Ob/Gyn & Women s Health Institute Outcomes

Transcription

1 Ob/Gyn & Women s Health Institute 16 Outcomes

2 Measuring Outcomes Promotes Quality Improvement Clinical Trials Cleveland Clinic is running more than clinical trials at any given time for conditions including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. Cancer Clinical Trials is a mobile app that provides information on the more than active clinical trials available to cancer patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp Healthcare Executive Education Cleveland Clinic has programs to share its expertise in operating a successful major medical center. The Executive Visitors Program is an intensive, 3-day behind-the-scenes view of the Cleveland Clinic organization for the busy executive. The Samson Global Leadership Academy is a -week immersion in challenges of leadership, management, and innovation taught by Cleveland Clinic leaders, administrators, and clinicians. Curriculum includes coaching and a personalized 3-year leadership development plan. clevelandclinic.org/executiveeducation Consult QD Physician Blog A website from Cleveland Clinic for physicians and healthcare professionals. Discover the latest research insights, innovations, treatment trends, and more for all specialties. consultqd.clevelandclinic.org Social Media Cleveland Clinic uses social media to help caregivers everywhere provide better patient care. Millions of people currently like, friend, or link to Cleveland Clinic social media including leaders in medicine. Facebook for Medical Professionals facebook.com/cmeclevelandclinic Follow us on Connect with us on LinkedIn clevelandclinic.org/mdlinkedin Ob/Gyn & Women s Health Institute 18376_CCFBCH_17OUT415_Rev1_acg.indd 4-6 9/7/17 11:47 AM

3 Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its clinical institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with a focus on outcomes data and a review of new technologies and innovations. The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical and procedural techniques. In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data. The following reports are available to the public: Joint Commission Performance Measurement Initiative (qualitycheck.org) Centers for Medicare and Medicaid Services (CMS) Hospital Compare (medicare.gov/hospitalcompare), and Physician Compare (medicare.gov/physiciancompare) Cleveland Clinic Quality Performance Report (clevelandclinic.org/qpr) Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic s culture of continuous improvement and may help referring physicians make informed decisions. We hope you find these data valuable, and we invite your feedback. Please send your comments and questions via to: OutcomesBooksFeedback@ccf.org. To view all of our Outcomes books, please visit clevelandclinic.org/outcomes _CCFBCH_17OUT415_Rev1_acg.indd 1 9/19/17 5: PM

4 Dear Colleague: Welcome to this 16 Cleveland Clinic Outcomes book. Every year, we publish Outcomes books for 14 clinical institutes with multiple specialty services. These publications are unique in healthcare. Each one provides an overview of medical or surgical trends, innovations, and clinical data for a particular specialty over the past year. We are pleased to make this information available. Cleveland Clinic uses data to manage outcomes across the full continuum of care. Our unique organizational structure contributes to our success. Patient services at Cleveland Clinic are delivered through institutes, and each institute is based on a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Institutes define quality benchmarks for their specialty services and report on longitudinal progress. All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Reports (clevelandclinic.org/qpr). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites. Our practice of releasing annual Outcomes books has become increasingly relevant as healthcare transforms from a volume-based to a value-based system. We appreciate your interest and hope you find this information useful and informative. Sincerely, Delos M. Cosgrove, MD CEO and President Outcomes 16

5 what s inside Chairman s Letter 4 Institute Overview 5 Quality and Outcomes Measures Benign Gynecology 8 Reproductive Endocrinology and Infertility 11 Urogynecology 15 Gynecologic Oncology Breast Disease 4 Specialized Women s Health 5 Maternal-Fetal Medicine 5 Obstetrics 56 Surgical Quality Improvement 61 Institute Patient Experience 6 Cleveland Clinic Implementing Value-Based Care 64 Innovations 7 Contact Information 74 About Cleveland Clinic 76 Resources 78 Ob/Gyn & Women s Health Institute 3

6 Chairman s Letter I appreciate your interest in our Ob/Gyn & Women s Health Institute and taking the time to glance through our 16 outcomes report. Each year we collect and analyze vital data, not just to satisfy our curiosity, but to ensure that we are indeed improving the quality of care we provide and quality of life for our patients. We remain devoted to excellence and innovation in all aspects of our work -- clinical care, research, and education. We believe our consistently high rankings by U.S. News & World Report (No. 3 in the nation in 16) reflect this dedication and hard work. Significant achievements for our institute in 16 include:.1% elective induction rate for deliveries < 39 weeks gestation Maintained a primary cesarean rate for low-risk, nulliparous, vertex, singleton births below the HealthyPeople.gov target of 3.9% Decreased all cause 3-day readmissions by.% to 1.4% Maintained a low surgical-site infection rate for hysterectomies (.1%) enterprise-wide In addition, Cleveland Clinic s new Transgender Surgery & Medicine Program provides comprehensive psychiatric, medical, and surgical care for transgender, gender fluid, and gender non-conforming adults and adolescents. In 16, over patients were cared for through this program. Cecile Unger, MPH, MD, serves as the program Director. I welcome your feedback, questions, and ideas for collaboration. Please contact me via at OutcomesBooksFeedback@ccf.org, and reference the Ob/Gyn & Women s Health Institute book in your message. Sincerely, Tommaso Falcone, MD Chairman, Ob/Gyn & Women s Health Institute Professor of Surgery, Cleveland Clinic Lerner College of Medicine 4 Outcomes 16

7 Institute Overview Cleveland Clinic s Ob/Gyn & Women s Health Institute is committed to providing world-class care for women of all ages. In 16, the institute s gynecology program was again ranked third in the nation by U.S. News & World Report, the top-ranked program in Ohio. The institute offers a full complement of women s health services, including general obstetric/ gynecologic care and screenings; advanced minimally invasive procedures for uterine fibroids and endometriosis; complex oncologic surgery for breast and gynecologic malignancies; management of fetal anomalies; management of complex surgical mesh complications; and innovative approaches to cryopreservation of gametes and ovarian tissue. The institute also has specialty clinics for gynecologic infectious disease, pediatric gynecology, chronic pelvic pain, and women s medical weight management. Its 151 obstetrician/gynecologists and 18 certified nurse midwives see patients at the main campus, at Cleveland Clinic regional hospitals and family health centers across northeast Ohio, and at Cleveland Clinic Florida. Cleveland Clinic s gynecology program is ranked No. 3 in the nation by U.S. News & World Report. The institute s staff participates in resident, fellow, and medical student education at Cleveland Clinic Lerner College of Medicine. A unique residency training program offers tracking into subspecialty areas. Fellowships are offered in women s health, gynecologic oncology, urogynecology/reconstructive pelvic surgery, and reproductive endocrinology. A new Global Health Research Program allows residents and fellows to participate in research. Cleveland Clinic s specialty services include team-based lesbian, gay, bisexual, and transgender healthcare services, including transgender consultations for medical and surgical gynecologic care. The Gyn Oncology Program offers genomic tumor profiling, which identifies and targets genomic alterations for clinically approved or investigational treatments. Hyperthermic intraperitoneal chemotherapy (HIPEC) is offered after surgical debulking for qualified patients with certain pelvic cancers. Ob/Gyn & Women s Health Institute 5

8 Institute Overview 36 Number of locations at which the Ob/Gyn & Women s Health Institute staff provide comprehensive care 16 Volumes Outpatient Visits (Epic Reports) Obstetrics & Gynecology 133,464 Regional obstetrics and gynecology 41,7 WHI TOTAL VISITS 374,671 Breast Services Screening mammograms 67,84 Screening mammograms resulting in call-back 1,176 Surgical Procedure Distribution General obstetrics and gynecology 734 Gynecologic oncology 1756 Urogynecology 746 Reproductive endocrinology 145 Maternal-fetal medicine 34 Hysteroscopy (RCM) Operative - outpatient Ablation 36 Myomectomy 1 Polyps 151 Sterilization 13 Diagnostic - office 93 Diagnostic - outpatient 3 Hysterectomy (including cancer patients) (Optime) Abdominal 449 Vaginal 477 Laparoscopic 699 Robotic 75 6 Outcomes 16

9 Incontinence and Prolapse (Visiquate) Prolapse 36 Incontinence 5 Incontinence and prolapse 395 In Vitro Fertilization Egg retrievals (excluding oocyte donor and surrogate) 383 Intrauterine insemination 13 Deliveries (Pro Rev Stats) 374,671 Number of outpatient visits to the Ob/Gyn & Women s Health Institute in 16 Deliveries 984 Perinatal Testing Performed by Cleveland Clinic Staff (RCM) Dopplers 313 Amniocentesis 8 Biophysical profiles 5858 Chorionic villus sampling 56 Nuchal translucency 655 Gynecology Ultrasound,34 Ob/Gyn & Women s Health Institute 7

10 Benign Gynecology Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing in Cleveland Clinic facilities in northeast Ohio. Surgical Site Infection for Abdominal Hysterectomy (Benign and Malignant) (N = 1891) Rate per 1 Surgeries 5 In 11, an interdisciplinary project team was formed to identify risk points for infection during the perioperative period. Action steps were implemented to reduce these risks, resulting in lower surgical site infection rates in hysterectomy cases N = Cleveland Clinic provides several treatment options for uterine fibroids, including uterine fibroid embolization, myomectomy, and hysterectomy. Procedures to Treat Uterine Fibroids (N = 176) Percent Uterine fibroid Myomectomy Hysterectomy embolization N = Surgical Approach for Myomectomy (N = 898) Percent Laparoscopic/robotic Vaginal Abdominal N = Outcomes 16

11 Hysterectomy Following Myomectomy or Uterine Fibroid Embolization Percent Myomectomy UFE Months After Surgery Numbers at Risk: Myomectomy N = UFE N = UFE = uterine fibroid embolization Between 11 and 16, 177 patients underwent uterine fibroid embolization (UFE) and had at least 1 year of follow-up. The figure illustrates the percentage of these patients who subsequently underwent hysterectomy relative to the time of their initial procedure. The number of patients at risk represents those patients with the indicated length of follow-up who did not have a hysterectomy. The 3-year hysterectomy rate following UFE for Cleveland Clinic gynecologic surgeons is approximately 3.8%. Between 11 and 16, 146 patients underwent myomectomy and had at least 1 year of follow-up. The figure illustrates the percentage of these patients who subsequently underwent hysterectomy relative to the time of their initial procedure. The number of patients at risk represents those patients with the indicated length of follow-up who did not have a hysterectomy. The 3-year hysterectomy rate following myomectomy for Cleveland Clinic gynecologic surgeons is approximately 5.3%. Ob/Gyn & Women s Health Institute 9

12 Benign Gynecology Endometriosis Treatment (N = 4743) Percent N = Medical treatment Surgical (no hysterectomy) Hysterectomy Medical treatment is the primary method used for treating endometriosis. When surgical methods are used, hysterectomy is seldom the course of action taken. 1 Outcomes 16

13 Reproductive Endocrinology and Infertility While success rates for in vitro fertilization (IVF) continue to improve over time, patient age remains the strongest predictor of success. Cleveland Clinic s In Vitro Fertilization Laboratory employs cutting edge technology for the culture, growth, and assessment of embryos. The laboratory s extensive database allows tracking and analysis of morphologic features that indicate which embryos are most likely to result in pregnancies. The EmbryoScope time-lapse system, introduced to the laboratory in 1, enables continuous monitoring of embryo growth with time-lapse imaging, further enhancing the ability to select embryos most likely to implant successfully. The research laboratory has also been instrumental in developing and advancing novel technologies for cryopreservation of embryos, oocytes, and individually selected sperm. Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing in Cleveland Clinic facilities in northeast Ohio. IVF Success Rates IVF Cycle Outcomes With Transfer of Day 5 Cleavage and Blastocyst Stage Embryos 16 Patient Age (Years) < > 4 Retrievals Transfers Average embryos transferred Clinical pregnancy rate a 6% 5% 58% 56% 33% Implantation rate b 51% 4% 37% 7% 7% a Clinical pregnancy determined by presence of fetal heart on ultrasound b Implantation rate per embryo transferred to the uterus Ob/Gyn & Women s Health Institute 11

14 Reproductive Endocrinology and Infertility Day 5 Blastocyst Stage Embryo Transfers Resulting in Pregnancy (N = 11 a ) 16 Percent 6 4 Triplets (or more) Twins Singleton < Patient Age (Years) 41 4 N b = a Includes 6 day 3 transfers b Pregnancies IVF Cycle Outcomes With Frozen Embryo Transfers 16 Patient Age (Years) < Thaws 43 8 Transfers Survival 94% 95% Average embryos transferred Implantation rate a 51% 38% Clinical pregnancy rate b 6% 53% Singleton pregnancies 65% % Twin pregnancies 13% % Triplet pregnancies 1% % IVF Success Rates With Donor Oocytes 16 Transfers 3 Average embryos transferred 1.3 Clinical pregnancy rate a 57% Implantation rate b 48% a Clinical pregnancy determined by presence of fetal heart on ultrasound b Implantation rate per embryo transferred to the uterus a Implantation rate per embryo transferred to the uterus b Clinical pregnancy determined by presence of fetal heart on ultrasound 1 Outcomes 16

15 Fresh Embryo Transfer Pregnancy Rate (N = 54) 15 Percent < Patient Age (Years) N = Frozen Embryo Transfer Pregnancy Rate (N = 3) 15 Percent < N = Patient Age (Years) Ob/Gyn & Women s Health Institute 13

16 Reproductive Endocrinology and Infertility IVF and Live Births Fresh Embryo Transfer Live Birth Rate (N = 54) 15 Percent < Patient Age (Years) N = Frozen Embryo Transfer Live Births (N = 3) 15 Percent < N = Patient Age (Years) Outcomes 16

17 Urogynecology Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing in Cleveland Clinic facilities in northeast Ohio. Surgical Case Approach (N = 3899) 1 16 Procedures Abdominal Laparoscopic/robotic Vaginal/perineal N = Adverse Events Within 3 Days of Urogynecologic Surgery (N = 3311) Rate per 1 Surgeries Deep vein thrombosis Pulmonary embolism Small bowel obstruction N a = a Total number of urogynecologic surgical procedures per year Ob/Gyn & Women s Health Institute 15

18 Urogynecology Three-Year Prolapse Reoperation Percentage (N = 1765) 9 15 Percent Months After Surgery Number at Risk = Between 9 and 15, 1765 patients underwent prolapse surgery and had at least 1 year of followup. The figure at left illustrates the percentage of these patients who had a reoperation for prolapse relative to the time of their initial surgery. The number of patients at risk represents those patients with the indicated length of followup who did not have a prolapse reoperation. The 3-year prolapse reoperation rate for Cleveland Clinic urogynecologic surgeons is approximately.6%. Three-Year Sling Revision Rate (N = 1846) 9 15 Percent Months After Surgery Number at Risk = Between 9 and 15, 1846 patients received incontinence (sling) surgery and had at least 1 year of follow-up. The figure at left illustrates the percentage of these patients who had sling revision urethrolysis relative to the time passed after their initial surgery. The number of patients at risk represents those patients with the indicated length of follow-up who have not had sling revision. The 3-year sling revision rate for Cleveland Clinic urogynecologic surgeons is.%. 16 Outcomes 16

19 Urinary Incontinence Procedures Following Sacrospinous Fixation, Uterosacral Suspension, and Minimally Invasive Sacrocolpopexy 9 16 Percent Minimally invasive sacrocolpopexy Sacrospinous fixation Uterosacral suspension Months After Surgery Number at Risk: Minimally invasive sacrocolpopexy Sacrospinous fixation Uterosacral suspension A total of 1 patients underwent minimally invasive abdominal sacrocolpopexy. Using survival modeling, the cumulative incidence for transurethral bulking or midurethral sling placement (with adjustment for loss to follow-up) was 7.5% over 3 years. A total of 31 patients underwent sacrospinous fixation. Using survival modeling, the cumulative incidence for transurethral bulking or midurethral sling placement (with adjustment for loss to follow-up) was 3.6% over 3 years. A total of 549 patients underwent uterosacral ligament vaginal vault suspension. Using survival modeling, the cumulative incidence for transurethral bulking or midurethral sling placement (with adjustment for loss to follow-up) was.% over 3 years. Ob/Gyn & Women s Health Institute 17

20 Urogynecology 3-Day Readmission Rate a Inpatient Following Urogynecologic Surgery (N = 311) Rate per 1 Surgeries Severity Index Readmission rate Benchmark b Severity index c 13 N = d d a These data are prepared using the Vizient Clinical Database. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b Benchmark derived from review of peer organization members of Vizient for surgical cases performed for MS-DRGs 748, 749, and 75. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. c The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3m/en_us/health-information-systems/his/products-and- Services/Products-List-A-Z/APR-DRG-Software. d In 14 and 15, the number of inpatient admissions was reduced due to payer reclassification of the majority of major surgery admissions to outpatient status (less than a midnight stay). Patients meeting criteria for inpatient admission had more complex surgeries and more comorbidities than patients meeting criteria for discharge at less than a midnight stay. 18 Outcomes 16

21 Length of Stay a Following Inpatient Urogynecologic Surgery (N = 311) Days Severity Index Observed LOS Expected LOS Severity index b N c = LOS = length of stay a These data are prepared using the Vizient Clinical Database. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b The 3M All Patient Refined Diagnosis Related Groups (APR DRG)Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3m/en_us/health-information-systems/his/productsand-services/products-list-a-z/apr-drg-software. c Total number of surgical cases performed for MS-DRGs 748, 749, and 75. In 14 and 15, the number of inpatient admissions was reduced due to payer reclassification of the majority of major surgery admissions to outpatient status (less than a midnight stay). Patients meeting criteria for inpatient admission had more complex surgeries and more comorbidities than patients meeting criteria for discharge at less than a midnight stay. Ob/Gyn & Women s Health Institute 19

22 Gynecologic Oncology Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing in Cleveland Clinic facilities in northeast Ohio. The advent of robotic-assisted laparoscopy has prompted an increase in minimally invasive procedures in the gynecologic subspecialties. Cleveland Clinic gynecologic oncology surgeons strive to provide the best care for patients while using minimally invasive procedures when possible. Surgical Case Approach for Complex Benign and Malignant Cases (N = 671) Number of Procedures 15 1 Laparoscopic/robotic Abdominal Vaginal/perineal N = New Surgical Cancer Case Distribution (N = 156) Percent Vulvar Uterine Ovarian Cervical N = Outcomes 16

23 Primary Cytoreduction for Ovarian Cancer a (N = 114) Suboptimally debulked Percent Optimally debulked Length of Stay a and Severity Index Following Inpatient Gynecologic Oncology Surgery (N = 981) Days 8 6 Severity Index Observed LOS 4 Expected LOS Severity Index b N = a Data exclude patients who received chemotherapy N c = d d prior to primary cytoreduction LOS = length of stay a These data are prepared using the Vizient Clinical Database. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3m/en_us/health-information- Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG- Software c Total number of surgical cases for gynecologic malignancy identified by MS-DRGs 734, 735, 736, 737, 738, 739, 74, 741, 754, 755, and 756. d In 15 and 16, the number of inpatient admissions was reduced due to payer reclassification of the majority of major surgery admissions to outpatient status (less than a midnight stay). Patients meeting criteria for inpatient admission had more complex surgeries and more comorbidities than patients meeting criteria for discharge at less than a midnight stay. Ob/Gyn & Women s Health Institute 1

24 Gynecologic Oncology 3-Day Readmission Rate a and Severity Index Following Inpatient Gynecologic Oncology Surgery (N = 981) Rate per 1 Surgeries 8 6 Severity Index Readmission rate 4 Readmission benchmark b Severity Index c 3 3-Day Mortality Rate a and Severity Index Following Inpatient Gynecologic Oncology Surgery (N = 981) Rate per 1 Surgeries 4 3 Severity Index Observed LOS 4 Expected LOS Severity Index b N d = e N c = d a These data are prepared using the Vizient Clinical Database. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b Benchmark derived from review of peer organization members of the Vizient for surgical cases for gynecologic malignancy identified by MS-DRGs 734, 735, 736, 737, 738, 739, 74, 741, 754, 755, and 756. c The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3m/en_us/health-information- Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG- Software d Total number of surgical cases for gynecologic malignancy identified by MS-DRGs 734, 735, 736, 737, 738, 739, 74, 741, 754, 755, and 756. e In 15 and 16, the number of inpatient admissions was reduced due to payer reclassification of the majority of major surgery admissions to outpatient status (less than a midnight stay). Patients meeting criteria for inpatient admission had more complex surgeries and more comorbidities than patients meeting criteria for discharge at less than a midnight stay. a These data are prepared using the Vizient Clinical Database. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3m/en_us/health-information-systems/ HIS/Products-and-Services/Products-List-A-Z/APR-DRG-Software c Total number of surgical cases for gynecologic malignancy identified by MS-DRGs 734, 735, 736, 737, 738, 739, 74, 741, 754, 755, and 756. d In 15 and 16, the number of inpatient admissions was reduced due to payer reclassification of the majority of major surgery admissions to outpatient status (less than a midnight stay). Patients meeting criteria for inpatient admission had more complex surgeries and more comorbidities than patients meeting criteria for discharge at less than a midnight stay. Outcomes 16

25 Radiation oncologists and medical oncologists at Cleveland Clinic work in close collaboration to treat patients with gynecologic cancers. Gynecologic tumor sites include the vulva, vagina, cervix, uterine body, and uterine adnexa. Standard radiation treatment employs high-dose-rate brachytherapy and external beam radiotherapy. Cervical Cancer Five-Year Overall Survival of Patients With Cervical Cancer a (N = 386) 7 15 Survival (%) 1 Cleveland Clinic National comparison b Years After Diagnosis Number at Risk = a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. gov/statfacts/html/cervix.html. Accessed on Mar. 9, 17. Ob/Gyn & Women s Health Institute 3

26 Gynecologic Oncology Historically cervical cancer was subdivided into stage IA (microinvasive carcinoma), which can be treated by a simple hysterectomy, and stage IB (more than microinvasive carcinoma), which is treated with radical surgery or radiation therapy. Five-Year Overall Survival of Patients With Stage IA and IB Cervical Cancer a (N = 154) 7 15 Survival (%) 1 8 Stage IA CC (N = 41) Stage IA AJCC b Stage IB CC (N = 113) Stage IB AJCC b 6 4 Number at Risk Years After Diagnosis Stage IA Stage IB AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b Comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. 4 Outcomes 16

27 In 1994, cervical cancer was further subdivided into stage IA1, IA, IB1, and IB to better estimate the risk of recurrence and survival. This is reflected in the Cleveland Clinic data listed below. Five-Year Overall Survival of Patients With Stage IA1, IA, IB1, and IB Cervical Cancer a (N = 145) 7 15 Survival (%) Stage IA1 (N = 6) Stage IA (N = 14) Stage IA REF b Stage IB1 (N = 77) Stage IB (N = 8) Stage IB REF b 4 Number at Risk Years After Diagnosis Stage IA Stage IA Stage IB Stage IB a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b Comparison group data from the American Cancer Society, as reported in: Survival rates for cervical cancer, by stage. American Cancer Society Web site. Retrieved from: html#written_by. Updated Dec. 5, 16. Accessed on Apr. 13, 17. Ob/Gyn & Women s Health Institute 5

28 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage IB by Treatment Modality a (N = 73) 7 15 Survival (%) 1 Stage IB S+C+R (N = 7) Stage IB S+R (N = 9) Number at Risk Years After Diagnosis Stage IB S+C+R Stage IB S+R C = chemotherapy, R = radiation, S = surgery a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital Following surgery for stage I cervical cancer, certain patients have high risk factors (including lymph node metastasis, extension beyond the cervix, and positive margins) or intermediate risk factors (including large tumor size, presence of lymph-vascular space invasion, and extended cervical stromal invasion) that require radiation therapy of the pelvis. The graph above demonstrates that those patients with the lowest risk factors have the best outcomes. Patients treated with adjuvant radiation and concurrent chemotherapy had a better overall survival rate than those treated with radiation only. 6 Outcomes 16

29 Five-Year Overall Survival of Patients With Stage IIA and IIB Cervical Cancer a (N = 59) 7 15 Survival (%) 1 8 Stage IIA CC (N = 14) Stage IIA AJCC b Stage IIB CC (N = 45) Stage IIB AJCC b 6 4 Number at Risk Years After Diagnosis Stage IIA Stage IIB AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b Comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. Ob/Gyn & Women s Health Institute 7

30 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage IIIB and IVA Cervical Cancer a (N = 97) 7 15 Survival (%) 1 8 Stage IIIB CC (N = 87) Stage IIIB AJCC b Stage IVA CC (N = 1) Stage IVA AJCC b 6 4 Number at Risk Years After Diagnosis Stage IIIB Stage IVA AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b Comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. 8 Outcomes 16

31 Endometrial Cancer Five-Year Overall Survival of Patients With Endometrial Cancer a (N = 69) 7 15 Survival (%) 1 Cleveland Clinic National comparison b Years After Diagnosis Number at Risk = a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. gov/statfacts/html/corp.html. Accessed on Mar. 3, 17. Ob/Gyn & Women s Health Institute 9

32 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage IA and IB Endometrial Cancer a (N = 194) 7 15 Survival (%) 1 9 Stage IA CC (N = 961) Stage IA AJCC b Stage IB CC (N = 333) Stage IB AJCC b Number at Risk Years After Diagnosis Stage IA Stage IB AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b Comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. 3 Outcomes 16

33 Five-Year Overall Survival of Patients With Stage II Endometrial Cancer a (N = 116) 7 15 Survival (%) 1 8 Cleveland Clinic National comparison b Years After Diagnosis Number at Risk = a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. Accessed on Mar. 3, 17. Ob/Gyn & Women s Health Institute 31

34 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage II Endometrial Cancer by Treatment Modality a (N = 11) 7 15 Survival (%) 1 8 Stage II S+C+R (N = 8) Stage II S+R (N = 51) Stage II S (N = ) 6 4 Number at Risk Years After Diagnosis Stage II S+C+R Stage II S+R Stage II S C = chemotherapy, R = radiation, S = surgery a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital 3 Outcomes 16

35 Five-Year Overall Survival of Patients With Stage III and IV Endometrial Cancer a (N = 458) 7 15 Survival (%) 1 8 Stage III (N = 317) Stage IV (N = 141) 6 4 Number at Risk Years After Diagnosis Stage III Stage IV a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital Ob/Gyn & Women s Health Institute 33

36 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage III and IV Endometrial Cancer by Treatment Modality a (N = 398) 7 15 Survival (%) 1 8 Stage III and IV S+C+R (N = 165) Stage III and IV S+R (N = 5) Stage III and IV S+C (N = 17) Stage III and IV C (N = 54) 6 4 Percent Survival (Number at Risk) Years After Diagnosis Stage III and IV S+C+R Stage III and IV S+R Stage III and IV S+C Stage III and IV C C = chemotherapy, R = radiation, S = surgery a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital 34 Outcomes 16

37 Ovarian Cancer Five-Year Overall Survival of Patients With Ovarian Cancer a (N = 847) 7 15 Survival (%) 1 Cleveland Clinic National comparison b Years After Diagnosis Number at Risk = a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. Accessed on Mar. 3, 17. Ob/Gyn & Women s Health Institute 35

38 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage IA, IB, and IC Ovarian Cancer a (N = 171) 7 15 Survival (%) Stage IA CC (N = 99) Stage IA AJCC b Stage IB CC (N = 1) Stage IB AJCC b Stage IC CC (N = 6) Stage IC AJCC b Number at Risk Years After Diagnosis Stage IA Stage IB Stage IC AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; Outcomes 16

39 Five-Year Overall Survival of Patients With Stage IIA, IIB, and IIC Ovarian Cancer a (N = 58) 7 15 Survival (%) 1 8 Stage IIA CC (N = 15) Stage IIA AJCC b Stage IIB CC (N = 1) Stage IIB AJCC b Stage IIC CC (N = ) Stage IIC AJCC b 6 4 Number at Risk Years After Diagnosis Stage IIA Stage IIB Stage IIC AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. Ob/Gyn & Women s Health Institute 37

40 Gynecologic Oncology Five-Year Overall Survival of Patients With Stage III and IV Ovarian Cancer a (N = 536) 7 15 Survival (%) Stage IIIA CC (N = ) Stage IIIA AJCC b Stage IIIB CC (N = 5) Stage IIIB AJCC b Stage IIIC CC (N = 44) Stage IIIC AJCC b Stage IV CC (N = 45) Stage IV AJCC b 4 Number at Risk Years After Diagnosis Stage IIIA Stage IIIB Stage IIIC Stage IV AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital b National comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; Outcomes 16

41 Five-Year Overall Survival of Patients With Stage III and IV Ovarian Cancer by Treatment Modality a (N = 54) 7 15 Survival (%) 1 8 Stage III and IV S+C (N = 44) Stage III and IV C (N = 116) Number at Risk Years After Diagnosis Stage III and IV S+C Stage III and IV C C = chemotherapy, S = surgery a Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital Ob/Gyn & Women s Health Institute 39

42 Breast Disease Cleveland Clinic s Breast Center is committed to providing patients with the best possible prevention, detection, and treatment options for breast disease. A multidisciplinary team comprising surgeons, medical oncologists, radiation oncologists, nurses, and social workers collaborates with each patient to develop a tailored care plan at 4 accredited a breast centers throughout northeast Ohio. Prevention and Screening Percentage of Screening Mammograms Resulting in Callback 1 16 Percent N = 6,959 63,355 65,875 66,934 67,84 Cleveland Clinic offers a diagnostic callback program for patients with abnormal screening mammograms. a Accredition by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons 4 Outcomes 16

43 Quality Measures Needle Core or Fine Needle Aspirate Biopsy Prior to Surgical Treatment of Breast Cancer (N = 35) % Not performed (N = 18) 1% 94.9% Performed (N = 33) Source: Data from Cleveland Clinic tumor registry for main campus and family health center locations Cleveland Clinic s performance was 94.9% (33 of 35 patients) in 15 for this Commission on Cancer standard of care quality measure (95% confidence interval [CI], ). Cleveland Clinic performs within the acceptable range for biopsy prior to surgical treatment of breast cancer. Ob/Gyn & Women s Health Institute 41

44 Breast Disease Breast Conservation Surgery Rate for Women With Clinical Stage a, I, or II Breast Cancer (N = 563) 15 43% Not performed (N = 4) 1% 57% Performed (N = 31) Source: Data from Cleveland Clinic tumor registry for main campus and family health center locations a American Joint Committee on Cancer (AJCC) stage I IV breast cancer Cleveland Clinic s performance was 57% (31 of 563 patients) in 15 for this Commission on Cancer (CoC) standard of care quality surveillance measure (95% CI, ). The CoC does not define a benchmark performance rate. The National Accreditation Program for Breast Centers standard is 5%. The rate at Cleveland Clinic reflects patient choice and referral bias of patients seeking surgery and reconstruction at Cleveland Clinic. 4 Outcomes 16

45 Treatment Five-Year Overall Survival of Female Patients With All Stages a of Breast Cancer (N = 763) 7 15 Survival (%) Years After Diagnosis Number at Risk a AJCC stage I IV breast cancer Five-Year Overall Survival of Female Patients With Breast Cancer by Race a (N = 7381) 7 15 Survival (%) Years After Diagnosis Number at Risk White Black White (N = 663) Black (N = 1118) a Self-reported Ob/Gyn & Women s Health Institute 43

46 Breast Disease Five-Year Overall Survival of Female Patients With Breast Cancer by Hormone Receptor Status (N = 6155) 7 15 Survival (%) Years After Diagnosis Number at Risk ER/PR negative ER/PR positive ER/PR negative (N = 131) ER/PR positive (N = 4834) ER = estrogen receptor, PR = progesterone receptor Five-Year Overall Survival of Female Patients With Breast Cancer by HER Status (N = 3881) 7 15 Survival (%) 1 8 HER negative (N = 3183) HER positive (N = 698) 6 4 Number at Risk HER negative HER positive Years After Diagnosis HER = human epidermal growth factor receptor Outcomes 16

47 Five-Year Overall Survival of Female Patients With Breast Cancer by Estrogen Receptor, Progesterone Receptor, and HER Status (N = 65) 7 15 Survival (%) Years After Diagnosis Number at Risk ER/PR positive HER positive Triple-negative ER/PR positive (N = 4834) HER positive (N = 698) Triple-negative (N = 493) ER = estrogen receptor, HER = human epidermal growth factor receptor, PR = progesterone receptor Ob/Gyn & Women s Health Institute 45

48 Breast Disease Five-Year Overall Survival of Female Patients With Stage a and I Breast Cancer (N = 445) 7 15 Survival (%) 1 8 Stage CC (N = 1345) Stage NCDB b Stage I CC (N = 36) Stage I NCDB b Years After Diagnosis Number at Risk Stage CC Stage I CC CC = Cleveland Clinic, NCDB = National Cancer Database a AJCC stage I IV breast cancer b Reference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; Outcomes 16

49 Five-Year Overall Survival of Female Patients With Stage a IIA and IIB Breast Cancer (N = 1947) 7 15 Survival (%) Stage IIA CC (N = 1339) Stage IIA NCDB b Stage IIB CC (N = 68) Stage IIB NCDB b 4 1 CC = Cleveland Clinic, NCDB = National Cancer Database a AJCC stage I IV breast cancer Years After Diagnosis Number at Risk Stage IIA Stage IIB b Reference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. Ob/Gyn & Women s Health Institute 47

50 Breast Disease Five-Year Overall Survival of Female Patients With Stage a IIIA and IIIB Breast Cancer (N = 55) 7 15 Survival (%) CC = Cleveland Clinic, NCDB = National Cancer Database a AJCC stage I IV breast cancer Years After Diagnosis Number at Risk Stage IIIA Stage IIIB b Reference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. Stage IIIA CC (N = 49) Stage IIIA NCDB b Stage IIIB CC (N = 13) Stage IIIB NCDB b 48 Outcomes 16

51 Five-Year Overall Survival of Female Patients With Late Stage a Breast Cancer (N = 45) 7 15 Survival (%) CC = Cleveland Clinic, NCDB = National Cancer Database a AJCC stage I IV breast cancer Years After Diagnosis Number at Risk Stage IIIC Stage IV Stage IIIC CC (N = 157) Stage IIIC NCDB b Stage IV CC (N = 95) Stage IV NCDB b b Reference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the American Cancer Society), as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 1. Ob/Gyn & Women s Health Institute 49

52 Specialized Women s Health The Center for Specialized Women s Health comprises an interdisciplinary team that specializes in addressing health issues specific to women, such as menstrual disorders, menopause, menopausal hormone therapy, female sexual dysfunction, medical treatment of urinary and fecal incontinence, alternatives to hysterectomy, hormone therapies, uterine fibroids, and osteoporosis. Outcomes reported here relate to care by women s health staff practicing at Cleveland Clinic s main campus. Diagnosis of Patients Following Dual-Energy X-Ray Absorptiometry Scan (N = 6976) 1 16 Number Osteoporosis a Osteopenia b Normal a Osteoporosis = T-score -.5 b Osteopenia = - < T-score < N = Zoledronic Acid Injections Administered for Low Bone Mineral Density (N = 63) a 1 16 Number N = a Some patients received more than one injection. The center began using zoledronic acid in 8 to treat women with osteopenia and osteoporosis. In the majority of patients, this treatment has helped prevent further deterioration of bone mineral density. 5 Outcomes 16

53 Change in Bone Mineral Density by Treatment Duration and Treatment 7 16 Percent N = No Treatment 3166 Zoledronic Acid No Treatment Zoledronic Acid No Treatment Bisphosphonates Bisphosphonates Bisphosphonates 3 Years 4 5 Years 6 7 Years Treatment Duration Zoledronic Acid b 148 Improved a Stable Worsened a a Improvement or deterioration in bone mineral density is defined as a difference of at least.3 g/cm between the baseline and follow-up scans. b Patients receiving zoledronic acid injections completed a maximum of 6 years of therapy. Patients included those having a dual-energy x-ray absorptiometry scan between 7 and 16 who were diagnosed with osteoporosis or osteopenia at any age. Follow-up scans were used to track changes in bone mineral density as often as every years, and their progress over time is reflected in the figure (individual patients may be represented in more than 1 of the 3 time periods). Ob/Gyn & Women s Health Institute 51

54 Maternal-Fetal Medicine Outcomes reported here relate to care by maternal-fetal medicine staff practicing in Cleveland Clinic facilities in northeast Ohio. While the acuity of Cleveland Clinic s obstetrical population has not changed significantly, the implementation of guidelines for fetal surveillance together with an organization-wide emphasis on containing costs have likely led to more judicious use of antenatal fetal surveillance methods. Tests of Fetal Well-Being (N = 14,99) 1 16 Number 4, 3,, 1, Doppler Biophysical profiles Nonstress test N = 3,814 8,333 3,966 9,5 16 7,66 With the incorporation of cell-free DNA technology and noninvasive prenatal testing in late 1, the institute continues to see a greater uptake of aneuploidy screening in the obstetrical population. Cell-free DNA technology offers higher detection rates and far fewer false-positive results than traditional screening tests, leading to a significant decline in the number of invasive diagnostic procedures being performed. While cell-free DNA technology is reserved for higher risk patients, the institute has also noted that low-risk patients are more likely to pursue aneuploidy screening. A positive screen with a traditional test, such as sequential screening, can now be followed up with cell-free DNA testing rather than an invasive procedure, thus avoiding the main drawback with traditional screening tests and making screening more palatable for more patients. 5 Outcomes 16

55 Genetic Diagnostic Tests (N = 81) 1 16 Number N = Cell-free DNA Chorionic villus sampling Amniocentesis Fetal Care Center The goal of the Fetal Care Center is to coordinate care for women with pregnancies complicated by fetal anomalies or critical maternal illness. Disciplines involved in prenatal diagnosis and counseling include maternal-fetal medicine specialists, neonatologists, and pediatric specialists in surgery, imaging, and medical management. In the event of critical maternal illness, consultation is sought from appropriate medical and surgical subspecialists. A collaborative plan is then developed for the pregnancy and may include fetal interventions or maternal medical and/or surgical treatment. The fetal care coordinator supports patients and their families throughout the entire process by providing education, facilitating communication, and incorporating the appropriate ancillary services and resources available during these difficult circumstances. The most complex of these cases are delivered in the Special Delivery Unit, a small, full-service labor and delivery unit located within Cleveland Clinic Children s. In 16, the Fetal Care Center provided services for 37 families and arranged for 436 prenatal consultations. Number of Families Served By Fetal Care Center 1 16 Number N = Ob/Gyn & Women s Health Institute 53

56 Maternal-Fetal Medicine Fetal Abnormalities (N = 99) a Face/Neck Other/Multiple Issues Chromosomal Musculoskeletal GI/Abdomen Urologic Brain/Spine Cardiac Number a Some fetuses exhibited more than one abnormality. Fetal Care Center Infant Surgical Cases Within 1 Year of Birth Number of Procedures Other Urology Plastic surgery Orthopaedic Neurology Cardiovascular/Cardiothoracic N = Outcomes 16

57 Obstetrics With societal trends such as delayed childbearing, the obesity epidemic, and increased prevalence of chronic diseases such as hypertension and diabetes, the incidence of critical maternal illness during pregnancy has increased significantly. The Fetal Care Center specializes in coordinating multidisciplinary care for women whose pregnancies are complicated by significant medical or surgical conditions. These patients receive obstetrical care in the Special Delivery Unit at Cleveland Clinic s main campus, while in close proximity to their medical and surgical care teams. The collaborative approach allows each patient s needs to be addressed individually and optimizes care for both mother and baby. Maternal Critical Illness (N = 618) a Face/Neck Other Chromosomal Musculoskeletal GI/Abdomen Urologic Brain/Spine Cardiac Number a Some mothers exhibited more than one abnormality. Ob/Gyn & Women s Health Institute 55

58 Obstetrics Obstetric outcomes are reported for births attended by both staff and private physicians and midwives at Cleveland Clinic health system regional hospitals and main campus. In 16, 93.% of births in the system were attended by Cleveland Clinic staff physicians or midwives. Cesarean Delivery Percent 3 Cleveland Clinic target a 1 Better N b = Source: Joint Commission National Quality Measures Perinatal Care- a Cleveland Clinic Target: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Reduce cesarean births among low-risk (full-term, singleton, and vertex presentation) women. Healthy People. Washington, DC: 1 b Number of low-risk, first-birth women (ie, nulliparous, term, singleton, vertex presentation) Labor Induction Percent 3 Cleveland Clinic target a 1 Better N b = 13 1, , , ,83 a Cleveland Clinic Target: Fisch JM, English D, Pedaline S, Brooks K, Simhan HN. Labor induction process improvement: a patient quality-of-care initiative. Obstet Gynecol. 9 Apr;113(4): b All deliveries Induction of labor is an intervention designed to artificially initiate uterine contractions, leading to progressive dilation and effacement of the cervix and birth of the baby. 56 Outcomes 16

59 Outcomes Vaginal Birth After Cesarean Delivery Percent 5 Cleveland Clinic target a 15 1 Better 5 N b = Source: Vaginal Birth After Cesarean (VBAC) Rate, All Inpatient Quality Indicators #34 Area-Level Indicator, Procedure Utilization Indicator, AHRQ Quality Indicators, Version 4.3, August 11. qualityindicators.ahrq.gov/downloads/modules/iqi/v43/techspecs/iqi%34% Vaginal%Birth%After%Cesarean%(VBAC)%Rate%All.pdf. a Cleveland Clinic target derived from review of peer organization members of Vizient. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b Number of patients with prior cesarean delivery Successful Trial of Labor After Cesarean Delivery Percent ACOG guidelines a Better N b = ACOG = American Congress of Obstetricians and Gynecologists a Cleveland Clinic target: ACOG practice bulletin. Vaginal birth after previous cesarean delivery. Number 5, July 1999 (replaces practice bulletin number, October 1998). Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet Aug;66(): b Patients with prior cesarean delivery who underwent trial of labor Ob/Gyn & Women s Health Institute 57

60 Obstetrics Episiotomy Percent 1 8 ACNM benchmark a 6 4 Better N b = ACNM = American College of Nurse-Midwives Source: National Perinatal Information Center a American College of Nurse-Midwives (ACNM) Benchmarking Project 1: Practices with > 5 deliveries per year. med.unc.edu/obgyn/highlights-honors/acnm_benchmarkingproject_11-1.pd. b Number of vaginal deliveries Third- and Fourth-Degree Lacerations in Vaginal Deliveries With Instrument Assistance Rate per 1 Deliveries Cleveland Clinic target a 15 1 Better 5 N b = Source: Obstetric Trauma Rate-Vaginal Delivery With Instrument, Patient Safety Indicator #18, Provider-Level Indicator, AHRQ Quality Indicators, Version 4.3, August 11. qualityindicators.ahrq.gov/downloads/modules/psi/v43/techspecs/ PSI%18%Obstetric%Trauma%Rate-Vaginal%Delivery%With%Instrument.pdf a Cleveland Clinic target: derived from review of peer organization members of Vizient. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b Total number of instrument-assisted vaginal deliveries 58 Outcomes 16

61 Third- and Fourth-Degree Lacerations in Vaginal Deliveries Without Instrument Assistance Rate per 1 Deliveries 3 Cleveland Clinic target a Better 1 N b = Source: Obstetric Trauma Rate-Vaginal Delivery With Instrument, Patient Safety Indicator #18, Provider-Level Indicator, AHRQ Quality Indicators, Version 4.3, August 11. qualityindicators.ahrq.gov/downloads/modules/psi/v43/techspecs/ PSI%18%Obstetric%Trauma%Rate-Vaginal%Delivery%With%Instrument.pdf a Cleveland Clinic target: derived from review of peer organization members of Vizient. Data from the Vizient Clinical Data Base/Resource Manager used by permission of Vizient. All rights reserved. b Total number of spontaneous vaginal deliveries Postpartum Depression Screening Percent Cleveland Clinic target N a = a Patients presenting for 6-week postpartum visit The institute screened more than 9% of postpartum patients for depression in 16. This was accomplished by incorporating screening for postpartum depression into an electronic questionnaire that was developed within the electronic medical record for all postpartum encounters. A -item patient health questionnaire is used to evaluate all postpartum patients. If either question is answered yes, a complete Edinburgh Postnatal Depression Scale is administered. With this screening and provider education, patients with symptoms of depression are identified, and opportunities for treatment and intervention are maximized. Ob/Gyn & Women s Health Institute 59

62 Obstetrics Appropriate Use of Antenatal Steroids Percent Cleveland Clinic target a N = All patients between 4 and 3 weeks of gestation who were at risk for preterm delivery received antenatal steroids to enhance fetal lung maturity prior to delivery, in keeping with national guidelines. 1, References 1. The Joint Commission. 1. Specifications Manual for Joint Commission National Quality Measures (v13a1), PC-3 Antenatal Steroids.. Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH Consensus Statement Feb 8-Mar ;1():1-4. Exclusive Breast Milk Feeding During Newborn s Entire Hospitalization Percent Cleveland Clinic target a N = 1465 b Source: Obstetric Joint Commission National Quality Measures Perinatal Care PC-5 a Cleveland Clinic target derived from review of peer organization members of Vizient. Data from the Vizient Clinical Data Base/Resource Manager TM used by permission of Vizient. All rights reserved. b Denominator reported beginning in second quarter of 14. Exclusive breast milk feeding for the first 6 months of life is associated with improved health and neonatal survival. Initiation of breastfeeding in the hospital soon after birth increases the rate of continuation after hospital discharge. 6 Outcomes 16

63 Surgical Quality Improvement The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP ) objectively measures and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. These outcomes data reflect Cleveland Clinic s gynecology surgery ACS NSQIP performance benchmarked against 56 participating sites. Gynecology Surgery July 15 June 16 Outcome N Observed Rate (%) Expected Rate (%) 3-day morbidity Surgical site infection Urinary tract infection Return to operating room Readmission Hysterectomy/Myomectomy Outcomes July 15 June 16 Outcome N Observed Rate (%) Expected Rate (%) 3-day mortality day morbidity Pneumonia a.49 Ventilator > 48 hours Return to operating room Ureteral obstruction 19. a.8 a Identified as a statistical outlier (lower than expected) by the ACS NSQIP hierarchical model These NSQIP outcomes are based on abdominal hysterectomies performed at Cleveland Clinic main campus; 4.7% of patients had known gynecologic malignancy. Source: facs.org/quality-programs/acs-nsqip Ob/Gyn & Women s Health Institute 61

64 Patient Experience Ob/Gyn & Women's Health Institute Keeping patients at the center of all that Cleveland Clinic does is critical. Patients First is the guiding principle at Cleveland Clinic. Patients First is safe care, high-quality care, in the context of patient satisfaction, and high value. Ultimately, caregivers have the power to impact every touch point of a patient s journey, including their clinical, physical, and emotional experience. Cleveland Clinic recognizes that patient experience goes well beyond patient satisfaction surveys. Nonetheless, sharing the survey results with caregivers and the public affords opportunities to improve how Cleveland Clinic delivers exceptional care. Outpatient Office Visit Survey Ob/Gyn & Women's Health Institute CG-CAHPS Assessment a Best Response (%) (N = 13,67) 16 (N = 14,18) CG-CAHPS 15 database average (all practices) b Appointment Access (% Always) c a In 13, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the AHRQ CG-CAHPS database from 89 practices in 15 c Response options: Always, Usually, Sometimes, Never d Response options: Yes, definitely; Yes, somewhat; No Source: Press Ganey, a national hospital survey vendor Primary Care Specialty Care Doctor Communication (% Always) c (% Yes, Definitely) d Doctor Rating (% 9 or 1) 1 Scale Clerical Staff (% Always) c Test Results Communication (% Always) c 6 Outcomes 16

65 Inpatient Survey Ob/Gyn & Women's Health Institute HCAHPS Overall Assessment Best Response (%) Hospital Rating (% 9 or 1) 1 Scale Recommend Hospital (% Definitely Yes) b a Based on national survey results of discharged patients, January 15 December 15, from 417 US hospitals. medicare.gov/hospitalcompare b Response options: Definitely yes, Probably yes, Probably no, Definitely no 15 (N = 61) 16 (N = 4) National average all patients a The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/ hospitalcompare. HCAHPS Domains of Care a Best Response (%) (N = 61) 16 (N = 4) National average all patients b 6 4 Discharge Information % Yes Care Transition % Strongly Doctor Communication Nurse Communication Pain Management Room Clean % Always Agree New Medications Communication (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. b Based on national survey results of discharged patients, January 15 December 15, from 417 US hospitals. medicare.gov/hospitalcompare Source: Press Ganey, a national hospital survey vendor, 16 Quiet at Night Ob/Gyn & Women s Health Institute 63

66 Cleveland Clinic Implementing Value-Based Care Overview Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing 3 goals: improving the patient experience of care (including quality and satisfaction), improving population health, and reducing the cost of healthcare. The following measures are examples of 16 focus areas in pursuit of this 3-part aim. Throughout this section, Cleveland Clinic refers to the academic medical center or main campus, and those results are shown. Real-time data are leveraged in each Cleveland Clinic location to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels and support improved care in all clinical locations. Improve the Patient Experience of Care Cleveland Clinic Overall Mortality Ratio O/E Ratio Cleveland Clinic Central Line-Associated Bloodstream Infection, reported as Standardized Infection Ratio (SIR) Rate per 1 Line Days 1.5 CC Performance CC target CC Performance CC target.5. Q1 Q Q3 Q4 Q1 Q Q3 Q Source: Data from the Vizient Clinical Data Base/Resource Manager TM used by permission of Vizient. All rights reserved. Cleveland Clinic s observed/expected (O/E) mortality ratio outperformed its internal target derived from the Vizient 16 risk model. Ratios less than 1. indicate mortality performance better than expected in Vizient s risk adjustment model.. Q1 Q Q3 Q4 Q1 Q Q3 Q Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSIs), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews of every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population. 64 Outcomes 16

67 Cleveland Clinic Postoperative Respiratory Failure Risk-Adjusted Rate Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult) Rate per 1 Eligible Patients CC Performance CC target Percent CC Performance NDNQI 5 th (Academic Medical Centers) Q1 Q Q3 Q4 Q1 Q Q3 Q Q1 Q Q3 Q4 Q1 Q Q3 Q Source: Data from the Vizient Clinical Data Base/Resource Manager TM used by permission of Vizient. All rights reserved. Efforts continue toward reducing intubation time, assessing readiness for extubation, and preventing the need for reintubation. Cleveland Clinic has leveraged the technology within the electronic medical record to support ongoing improvement efforts in reducing postoperative respiratory failure (AHRQ Patient Safety Indicator 11). Prevention of respiratory failure remains a safety priority for Cleveland Clinic. Source: Data reported from the National Database for Nursing Quality Indicators (NDNQI ) with permission from Press Ganey. A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing position on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur. Cleveland Clinic strategies to mitigate the risk of these pressure injuries include routine rounding to accurately stage pressure injuries, monthly multidisciplinary wound care meetings, and ongoing nursing education, both in the classroom and at the bedside. Ob/Gyn & Women s Health Institute 65

68 Cleveland Clinic Implementing Value-Based Care Keeping patients at the center of all that we do is critical. Patients First is the guiding principle at Cleveland Clinic. Patients First is safe care, high-quality care, in the context of patient satisfaction, and high value. Ultimately, our caregivers have the power to impact every touch point of a patient s journey, including their clinical, physical, and emotional experience. We know that patient experience goes well beyond patient satisfaction surveys. Nonetheless, by sharing the survey results with our caregivers and the public, we constantly identify opportunities to improve how we deliver exceptional care. Outpatient Office Visit Survey Cleveland Clinic CG-CAHPS Assessment a Best Response (%) (N = 5,95) 16 (N = 54,179) CG-CAHPS 15 database average (all practices) b Appointment Access (% Always) c a In 16, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the AHRQ CG-CAHPS database from 89 practices in 15 c Response options: Always, Usually, Sometimes, Never d Response options: Yes, definitely; Yes, somewhat; No e Response options: Yes, No Source: Press Ganey, a national hospital survey vendor Specialty Care Primary Care Doctor Communication (% Yes, Definitely) d (% Always) c Doctor Rating (% 9 or 1) 1 Scale Clerical Staff (% Yes, Definitely) d Test Results Communication (% Yes) e 66 Outcomes 16

69 Inpatient Survey Cleveland Clinic HCAHPS Overall Assessment Best Response (%) Hospital Rating (% 9 or 1) 1 Scale a At the time of publication, 15 ratings have not been reported by the Centers for Medicare & Medicaid Services and ratings are not adjusted for patient mix. b Based on national survey results of discharged patients, January 15 December 15, from 417 US hospitals. medicare.gov/hospitalcompare c Response options: Definitely yes, Probably yes, Probably no, Definitely no HCAHPS Domains of Care a Best Response (%) 1 8 Recommend Hospital (% Definitely Yes) c 15 (N = 1,7) 16 (N = 97) a National average all patients b The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/ hospitalcompare. 14 (N = 1,369) 15 (N = 9966) b National average all patients c 6 4 Discharge Information % Yes Care Transition % Strongly Doctor Communication Nurse Communication Pain Management Room Clean % Always Agree New Medications Communication (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs Quiet at Night a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. b At the time of publication, 16 ratings have not been reported by the Centers for Medicare & Medicaid Services and ratings are not adjusted for patient mix. c Based on national survey results of discharged patients, January 15 December 15, from 417 US hospitals. medicare.gov/hospitalcompare Source: Centers for Medicare & Medicaid Services, 15; Press Ganey, a national hospital survey vendor, 16 Ob/Gyn & Women s Health Institute 67

70 Cleveland Clinic Implementing Value-Based Care Focus on Value Cleveland Clinic has developed and implemented new models of care that focus on Patients First and aim to deliver on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new models of Value-Based Care is a strategic priority for Cleveland Clinic. As care delivery shifts from fee-for-service to a population health and bundled payment delivery system, Cleveland Clinic is focused on concurrently improving patient safety, outcomes, and experience. What does this new model of care look like? Integrated Care Model Retail Venues Home Community-Based Organizations Care System Outpatient Clinics Post-acute (other) Emergency Independent Physician Offices Skilled Nursing Facilities MyChart Rehabilitation Facilities Hospitals Ambulatory Diagnosis & Treatment The Cleveland Clinic Integrated Care Model (CCICM) is a value-based model of care, designed to improve outcomes while reducing cost. It is designed to deliver value in both population health and specialty care. The patient remains at the heart of the CCICM. The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in different settings. The care system represents integration of care across the continuum. Critical competencies are required to build this new care system. Cleveland Clinic is creating disease- and condition-specific care paths for a variety of procedures and chronic diseases. Another facet is implementing comprehensive care coordination for high-risk patients to prevent unnecessary hospitalizations and emergency department visits. Efforts include managing transitions in care, optimizing access and flow for patients through the CCICM, and developing novel tactics to engage patients and caregivers in this work. Measuring performance around quality, safety, utilization, cost, appropriateness of care, and patient and caregiver experience is an essential component of this work. 68 Outcomes 16

71 Improve Population Health Cleveland Clinic Accountable Care Organization Measure Performance 16 National Percentile Ranking 9th 8th Falls Screening Heart Failure Ischemic Vascular Disease BMI Screening Tobacco Screening Coronary Artery Disease Diabetes Breast Cancer Screening Pneumonia Vaccination 7th Colorectal Cancer Screening Influenza Vaccination Blood Pressure Screening Hypertension 5th Depression Screening Higher percentiles are better As part of Cleveland Clinic s commitment to population health and in support of its Accountable Care Organization (ACO), these ACO measures have been prioritized for monitoring and improvement. Cleveland Clinic is improving performance in these measures by enhancing care coordination, optimizing technology and information systems, and engaging primary care specialty teams directly in the improvement work. These pursuits are part of Cleveland Clinic s overall strategy to transform care in order to improve health and make care more affordable. Ob/Gyn & Women s Health Institute 69

72 Cleveland Clinic Implementing Value-Based Care Reduce the Cost of Care Cleveland Clinic All-Cause 3-Day Readmission Rate to Any Cleveland Clinic Hospital Percent Readmission Rate CC Rate CC CMI Vizient AAMC CMI Case Mix Index 3 Q1 Q Q3 Q4 Q1 Q Q3 Q CMI = case mix index Source: Data from the Vizient Clinical Data Base/Resource Manager TM used by permission of Vizient. All rights reserved. Cleveland Clinic monitors 3-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Comprehensive care coordination and care management for high-risk patients has been initiated in an effort to prevent unnecessary hospitalizations and emergency department visits. Sicker, more complex patients are more susceptible to readmission. Case mix index (CMI) reflects patient severity of illness and resource utilization. Cleveland Clinic s CMI remains one of the highest among American academic medical centers. 1 7 Outcomes 16

73 Accountable Care Organization (ACO) Improving Outcomes and Reducing Costs Additional 1,5 in control 131 fewer strokes 1 fewer heart attacks 75 fewer early deaths 74% 68% Cleveland Clinic was one of the top performing new ACOs in the United States (for 15 performance as determined in 16) due to efficiency, cost reduction, and improvements in effectiveness of chronic disease management such as treating hypertension, reducing preventable hospitalizations through care coordination, and optimizing the care at skilled nursing facilities through its Connected Care program. For example, a system-wide effort to improve the control of blood pressure for patients with hypertension was begun in 16 and resulted in an additional 1,5 patients with blood pressure controlled. This will translate to many fewer strokes, heart attacks, and preventable deaths. Ob/Gyn & Women s Health Institute 71

74 Innovations Uterine Transplant The first uterine transplant in the United States was performed at Cleveland Clinic in February 16 as part of a 1-patient clinical trial to treat uterine factor infertility (UFI). Selected trial participants ages 1 to 39 years will receive matched deceased donor transplants and will undergo in vitro fertilization to create embryos prior to transplantation. The uterus will be removed after the delivery of 1 or children to avoid prolonged maternal exposure to immunosuppressants. Ethical considerations will be prioritized, 1 and patients will be managed by a multidisciplinary team of transplant and gynecologic surgeons, high-risk obstetricians, psychologists, social workers, patient advocates, and bioethicists. The first transplanted uterus was removed weeks after surgery due to an infection that disrupted blood supply to the organ. Details of this initial experience have been published. Women with UFI are either born without a uterus, have a nonfunctioning uterus, or have had their uterus surgically removed. Until recently, UFI has been considered an irreversible form of infertility with gestational surrogacy and adoption as the only parenting options. Successful live births after uterine transplantation have been reported in Sweden, 3 and many centers worldwide are considering or embarking on uterine transplantation studies. References 1. Farrell RM, Falcone T. Uterine transplant: new medical and ethical considerations. Lancet. 15 Feb 14;385(9968): Flyckt RL, Farrell RM, Perni UC, Tzakis AG, Falcone T. Deceased donor uterine transplantation: innovation and adaptation. Obstet Gynecol. 16 Oct;18(4): Brännström M, Johannesson L, Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Milenkovic M, Ekberg J, Diaz-Garcia C, Gäbel M, Hanafy A, Hagberg H, Olausson M, Nilsson L. Livebirth after uterus transplantation. Lancet. 15 Feb 14;385(9968): Outcomes 16

75 Cleveland Clinic s Transgender Surgery and Medicine Program In spring 16, the Center for LGBT Care opened its doors to patients at Cleveland Clinic family health centers. Cecile Unger, MD, directs the Transgender Surgery and Medicine Program through the Center for LGBT Care within the Ob/Gyn & Women s Health Institute. This program provides comprehensive psychiatric, medical, and surgical care for transgender, gender fluid, and gender nonconforming individuals. Gender affirmation surgeries are offered through the center and include simple orchiectomy and vaginoplasty for transgender women and hysterectomy for transgender men. Nonsurgical services offered through the program include mental health care and support, primary care, and cross-sex hormone therapy and surveillance. The Center for LGBT Care was recently cited by The Wall Street Journal as one of a handful of United States academic centers offering these comprehensive services. The center is currently at the forefront of incorporating this type of care into training program curricula throughout Cleveland Clinic and is accommodating trainees from outside programs who are interested in learning about the care of these patients. Reference 1. Reddy S. With Insurers on Board, More Hospitals Offer Transgender Surgery. The Wall Street Journal. Sept. 6, Accessed Jan. 5, 16. Ob/Gyn & Women s Health Institute 73

76 Contact Information Obstetrics and Gynecology Appointments/Referrals or , ext Women s Health and Breast Pavilion Appointments/Referrals or , ext HER Women s Health Advice Line Monday through Friday, 8:3 a.m. to 4:3 p.m HER (4437) or , ext Staff Listing For a complete listing of Cleveland Clinic s Ob/Gyn Institute staff, please visit clevelandclinic.org/staff. Publications Obstetrics and Gynecology Institute staff authored 6 publications in 16 as indexed within Web of Science. On the Web at clevelandclinic.org/obgyn clevelandclinic.org/womenshealth clevelandclinic.org/breastcenter Locations For a complete listing of Ob/Gyn Institute locations, please visit clevelandclinic.org/obgyn. 74 Outcomes 16

77 Additional Contact Information General Patient Referral 4/7 hospital transfers or physician consults General Information Hospital Patient Information General Patient Appointments or Referring Physician Center and Hotline 855.REFER.13 ( ) Or or visit clevelandclinic.org/refer13 Request for Medical Records or , ext. 464 Same-Day Appointments CARE (73) Global Patient Services/ International Center Complimentary assistance for international patients and families or visit clevelandclinic.org/gps Medical Concierge Complimentary assistance for out-of-state patients and families , ext. 5558, or Cleveland Clinic Abu Dhabi clevelandclinicabudhabi.ae Cleveland Clinic Canada Cleveland Clinic Florida Cleveland Clinic Nevada For address corrections or changes, please call Ob/Gyn & Women s Health Institute 75

78 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 35 Cleveland Clinic staff physicians and scientists in 14 medical specialties and subspecialties care for more than 7.1 million patients across the system annually, performing nearly 8, surgeries and conducting more than 65, emergency department visits. Patients come to Cleveland Clinic from all 5 states and 185 nations. Cleveland Clinic s CMS case-mix index is the second-highest in the nation. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 14-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 44 buildings on 167 acres. Cleveland Clinic has more than 15 northern Ohio outpatient locations, including 1 regional hospitals, 18 full-service family health centers, 3 health and wellness centers, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida; Cleveland Clinic Nevada; Cleveland Clinic Canada; Cleveland Clinic Abu Dhabi, UAE; Sheikh Khalifa Medical City (management contract), UAE; and Cleveland Clinic London (opening in ). Cleveland Clinic is the largest employer in Ohio, with more than 51, employees. It generates $1.6 billion of economic activity a year. Cleveland Clinic supports physician education, training, consulting, and patient services around the world through representatives in the Dominican Republic, Guatemala, India, Panama, Peru, Saudi Arabia, and the United Arab Emirates. Dedicated Global Patient Services offices are located at Cleveland Clinic s main campus, Cleveland Clinic Abu Dhabi, Cleveland Clinic Canada, and Cleveland Clinic Florida. The Cleveland Clinic Model Cleveland Clinic was founded in 191 by 4 physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the nonprofit, multispecialty group practice they established. 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. Cleveland Clinic Florida was established in Cleveland Clinic began opening family health centers in surrounding communities in the 199s. Marymount Hospital joined Cleveland Clinic in 1995, followed by regional hospitals including Euclid Hospital, Fairview Hospital, Hillcrest Hospital, Lutheran Hospital, Medina Hospital, South Pointe Hospital, and affiliate Ashtabula County Medical Center. In 15, the Akron General Health System joined the Cleveland Clinic health system. Internally, Cleveland Clinic services are organized into patient-centered integrated practice units called institutes, each institute combining medical and surgical care for a specific disease or body system. Cleveland Clinic was among the first academic medical centers to establish an Office of Patient Experience, to promote comfort, courtesy, and empathy across all patient care services. A Clinically Integrated Network Cleveland Clinic is committed to providing value-based care, and it has grown the Cleveland Clinic Quality Alliance into the nation s second-largest, and northeast Ohio s largest, clinically integrated network. The network comprises more than 63 physician members, including both Cleveland Clinic staff and independent physicians from the community. Led by its physician members, the Quality Alliance strives to improve quality and consistency of care; reduce costs and increase efficiency; and provide access to expertise, data, and experience. 76 Outcomes 16

79 Cleveland Clinic Lerner College of Medicine Lerner College of Medicine is known for its small class sizes, unique curriculum, and full-tuition scholarships for all students. Each new class accepts 3 students who are preparing to be physician investigators. In 15, Cleveland Clinic broke ground on a 477,-square-foot multidisciplinary Health Education Campus. The campus, which will open in July 19, will serve as the new home of the Case Western Reserve University (CWRU) School of Medicine and Cleveland Clinic s Lerner College of Medicine, as well as the CWRU School of Dental Medicine, the Frances Payne Bolton School of Nursing, and physician assistant and allied health training programs. Graduate Medical Education In 16, nearly residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida in our continually growing programs. U.S. News & World Report Ranking Cleveland Clinic is ranked the No. hospital in America by U.S. News & World Report (16). It has ranked No. 1 in heart care and heart surgery since In 16, 3 of its programs were ranked No. in the nation: gastroenterology and GI surgery, nephrology, and urology. Ranked among the nation s top five were gynecology, orthopaedics, rheumatology, pulmonology, and diabetes and endocrinology. Cleveland Clinic Physician Ratings Cleveland Clinic believes in transparency and in the positive influence of the physician-patient relationship on healthcare outcomes. To continue to meet the highest standards of patient satisfaction, Cleveland Clinic physician ratings, based on nationally recognized Press Ganey patient satisfaction surveys, are published online at clevelandclinic.org/staff. Ob/Gyn & Women s Health Institute 18376_CCFBCH_17OUT415_Rev1_acg.indd /19/17 5: PM