

80 Cleveland Clinic Improving Quality, Safety, and the Patient Experience Patient Experience The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a standardized national tool used to measure patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare. Cleveland Clinic HCAHPS Overall Assessment Percent Best Response* (N = 1,378) 212 (N = 11,19) 4 National Average July 1, 211 June 3, Recommend Hospital (% Definitely Yes)* Hospital Rating (% 9 or 1) 1 Scale *Response options: Definitely Yes, Probably Yes, Probably No, Definitely No Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor 78 Outcomes 212

81 Cleveland Clinic HCAHPS Domains of Care Percent Best Response* (N = 1,378) 212 (N = 11,19) National Average July 1, 211 June 3, Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs *Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor Quiet at Night The guiding principle of Cleveland Clinic is Patients First, and improving the patient experience is a major strategic organizational goal. The Office of Patient Experience collaborates with physician and nursing leadership to establish best practices and implement standardized protocols that ensure delivery of patient-centered care. Digestive Disease Institute 79

82 Innovations Wireless Capsule Provides Motility Data Digestive Disease Institute gastroenterologists are utilizing a new technology in the evaluation of chronic constipation and gastroparesis. The SmartPill GI Monitoring System is an office-based procedure that may offer advantages over marker studies and gastric emptying studies. These include: Eliminates radiation exposure Provides direct access to gastrointestinal motility data Measures both regional and whole gut transit time Is an ambulatory procedure To date, Cleveland Clinic s capsule endoscopy team has performed more than 2 procedures using the monitoring system, more than any other medical facility in the United States. Mobile Data Management Software for Inherited Colorectal Cancer A team of Cleveland Clinic surgeons, genetic counselors, and computer scientists designed Cologene, data management software that allows clinicians to draw pedigrees and collect histories of families with colorectal cancer on mobile devices such as the ipad. The benefits of the software include: An individual s family history can be combined with other clinical and genetic data to develop more effective personalized treatments. The software makes possible the use of structured family histories to examine clinical and genetic variation within hereditary diseases. Researchers can get insights into complex diseases by analyzing pedigree data and linking genetic findings to clinical outcomes. The software supports the largest hereditary colorectal cancer registry in the world. It can record data for syndromes such as familial polyposis, Lynch syndrome, juvenile polyposis, and Peutz-Jeghers syndrome. 8 Outcomes 212

83 Colorectal Cancer Translational Science Research Laboratory Findings BRAF Oncogene Mutations Linked to Decreased Survival Researchers analyzed genetic mutations in colorectal cancer and showed that mutations in the BRAF oncogene are associated with distinct clinical characteristics and with significantly worse survival in colorectal cancer (Dis Colon Rectum. 212;55[2]: ). Gene Expression Signatures Reveal Lymph Node Metastasis Surgeon-scientists evaluated gene expression profiles from rectal cancers and showed that distinct gene expression signatures from primary rectal cancers can help determine the presence or absence of lymph node metastasis (Dis Colon Rectum. 212;55[6]: ). Lymph node involvement is an important factor in determining preoperative therapy, which must be chosen before definitive pathologic staging is available. Traditional means of preoperative staging are only about 7% to 8% accurate in predicting node positivity. This more objective staging tool can help inform the management approach to the tumor. Variant Enhancer Loci Help Identify Colon Cancer Cleveland Clinic colorectal cancer researchers collaborated with colleagues from other institutions in a National Cancer Institute-supported multicenter study to identify variant enhancer loci (VELs). These master switches control key genes whose altered expression is defining for colon cancer. VELs are unique, previously unidentified factors that may exert important influences on individuals differing susceptibilities to colon cancer (Science. 212;336[682]: ). Stool Sample Screening for Genetic Tumor Markers Collaboration between Cleveland Clinic and Cleveland State University has resulted in refining a battery of tests to screen stool samples for genetic tumor markers. The battery applies customized quantitative polymerase chain reaction techniques to detect the presence of methylated DNA markers in fecal samples. In its current state of development covering a limited number of tumor markers, the battery has a sensitivity of about 85% for sporadic colon cancer and colitis-associated cancer. The screening battery builds on the collaborators hypothesis that fecal methylated DNA markers may precede endoscopic and histologic detection of colorectal adenocarcinoma by at least 12 months. In some cases, stool samples show tumor markers several years before adenoma or carcinoma was detectable otherwise. The effort to refine the battery takes advantage of a proprietary stool preservative that allows samples to be stored at room temperature for long periods without degradation. Flat, cancerous lesion of lower gut that went undetected with routine endoscopy. Genetic markers for cancer were present in the stool sample of the patient. Digestive Disease Institute 81

84 Innovations Genetic Defect Associated With Increased Risk of Developing Ulcerative Colitis The HLA region on chromosome 6 has always been suspected of playing a key role in the development of inflammatory bowel disease, but specific genetic variants have been difficult to identify and confirm. A large collaborative study between researchers at Cleveland Clinic and the University of Pittsburgh evaluated DNA samples from patients with inflammatory bowel disease and controls and found that variation in the HLA-DRβ1 gene was strongly related to ulcerative colitis. Specifically, a defect in this gene a variation at amino acid position 11 was found to be strongly associated with the risk of developing ulcerative colitis. This position is in a crucial binding pocket likely to have significant influence on immune response to antigens. Deficiency of Human Natural Antimicrobial Peptides May Explain Predisposition to Crohn s Disease Researchers from Cleveland Clinic and four other U.S. medical centers have discovered the key role of an antimicrobial peptide that is an important factor in healthy guts and those with disease, including Crohn s disease. The study showed that human α-defensin 6 (HD6) protects the gut from invasion by enteric bacteria (Science. 212; 337[693]: ). Patients with Crohn s disease characteristically have alterations in the bacterial profile of the surface of the intestinal epithelium. Their predisposition to inflammatory bowel disease may be, in part, the result of an HD5 and HD6 deficiency. Intestinal Paneth cell antimicrobial peptides (defensins and lysozymes) 82 Outcomes 212

85 Compound Mitigates Cirrhosis-Related Muscle Loss Cleveland Clinic hepatologists are using a five-year NIH award to examine the mechanisms of sarcopenia due to cirrhosis using a combination of tracer methodology and molecular biology tools, both in vivo and with in vitro cell systems. Initial animal research demonstrated the causal role of the protein myostatin in the reduced skeletal muscle mass that accompanies cirrhosis. Based on that finding, the team generated a compound called follistatin, which blocks myostatin and its effects on muscle. Follistatin was able to reverse cirrhosis-related muscle loss without affecting the liver. Further research is needed to assess follistatin s effect on other tissues. Application Enables Real-Time Tracking of Quality Metrics To optimize patient care pathways, Cleveland Clinic staff members have developed an Android tablet-based application. The program: Allows for real-time, efficient collection and tracking of important quality metrics by physicians and support staff Facilitates collection of staging and diagnosis information for patients treated in the multidisciplinary breast cancer program Generates real-time longitudinal performance reports The breast program leadership group is working on implementation of a real-time quality tracking system that will optimize patient care and meet ongoing requirements for maintenance of accreditation by the National Accreditation Program for Breast Centers of Excellence. Staff members hope to expand quality tracking into other solid tumor groups to allow further optimization of care pathways and outcomes for all patients with solid tumors. Digestive Disease Institute 83

86 Selected Publications The Digestive Disease Institute staff authored more than 4 publications in 212. For a complete list go to clevelandclinic.org/outcomes. Center for Human Nutrition Calogeras E, Zeller M, Hoover C, Cooper K, Tuininga P, Ashton K. Sleeve gastrectomy patients may be at increased risk postoperatively for decline in vitamin B12 values do they need monitoring? Bariatr Nurs Surg Patient Care. 212 Mar;7(1): Cresci G, Hummell AC, Raheem SA, Cole D. Nutrition intervention in the critically ill cardiothoracic patient. Nutr Clin Pract. 212 Jun;27(3): Glass C, Hipskind P, Cole D, Lopez R, Dasarathy S. Handheld calorimeter is a valid instrument to quantify resting energy expenditure in hospitalized cirrhotic patients: a prospective study. Nutr Clin Pract. 212 Oct;27(5): John BK, Khan MA, Speerhas R, Rhoda K, Hamilton C, Dechicco R, Lopez R, Steiger E, Kirby DF. Ethanol lock therapy in reducing catheterrelated bloodstream infections in adult home parenteral nutrition patients: results of a retrospective study. JPEN J Parenter Enteral Nutr. 212 Sep;36(5): Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr. 212 Nov;36(6): Konrad D, Corrigan ML, Hamilton C, Steiger E, Kirby DF. Identification and early treatment of dehydration in home parenteral nutrition and home intravenous fluid patients prevents hospital admissions. Nutr Clin Pract. 212 Dec;27(6): Suryadevara S, Celestin J, Dechicco R, Austhof S, Corrigan M, Speerhas R, Steiger E. Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge. Nutr Clin Pract. 212 Apr;27(2): Cleveland Clinic Florida Brown HW, Wexner SD, Segall MM, Brezoczky KL, Lukacz ES. Accidental bowel leakage in the mature women s health study: prevalence and predictors. Int J Clin Pract. 212 Nov;66(11): Devroede G, Giese C, Wexner SD, Mellgren A, Coller JA, Madoff RD, Hull T, Stromberg K, Iyer S. Quality of life is markedly improved in patients with fecal incontinence after sacral nerve stimulation. Female Pelvic Med Reconstr Surg. 212 Mar;18(2): Outcomes 212

87 Ding JH, Canedo J, Lee SH, Kalaskar SN, Rosen L, Wexner SD. Perineal rectosigmoidectomy for primary and recurrent rectal prolapse: are the results comparable the second time? Dis Colon Rectum. 212 Jun;55(6): Edden Y, Wexner SD, Berho M. The use of molecular markers as a method to predict the response to neoadjuvant therapy for advanced stage rectal adenocarcinoma. Colorectal Dis. 212 May;14(5): Colorectal Surgery Akhtar-Zaidi B, Cowper-Sal-lari R, Corradin O, Saiakhova A, Bartels CF, Balasubramanian D, Myeroff L, Lutterbaugh J, Jarrar A, Kalady MF, Willis J, Moore JH, Tesar PJ, Laframboise T, Markowitz S, Lupien M, Scacheri PC. Epigenomic enhancer profiling defines a signature of colon cancer. Science. 212 May 11;336(682): Alves-Ferreira PC, Gurland B, Zutshi M, Hull T. Perineal descent does not imply a more severe clinical disorder. Colorectal Dis. 212 Nov;14(11): Church J, Heald B, Burke C, Kalady M. Understanding MYHassociated neoplasia. Dis Colon Rectum. 212 Mar;55(3): Costedio MM, Aytac E, Gorgun E, Kiran RP, Remzi FH. Reduced port versus conventional laparoscopic total proctocolectomy and ileal J pouch-anal anastomosis. Surg Endosc. 212 Dec;26(12): Cullen J, Rosselli JM, Gurland BH. Ventral rectopexy for rectal prolapse and obstructed defecation. Clin Colon Rectal Surg. 212 Mar;25(1): Damaser MS, Salcedo L, Wang G, Zaszczurynski P, Cruz MA, Butler RS, Jiang HH, Zutshi M. Electrical stimulation of anal sphincter or pudendal nerve improves anal sphincter pressure. Dis Colon Rectum. 212 Dec;55(12): de Campos-Lobato LF, Dietz DW, Stocchi L, Vogel JD, Lavery IC, Goldblum JR, Skacel M, Pelley RJ, Kalady MF. Clinical implications of acellular mucin pools in resected rectal cancer with pathological complete response to neoadjuvant chemoradiation. Colorectal Dis. 212 Jan;14(1): El-Gazzaz G, Hull T, Church JM. Biological immunomodulators improve the healing rate in surgically treated perianal Crohn s fistulas. Colorectal Dis. 212 Oct;14(1): El-Gazzaz G, Zutshi M, Hannaway C, Gurland B, Hull T. Overlapping sphincter repair: does age matter? Dis Colon Rectum. 212 Mar;55(3): Guo S, Reddy CA, Kolar M, Woody N, Mahadevan A, Deibel FC, Dietz DW, Remzi FH, Suh JH. Intraoperative radiation therapy with the photon radiosurgery system in locally advanced and recurrent rectal cancer: retrospective review of the Cleveland Clinic experience. Radiat Oncol. 212;7:11. Hull TL, Joyce MR, Geisler DP, Coffey JC. Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg. 212 Feb;99(2): Kalady MF, Coffey JC, Dejulius K, Jarrar A, Church JM. Highthroughput arrays identify distinct genetic profiles associated with lymph node involvement in rectal cancer. Dis Colon Rectum. 212 Jun;55(6): Kalady MF, Dejulius KL, Sanchez JA, Jarrar A, Liu X, Manilich E, Skacel M, Church JM. BRAF mutations in colorectal cancer are associated with distinct clinical characteristics and worse prognosis. Dis Colon Rectum. 212 Feb;55(2): Kiran RP, Nisar PJ, Goldblum JR, Fazio VW, Remzi FH, Shen B, Lavery IC. Dysplasia associated with Crohn s colitis: segmental colectomy or more extended resection? Ann Surg. 212 Aug;256(2): Kirat HT, Ozturk E, Lavery IC, Kiran RP. The predictive value of preoperative carcinoembryonic antigen level in the prognosis of colon cancer. Am J Surg. 212 Oct;24(4): Lian L, Menon KVN, Shen B, Remzi F, Kiran RP. Inflammatory bowel disease complicated by primary sclerosing cholangitis and cirrhosis: is restorative proctocolectomy safe? Dis Colon Rectum. 212 Jan;55(1): Liang J, Kalady MF, Appau K, Church J. Serrated polyp detection rate during screening colonoscopy. Colorectal Dis. 212 Nov;14(11): Manilich E, Remzi FH, Fazio VW, Church JM, Kiran RP. Prognostic modeling of preoperative risk factors of pouch failure. Dis Colon Rectum. 212 Apr;55(4): Messick CA, Church J, Bennett A, Kalady MF. Serrated polyps: new classifications highlight clinical importance. Colorectal Dis. 212 Nov;14(11): Digestive Disease Institute 85

88 Selected Publications Nisar PJ, Appau KA, Remzi FH, Kiran RP. Preoperative hypoalbuminemia is associated with adverse outcomes after ileoanal pouch surgery. Inflamm Bowel Dis. 212 Jun;18(6): Ogilvie JW Jr., Dietz DW, Stocchi L. Anastomotic leak after restorative proctosigmoidectomy for cancer: what are the chances of a permanent ostomy? Int J Colorectal Dis. 212 Oct;27(1): Rottoli M, Remzi FH, Shen B, Kiran RP. Gender of the patient may influence perioperative and long-term complications after restorative proctocolectomy. Colorectal Dis. 212 Mar;14(3): Rottoli M, Stocchi L, Dietz DW. T4N colon cancer has oncologic outcomes comparable to stage III in a specialized center. Ann Surg Oncol. 212 Aug;19(8): Warrier SK, Kalady MF. Familial adenomatous polyposis: Challenges and pitfalls of surgical treatment. Clin Colon Rectal Surg. 212 Jun;25(2): Zutshi M, Ferreira P, Hull T, Gurland B. Biological implants in sphincter augmentation offer a good short-term outcome after a sphincter repair. Colorectal Dis. 212 Jul;14(7): Zutshi M, Hull T, Gurland B. Anal encirclement with sphincter repair (AESR procedure) using a biological graft for anal sphincter damage involving the entire circumference. Colorectal Dis. 212 May;14(5): Gastroenterology Achkar JP, Klei L, de Bakker PIW, Bellone G, Rebert N, Scott R, Lu Y, Regueiro M, Brzezinski A, Kamboh MI, Fiocchi C, Devlin B, Trucco M, Ringquist S, Roeder K, Duerr RH. Amino acid position 11 of HLA- DRß1 is a major determinant of chromosome 6p association with ulcerative colitis. Genes Immun. 212 Apr;13(3): Ahmed Ali U, Shen B, Remzi FH, Kiran RP. The management of anastomotic pouch sinus after IPAA. Dis Colon Rectum. 212 May;55(5): Alkhouri N, De Vito R, Alisi A, Yerian L, Lopez R, Feldstein AE, Nobili V. Development and validation of a new histological score for pediatric non-alcoholic fatty liver disease. J Hepatol. 212 Dec;57(6): Alkhouri N, Morris-Stiff G, Campbell C, Lopez R, Tamimi TAR, Yerian L, Zein NN, Feldstein AE. Neutrophil to lymphocyte ratio: a new marker for predicting steatohepatitis and fibrosis in patients with nonalcoholic fatty liver disease. Liver Int. 212 Feb;32(2): Altomare A, Ma J, Guarino MPL, Cheng L, Rieder F, Ribolsi M, Fiocchi C, Biancani P, Harnett K, Cicala M. Platelet-activating factor and distinct chemokines are elevated in mucosal biopsies of erosive compared with non-erosive reflux disease patients and controls. Neurogastroenterol Motil. 212 Oct;24(1):943-95, e463. Bell LN, Wang J, Muralidharan S, Chalasani S, Fullenkamp AM, Wilson LA, Sanyal AJ, Kowdley KV, Neuschwander-Tetri BA, Brunt EM, McCullough AJ, Bass NM, Diehl AM, Unalp-Arida A, Chalasani N. Relationship between adipose tissue insulin resistance and liver histology in nonalcoholic steatohepatitis: A pioglitazone versus vitamin E versus placebo for the treatment of nondiabetic patients with nonalcoholic steatohepatitis trial follow-up study. Hepatology. 212 Oct;56(4): Burke CA. Number needed to screen to detect adenomas, advanced adenomas and colorectal cancer is higher in women than in similarly aged men. Evid Based Med. 212 Oct;17(5): Cai X, Liu Y, Zhou X, Navaneethan U, Shen B, Guo B. An LC-ESI-MS method for the quantitative analysis of bile acids composition in fecal materials. Biomed Chromatogr. 212 Jan;26(1): Chandok N, Kamath PS, Blei A, Bosch J, Carey W, Grace N, Kowdley KV, Benner K, Groszmann RJ. Randomised clinical trial: the safety and efficacy of long-acting octreotide in patients with portal hypertension. Aliment Pharmacol Ther. 212 Apr;35(8): Chu H, Pazgier M, Jung G, Nuccio SP, Castillo PA, de Jong MF, Winter MG, Winter SE, Wehkamp J, Shen B, Salzman NH, Underwood MA, Tsolis RM, Young GM, Lu W, Lehrer RI, Baumler AJ, Bevins CL. Human alpha-defensin 6 promotes mucosal innate immunity through self-assembled peptide nanonets. Science. 212 Jul 27;337(693): Dasarathy S. Consilience in sarcopenia of cirrhosis. J Cachexia Sarcopenia Muscle. 212 Dec;3(4): de Souza HSP, West GA, Rebert N, de la Motte C, Drazba J, Fiocchi C. Increased levels of survivin, via association with heat shock protein 9, in mucosal T cells from patients with Crohn s disease. Gastroenterology. 212 Oct;143(4): Dunn W, Sanyal AJ, Brunt EM, Unalp-Arida A, Donohue M, McCullough AJ, Schwimmer JB. Modest alcohol consumption is associated with decreased prevalence of steatohepatitis in patients with non-alcoholic fatty liver disease (NAFLD). J Hepatol. 212 Aug;57(2): Outcomes 212

89 Fealy CE, Haus JM, Solomon TP, Pagadala M, Flask CA, McCullough AJ, Kirwan JP. Short-term exercise reduces markers of hepatocyte apoptosis in nonalcoholic fatty liver disease. J Appl Physiol. 212 Jul;113(1):1-6. Fiocchi C. IBD: advances in pathogenesis, complications, diagnosis, and therapy. Curr Opin Gastroenterol. 212 Jul;28(4): Ford AC, Khan KJ, Achkar JP, Moayyedi P. Efficacy of oral vs. topical, or combined oral and topical 5-aminosalicylates, in ulcerative colitis: Systematic review and meta-analysis. Am J Gastroenterol. 212 Feb;17(2): Goel GA, Deshpande A, Lopez R, Hall GS, van Duin D, Carey WD. Increased rate of spontaneous bacterial peritonitis among cirrhotic patients receiving pharmacologic acid suppression. Clin Gastroenterol Hepatol. 212 Apr;1(4): Hanouneh IA, Zein NN, Askar M, Lopez R, John B. Interleukin-28B polymorphisms are associated with fibrosing cholestatic hepatitis in recurrent hepatitis C after liver transplantation. Clin Transplant. 212 Jul-Aug;26(4):E335-E336. Imam H, Marrero F, Shay S. Impedance nadir values correlate with barium bolus amount. Dis Esophagus. 212 Sep-Oct;25(7):6-67. Jiang W, Shadrach B, Carver P, Goldblum JR, Shen B, Liu X. Histomorphologic and molecular features of pouch and peripouch adenocarcinoma: A comparison with ulcerative colitis-associated adenocarcinoma. Am J Surg Pathol. 212 Sep;36(9): Jostins L, Ripke S, Weersma RK, Duerr RH, McGovern DP, Hui KY, Lee JC, Schumm LP, Sharma Y, Anderson CA, Essers J, Mitrovic M, Ning K, Cleynen I, Theatre E, Spain SL, Raychaudhuri S, Goyette P, Wei Z, Abraham C, Achkar JP, Ahmad T, Amininejad L, Ananthakrishnan AN, Andersen V, Andrews JM, Baidoo L, Balschun T, Bampton PA, Bitton A, Boucher G, Brand S, Buning C, Cohain A, Cichon S, D Amato M, De Jong D, Devaney KL, Dubinsky M, Edwards C, Ellinghaus D, Ferguson LR, Franchimont D, Fransen K, Gearry R, Georges M, Gieger C, Glas J, Haritunians T, Hart A, Hawkey C, Hedl M, Hu X, Karlsen TH, Kupcinskas L, Kugathasan S, Latiano A, Laukens D, Lawrance IC, Lees CW, Louis E, Mahy G, Mansfield J, Morgan AR, Mowat C, Newman W, Palmieri O, Ponsioen CY, Potocnik U, Prescott NJ, Regueiro M, Rotter JI, Russell RK, Sanderson JD, Sans M, Satsangi J, Schreiber S, Simms LA, Sventoraityte J, Targan SR, Taylor KD, Tremelling M, Verspaget HW, De Vos M, Wijmenga C, Wilson DC, Winkelmann J, Xavier RJ, Zeissig S, Zhang B, Zhang CK, Zhao H, Silverberg MS, Annese V, Hakonarson H, Brant SR, Radford-Smith G, Mathew CG, Rioux JD, Schadt EE, Daly MJ, Franke A, Parkes M, Vermeire S, Barrett JC, Cho JH. Host-microbe interactions have shaped the genetic architecture of inflammatory bowel disease. Nature. 212 Nov 1;491(7422): Kalhan SC, Hanson RW. Resurgence of serine: an often neglected but indispensable amino acid. J Biol Chem. 212 Jun 8;287(24): Kiely JM, Fazio VW, Remzi FH, Shen B, Kiran RP. Pelvic sepsis after IPAA adversely affects function of the pouch and quality of life. Dis Colon Rectum. 212 Apr;55(4): Kochhar GS, Sanaka MR, Vargo JJ. Therapeutic management options for patients with obscure gastrointestinal bleeding. Therap Adv Gastroenterol. 212 Jan;5(1): Law R, Lopez R, Costanzo A, Parsi MA, Stevens T. Endoscopic pancreatic function test using combined secretin and cholecystokinin stimulation for the evaluation of chronic pancreatitis. Gastrointest Endosc. 212 Apr;75(4): Levitzky BE, Lopez R, Dumot JA, Vargo JJ. Moderate sedation for elective upper endoscopy with balanced propofol versus fentanyl and midazolam alone: a randomized clinical trial. Endoscopy. 212 Jan;44(1):13-2. Li L, Willard B, Rachdaoui N, Kirwan JP, Sadygov RG, Stanley WC, Previs S, McCullough AJ, Kasumov T. Plasma proteome dynamics: Analysis of lipoproteins and acute phase response proteins with 2H2O metabolic labeling. Mol Cell Proteomics. 212 Jul;11(7). Li Y, Shen B. Successful endoscopic needle knife therapy combined with topical doxycycline injection of chronic sinus at ileal pouch-anal anastomosis. Colorectal Dis. 212 Apr;14(4):e197-e199. Ma J, Altomare A, Guarino M, Cicala M, Rieder F, Fiocchi C, Li D, Cao W, Behar J, Biancani P, Harnett KM. HCl-induced and ATPdependent upregulation of TRPV1 receptor expression and cytokine production by human esophageal epithelial cells. Am J Physiol Gastrointest Liver Physiol. 212 Sep;33(5):G635-G645. Macaron C, Hanouneh IA, Suman A, Lopez R, Johnston D, Carey WW. Safety of cardiac surgery for patients with cirrhosis and Child-Pugh scores less than 8. Clin Gastroenterol Hepatol. 212 May;1(5): Digestive Disease Institute 87

90 Selected Publications Malin SK, Niemi N, Solomon TPJ, Haus JM, Kelly KR, Filion J, Rocco M, Kashyap SR, Barkoukis H, Kirwan JP. Exercise training with weight loss and either a high- or low-glycemic index diet reduces metabolic syndrome severity in older adults. Ann Nutr Metab. 212 Sep 28;61(2): Navaneethan U, Mukewar S, Venkatesh PGK, Lopez R, Shen B. Clostridium difficile infection is associated with worse long term outcome in patients with ulcerative colitis. J Crohns Colitis. 212 Apr;6(3): Navaneethan U, Venkatesh PGK, Kiran RP. Immunoglobulin E level and its significance in patients with primary sclerosing cholangitis. Clin Gastroenterol Hepatol. 212 May;1(5):563. Navaneethan U, Venkatesh PGK, Mukewar S, Lashner BA, Remzi FH, McCullough AJ, Kiran RP, Shen B, Fung JJ. Progressive primary sclerosing cholangitis requiring liver transplantation is associated with reduced need for colectomy in patients with ulcerative colitis. Clin Gastroenterol Hepatol. 212 May;1(5): Ootaki C, Stevens T, Vargo J, You J, Shiba A, Foss J, Borkowski R, Maurer W. Does general anesthesia increase the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration of pancreatic masses? Anesthesiology. 212 Nov;117(5): Otley A, Leleiko N, Langton C, Lerer T, Mack D, Evans J, Pfefferkorn M, Carvalho R, Rosh J, Griffiths A, Oliva-Hemker M, Kay M, Bousvaros A, Stephens M, Samson C, Grossman A, Keljo D, Markowitz J, Hyams J. Budesonide use in pediatric Crohn disease. J Pediatr Gastroenterol Nutr. 212 Aug;55(2):2-24. Pagadala MR, Zein CO, Dasarathy S, Yerian LM, Lopez R, McCullough AJ. Prevalence of hypothyroidism in nonalcoholic fatty liver disease. Dig Dis Sci. 212 Feb;57(2): Parsi MA, Stevens T, Vargo JJ. Diagnostic and therapeutic direct peroral cholangioscopy using an intraductal anchoring balloon. World J Gastroenterol. 212 Aug 14;18(3): Qiu J, Tsien C, Thapalaya S, Narayanan A, Weihl CC, Ching JK, Eghtesad B, Singh K, Fu X, Dubyak G, McDonald C, Almasan A, Hazen SL, Naga Prasad SV, Dasarathy S. Hyperammonemia-mediated autophagy in skeletal muscle contributes to sarcopenia of cirrhosis. Am J Physiol Endocrinol Metab. 212 Oct;33(8):E983-E993. Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, Burt RW, Goldblum JR, Guillem JG, Kahi CJ, Kalady MF, O Brien MJ, Odze RD, Ogino S, Parry S, Snover DC, Torlakovic EE, Wise PE, Young J, Church J. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol. 212 Sep;17(9): Rieder F, Hahn P, Finsterhoelzl L, Schleder S, Wolf A, Dirmeier A, Lopez R, Shen B, Rogler G, Klebl F, Lang T. Clinical utility of antiglycan antibodies in pediatric Crohn s disease in comparison with an adult cohort. Inflamm Bowel Dis. 212 Jul;18(7): Rizk MK, Tolba R, Kapural L, Mitchell J, Lopez R, Mahboobi R, Vrooman B, Mekhail N. Differential epidural block predicts the success of visceral block in patients with chronic visceral abdominal pain. Pain Pract. 212 Nov;12(8): Roychowdhury S, Chiang DJ, Mandal P, McMullen MR, Liu X, Cohen JI, Pollard J, Feldstein AE, Nagy LE. Inhibition of apoptosis protects mice from ethanol-mediated acceleration of early markers of CCl(4)-induced fibrosis but not steatosis or inflammation. Alcohol Clin Exp Res. 212 Jul;36(7): Sanaka MR, Navaneethan U, Kosuru B, Yerneni H, Lopez R, Vargo JJ. Antegrade is more effective than retrograde enteroscopy for evaluation and management of suspected small-bowel disease. Clin Gastroenterol Hepatol. 212 Aug;1(8): Sanyal R, Stevens T, Novak E, Veniero JC. Secretin-enhanced MRCP: Review of technique and application with proposal for quantification of exocrine function. AJR Am J Roentgenol. 212 Jan;198(1): Shen B. Bacteriology in the etiopathogenesis of pouchitis. Dig Dis. 212;3(4): Shen B, Yu C, Lian L, Remzi FH, Kiran RP, Fazio VW, Kattan MW. Prediction of late-onset pouch failure in patients with restorative proctocolectomy with a nomogram. J Crohns Colitis. 212 Mar;6(2): Stevens T, Berk MP, Lopez R, Chung YM, Zhang R, Parsi MA, Bronner MP, Feldstein AE. Lipidomic profiling of serum and pancreatic fluid in chronic pancreatitis. Pancreas. 212 May;41(4): Vargo JJ, DeLegge MH, Feld AD, Gerstenberger PD, Kwo PY, Lightdale JR, Nuccio S, Rex DK, Schiller LR. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastroenterology. 212 Jul;143(1):e18-e Outcomes 212

91 Wang Y, Bennett AE, Cai H, Lian L, Shen B. Evaluation of upper and lower gastrointestinal histology in patients with ileal pouches. J Gastrointest Surg. 212 Mar;16(3): Zein CO, Lopez R, Fu X, Kirwan JP, Yerian LM, McCullough AJ, Hazen SL, Feldstein AE. Pentoxifylline decreases oxidized lipid products in nonalcoholic steatohepatitis: New evidence on the potential therapeutic mechanism. Hepatology. 212 Oct;56(4): Zhong N, Zhang L, Takahashi N, Shalmiyev V, Canto MI, Clain JE, Deutsch JC, Dewitt J, Eloubeidi MA, Gleeson FC, Levy MJ, Mallery S, Raimondo M, Rajan E, Stevens T, Topazian M. Histologic and imaging features of mural nodules in mucinous pancreatic cysts. Clin Gastroenterol Hepatol. 212 Feb;1(2): General Surgery Abu-Elmagd KM, Kosmach-Park B, Costa G, Zenati M, Martin L, Koritsky DA, Emerling M, Murase N, Bond GJ, Soltys K, Sogawa H, Lunz J, Al Samman M, Shaefer N, Sindhi R, Mazariegos GV. Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation. Ann Surg. 212 Sep;256(3): Albeldawi M, Aggarwal A, Madhwal S, Cywinski J, Lopez R, Eghtesad B, Zein NN. Cumulative risk of cardiovascular events after orthotopic liver transplantation. Liver Transpl. 212 Mar;18(3): Bhatt S, Fung JJ, Lu L, Qian S. Tolerance-inducing strategies in islet transplantation. Int J Endocrinol. 212;212: Chalikonda S, Aguilar-Saavedra JR, Walsh RM. Laparoscopic roboticassisted pancreaticoduodenectomy: a case-matched comparison with open resection. Surg Endosc. 212 Sep;26(9): Dietz J, Lundgren P, Veeramani A, O Rourke C, Bernard S, Djohan R, Larson J, Isakov R, Yetman R. Autologous inferior dermal sling (autoderm) with concomitant skin-envelope reduction mastectomy: an excellent surgical choice for women with macromastia and clinically significant ptosis. Ann Surg Oncol. 212 Oct;19(1): Kelly DM, Bennett R, Brown N, McCoy J, Boerner D, Yu C, Eghtesad B, Barsoum W, Fung JJ, Kattan MW. Predicting the discharge status after liver transplantation at a single center: A new approach for a new era. Liver Transpl. 212 Jul;18(7): Quintini C, Ward G, Shatnawei A, Xhaja X, Hashimoto K, Steiger E, Hammel J, Diago Uso T, Burke CA, Church JM. Mortality of intraabdominal desmoid tumors in patients with familial adenomatous polyposis: a single center review of 154 patients. Ann Surg. 212 Mar;255(3): Rodriguez JH, Kroh M, El-Hayek K, Timratana P, Chand B. Combined paraesophageal hernia repair and partial longitudinal gastrectomy in obese patients with symptomatic paraesophageal hernias. Surg Endosc. 212 Dec;26(12): Sourianarayanane A, El-Gazzaz G, Sanabria JR, Menon KVN, Quintini C, Hashimoto K, Kelly D, Eghtesad B, Miller C, Fung J, Aucejo F. Loco-regional therapy in patients with Milan Criteriacompliant hepatocellular carcinoma and short waitlist time to transplant: an outcome analysis. HPB (Oxford). 212 May;14(5): Walsh RM, Saavedra JRA, Lentz G, Guerron AD, Scheman J, Stevens T, Trucco M, Bottino R, Hatipoglu B. Improved quality of life following total pancreatectomy and auto-islet transplantation for chronic pancreatitis. J Gastrointest Surg. 212 Aug;16(8): Digestive Disease Institute 89

92 Staff Listing Some physicians may practice in multiple locations. For a detailed list including staff photos, please visit clevelandclinic.org/staff. Institute Chairman John Fung, MD, PhD Institute Vice Chairman John Vargo, MD Institute Quality Improvement Officer Maged Rizk, MD Laura Buccini, DrPH, MPH Associate Staff Department of Colorectal Surgery Feza H. Remzi, MD Chairman David Dietz, MD Vice Chairman Jean Ashburn, MD James Church, MD Director, Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia Meagan Costedio, MD John Cullen, MD Thomas Garofalo, MD Emre Gorgun, MD Brooke Gurland, MD Tracy Hull, MD Section Head, Pelvic Floor and Motility Matthew Kalady, MD Hermann Kessler, MD Pokala Ravi Kiran, MD Section Head, Research Ian Lavery, MD James Merlino, MD Chief Experience Officer, Cleveland Clinic Gokhan Ozuner, MD Luca Stocchi, MD Scott Strong, MD Ursula Szmulowicz, MD Michael Valente, DO Jon Vogel, MD Quality Improvement Officer Director, Colorectal Surgery Fellowship Program Ryan Williams, MD James Wu, MD Massarat Zutshi, MD Department of Gastroenterology and Hepatology John Vargo, MD Chairman Vice Chairman, Digestive Disease Institute David Barnes, MD Vice Chairman 9 Outcomes 212

93 Institute Overview Edgar Achkar, MD Jean Paul Achkar, MD Director, Education Talal Adhami, MD Brian Baggott, MD Sigurbjorn Birgisson, MD Section Head, Swallowing Aaron Brzezinski, MD Carol Burke, MD Section Head, Colon Cancer William Carey, MD Director, CME Prabhleen Chahal, MD Dian Chiang, MD Michael Cline, MD Srinivasan Dasarathy, MD Kyrsten Fairbanks, MD Michelle Inkster, MD Sunguk Jang, MD Binu John, MD Parvez Khambatta, MD Donald Kirby, MD Director, Nutrition Brian Kirsh, MD Brett Lashner, MD Christine Lee, MD David Lever, MD Arthur McCullough, MD K.V. Narayanan Menon, MD Joseph Moses, MD James Murphy, MD Robert O Shea, MD Mansour Parsi, MD Section Head, Advanced Endoscopy Jessica Philpott, MD, PhD Brian Putka, MD Quality Improvement Officer, Gastroenterology Monica Ray, MD Maged Rizk, MD Carlos Romero-Marrero, MD Quality Improvement Officer, Hematology Madhusudhan Sanaka, MD Abdullah Shatnawei, MD Steven Shay, MD Bo Shen, MD Section Head, Pouchitis Tyler Stevens, MD Le-Chu Su, MD, PhD Anthony Tavill, MD Prashanthi Thota, MD Chung Tsai, MD Section Head, Comprehensive Gastroenterology Neha Wadwa, MD Jamile Wakim-Fleming, MD Yinghong Wang, MD Luke Weber, MD Claudia Zein, MD Nizar Zein, MD Section Head, Hepatology Gregory Zuccaro Jr., MD Section Head, Capsule Endoscopy Department of General Surgery R. Matthew Walsh, MD Chairman Kareem Abu-Elmagd, MD Director, Transplant Center Program Director, Intestinal Transplantation Diya Alaedeen, MD Federico Aucejo, MD Toms Augustin, MD David Baringer, MD Timothy Barnett, MD Kalman Bencsath, MD Brent Bogard, MD Tony Capizzani, MD Robert Cebul, MD Walter Cha, MD Digestive Disease Institute 91

94 Staff Listing Sricharan Chalikonda, MD Director, Robotic Surgery John Dorsky, MD Director, Hernia Center Bijan Eghtesad, MD Shukri Elkhairi, MD Masato Fujiki, MD John Fung, MD, PhD Rick Gemma, MD Sharon Grundfest- Broniatowski, MD Richard Guttman Jr., MD Koji Hashimoto, MD J. Michael Henderson, MD Chairman, Quality & Patient Safety Institute Dympna Kelly, MD Matthew Kroh, MD Director, Surgical Endoscopy Michelle Loor, MD Director, Acute Care Surgery Wound Care James Malgieri, MD Charles Miller, MD Program Director, Liver Transplantation Matthew Moorman, MD Quality Improvement Officer, Acute Care and General Surgery Richard Niemczura, MD William O Brien, MD Daniel Peabody III, MD Cristiano Quintini, MD Jose Roberto Ramirez, MD Steven Rosenblatt, MD Michael Samotowka, MD Section Head, Acute Care Surgery Andrew Smith, MD Ezra Steiger, MD Jeffrey Ustin, MD Aisha Violette, MD David Vogt, MD Jane Wey, MD Charles Winans, MD Quality Improvement Officer, Hepatobiliary and Transplant Surgery Department of General Anesthesiology Digestive Disease Section Wolf Stapelfeldt, MD Chairman Tatyana Kopyeva, MD Section Head Maged Argalious, MD Sekar Bhavani, MD Tom Bralliar, MD Jacek Cywinski, MD Ursula Galway, MD Robert Helfand, MD Maria Inton-Santos, MD Samuel Irefin, MD John Jerabek, DO Allen Keebler, DO Reem Khatib, MD Tatyana Kopyeva, MD Kamal Maheshwari, MD Theodore Marks, MD Brian Parker, MD Mauricio Perilla, MD Peter Schoenwald, MD John Seif, MD Claudene Vlah, MD Sivan Wexler, MD Eliyahu Zisman, MD Surgical Intensive Care Unit Steven Hata, MD Director, Center for Critical Care, Anesthesiology Institute Marc Popovich, MD Medical Director, Main Campus Surgical Intensive Care Unit Program Director, Critical Care Fellowship 92 Outcomes 212

95 Shiva Birdi, MD Demetrios Bourdakos, MD Tony Capizzani, MD Shahpour Esfandiari, MD Faith Factora, MD Samuel Irefin, MD Ali Jahan, MD Michele Loor, MD Piyush Mathur, MD Quality Improvement Officer, Anesthesiology Institute Matthew Moorman, MD Joti Juneja Mucci, MD Douglas Naylor, MD William Phillips, MD Nadeem Rahman, MD Nicholas Russo, MD Michael Samotowka, MD Anand Satyapriya, MD Jeff Ustin, MD Aisha Violette, MD Ellen Wurm, MD Breast Services Michael Cowher, MD Quality Improvement Officer, Breast Center Joseph Crowe, MD Jill Dietz, MD Pedro Escobar, MD Alicia Fanning, MD Stephen Grobmyer, MD Sharon Grundfest- Broniatowski, MD Katherine Lee, MD Mita Patel, MD Holly Pederson, MD Debra Pratt, MD Robyn Stewart, MD Stephanie Valente, DO Breast Imaging Alice Rim, MD Director Melanie Chellman-Jeffers, MD Paulette Lebda, MD Susan Miller, MD Tina Ruchalski, MD Eric Schreiber, MD Rajshri Shah, MD Wendy Shaw, MD Laura Shepherdson, MD Leah Sieck, MD Breast Pathology Christina Booth, MD Andrea Dawson, MD Erinn Downs-Kelly, MD Jonathan Myles, MD J. Jordi Rowe, MD Digestive Disease Institute 93

96 Contact Information General Patient Referral 24/7 hospital transfers or physician consults Colorectal Surgery, Gastroenterology and Hepatology, and General Surgery Appointments/Referrals , ext. 47 Breast Center Appointments/Referrals , ext Center for Human Nutrition Appointments/Referrals , ext On the Web at clevelandclinic.org/digestive Additional Contact Information General Information Hospital Patient Information General Patient Appointments or Referring Physician Center and Hotline 24/7 hotline to streamline access to our array of medical services and schedule patient appointments 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 outof-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 Outcomes 212

97 Institute Overview Locations Northeast Ohio Locations Cleveland Clinic Main Campus 95 Euclid Ave. Cleveland, OH Colorectal Surgery/A3 Gastroenterology and Hepatology/ A3 and A51 General Surgery/A1 Nutrition Therapy, Nutrition Support, Intestinal Rehabilitation and Transplant/Ab4 Women s Health and Breast Pavilion/A1 Avon Lake Family Health Center 45 Avon Belden Road Avon Lake, OH 4412 Colorectal surgery Beachwood Family Health and Surgery Center 269 Cedar Road Beachwood, OH Breast services, colorectal surgery, gastroenterology, general surgery, nutrition therapy Brunswick Family Health and Surgery Center 3574 Center Road Brunswick, OH Nutrition therapy Euclid Medical Building 99 Northline Circle, Suite 22 Euclid, OH General surgery Fairview Hospital 2455 Lorain Road, Suite 31 Fairview Park, OH Breast services, general surgery, colorectal surgery Hillcrest Hospital Atrium 678 Mayfield Road Mayfield Heights, OH Breast services, general surgery, colorectal surgery Independence Family Health Center Crown Centre II 51 Rockside Road Independence, OH Colorectal surgery, gastroenterology, general surgery, nutrition therapy Lakewood Family Health Center Madison Ave. Lakewood, OH 4417 Colorectal surgery, nutrition therapy Lakewood Hospital Detroit Ave. Lakewood, OH 4417 Colorectal surgery, nutrition therapy Lutheran Hospital 173 W. 25th St. Cleveland, OH General surgery Marymount Hospital 5555 Transportation Blvd., Suite D Garfield Heights, OH General surgery Medina Hospital South Medical Office Building, Suite 5A 97 E. Washington St. Medina, OH Colorectal surgery Mentor Medical Office Building 76 Wayside Drive Mentor, OH 446 Colorectal surgery Digestive Disease Institute 95

98 Institute Locations Richard E. Jacobs Health Center 331 Cleveland Clinic Blvd. Avon, OH 4411 Colorectal surgery, gastroenterology, general surgery, nutrition therapy Solon Family Health Center 298 Bainbridge Road Solon, OH Nutrition therapy South Pointe Hospital 2 Harvard Road Warrensville Heights, OH General surgery Stephanie Tubbs Jones Health Center Euclid Ave. East Cleveland, OH Gastroenterology, general surgery Strongsville Family Health and Surgery Center SouthPark Center Strongsville, OH Breast services, colorectal surgery, gastroenterology, general surgery, nutrition therapy Twinsburg Family Health and Surgery Center 871 Darrow Road Twinsburg, OH 4487 Breast services, colorectal surgery, gastroenterology, general surgery, nutrition therapy Willoughby Hills Family Health Center 257 SOM Center Road Willoughby Hills, OH 4494 Colorectal surgery, gastroenterology, nutrition therapy Wooster Milltown Specialty and Surgery Center 721 E. Milltown Road, Suite WR1 Wooster, OH Colorectal surgery, gastroenterology, general surgery, nutrition therapy A registered dietitian is available for appointments at the following locations: Main Campus Nutrition Therapy 95 Euclid Ave. Cleveland, OH Beachwood Family Health and Surgery Center 269 Cedar Road Beachwood, OH Brunswick Family Health Center 3724 Center Road Brunswick, OH Elyria Family Health and Surgery Center 33 Chestnut Commons Drive Elyria, OH 4435 Independence Cancer Center 61 W. Creek Road, Suites 15, 16 Independence, OH Independence Family Health Center Crown Centre II 51 Rockside Road Independence, OH Outcomes 212

99 Lakewood Family Health Center Madison Ave. Lakewood, OH 4417 Lorain Family Health and Surgery Center 57 Cooper Foster Park Road Lorain, OH 4453 Medina Medical Office Building 97 E. Washington St. Medina, OH Richard E. Jacobs Health Center 331 Cleveland Clinic Blvd. Avon, OH 4411 Willoughby Hills Family Health Center 257 SOM Center Road Willoughby Hills, OH 4494 Wooster Family Health Center 174 Cleveland Road Wooster, OH Other Locations Cleveland Clinic Florida 295 Cleveland Clinic Blvd. Weston, FL Colorectal surgery, gastroenterology, general surgery Solon Family Health Center 298 Bainbridge Road Solon, OH Sports Health at Marymount Ambulatory Surgery Center 5555 Transportation Blvd. Garfield Heights, OH Strongsville Family Health and Surgery Center SouthPark Center Strongsville, OH Digestive Disease Institute 97

100 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, Cleveland Clinic staff physicians and scientists in 12 medical specialties care for more than 5 million patients across the system, performing more than 2, surgeries and conducting 45, Emergency Department visits. Patients come to Cleveland Clinic from all 5 states and more than 132 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 1,45-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 46 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 Lou Ruvo Center for Brain Health in Las Vegas, 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 scheduled to begin offering services in 214. Cleveland Clinic is the second-largest employer in Ohio with nearly 44, employees. It generates $1.5 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. 98 Outcomes 212

101 Cleveland Clinic Lerner Research Institute At the Lerner Research Institute, hundreds of principal investigators, project scientists, research associates, and postdoctoral fellows are involved in laboratorybased translational and clinical research. Total research expenditures from external and internal sources exceeded $265 million in 212. 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, which celebrated its 1th anniversary in 212, is known for its small class size, unique curriculum, and full-tuition scholarships for all students. The program is open to 32 students who are preparing to be physician investigators. Graduate Medical Education In 212, 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 our heart and heart surgery program has been ranked No. 1 in the nation since In 212, Cleveland Clinic s urology and nephrology programs were both ranked No. 1 in the nation. For more information about Cleveland Clinic, please visit clevelandclinic.org. Digestive Disease Institute 99

102 Resources Referring Physician Center and Hotline 24/7 hotline to streamline access to our array of medical services and schedule patient appointments, call 855.REFER.123 ( ), or visit clevelandclinic.org/refer123 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 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. 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 fixedwing aircraft serve critically ill and highly complex patients across the globe. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call CODE (2633). For all other critical care transfers, call or 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. 1 Outcomes 212

103 Clinical Trials Since its establishment in 1921, Cleveland Clinic has been an innovator in medical breakthroughs, with a mission of unlocking basic science and pursuing clinical research. Today, Cleveland Clinic is running more than 2, clinical trials of various types. Our researchers are focusing 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. Healthcare Executive Education Cleveland Clinic s dynamic executive education program provides real-world insights into the highly competitive business of healthcare. The Executive Visitors Program is an intensive threeday program that provides a behind-thescenes view of our 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 11