Outcomes. Cardiovascular Services

Outcomes Cardiovascular Services 21

Introduction On behalf of Cleveland Clinic Florida, I am proud to present our 21 Cardiovascular Services Outcomes book. We have compiled outcomes by area of specialty to demonstrate our commitment to accountability, transparency and most of all, to outstanding patient care. These books are designed to help you and your patients make informed decisions about treatments and referrals. We consider it a privilege to work in partnership with you to care for your patients, and we continuously challenge ourselves to improve and to achieve excellent outcomes on their behalf. We hope you find the content informative.

Table of Contents 4 Chairman s Letter 6 Surgery 8 Heart Failure 12 Interventional Cardiology 18 Cardiac Rhythm Disorders 2 Cardiovascular Imaging 22 Vascular 24 Patient Experience 28 Staff Directory 29 Contact Information 3 Cleveland Clinic Florida Locations 31 About Cleveland Clinic Florida 32 Resources

To promote quality improvement, Cleveland Clinic Florida has created a series of Outcomes books similar to this one for many of its departments. Designed for a physician audience, the Outcomes books contain a summary of our surgical and medical trends and approaches, data on patient volumes and outcomes, and a review of new technologies and innovations. Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic Florida omission of outcomes for a particular treatment does not necessarily mean we do not offer that treatment our goal is to increase outcomes reporting each year. When outcomes for a specific treatment are unavailable, we often report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques. In addition to our internal efforts to measure clinical quality, Cleveland Clinic Florida 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 (CMS) Hospital Compare (hospitalcompare.hhs.gov) Agency for Healthcare Administration Centers for Disease Control Our commitment to providing accurate, timely information about patient care also will help patients and referring physicians make informed healthcare decisions. We hope you find these data valuable. To view all our Outcomes books, please visit our website at www.clevelandclinicflorida.org. 2 Outcomes 21

Dear Colleague: On behalf of Cleveland Clinic Florida, I am proud to present our 21 Cardiovascular Services Outcomes book. We have compiled outcomes by area of specialty to demonstrate our commitment to accountability, transparency and most of all, to outstanding patient care. These books are designed to help you and your patients make informed decisions about treatments and referrals. We consider it a privilege to work in partnership with you to care for your patients, and we continuously challenge ourselves to improve and to achieve excellent outcomes on their behalf. We hope you find the content informative. Sincerely, Bernie Fernandez, MD Chief Executive Officer Cleveland Clinic Florida Cleveland Clinic Florida 3

Chairman s Letter The Robert and Suzanne Tomsich Department of Cardiovascular Medicine provides comprehensive cardiovascular services. We are committed to not only providing the best outcomes, but also to sharing this information with the medical community and the public. This resource, which is a review the department s outcomes, trends and treatment approaches, underscores the dedication and achievement of our many health care professionals and caregivers. For the 17th consecutive year, Cleveland Clinic s heart program ranked as the best in the nation, earning the No. 1 ranking in U.S. News & World Report s 21-11 Best Hospitals. By adhering to the same mission statement and following similar protocols, we deliver world-class cardiovascular care in Florida through a seamless transfer of information and the benefit of cutting edge technology shared through our combined services. Our Florida and Cleveland campuses are integrated to synergize our collaborations and outcomes. Increasingly science-and-technology breakthroughs are transforming cardiovascular medicine and surgery. As the number of management options increase, patients benefit; however, choosing the best treatment can become a more difficult task. Our entire team is dedicated to determine the best strategy for each patient and to assure the highest quality of care is provided. We hope you will find this information useful. Randall C. Starling, MD, MPH, FACC Interim Chairman Department of Cardiovascular Medicine 4 Outcomes 21

The Robert and Suzanne Tomsich Department of Cardiology is a national leader in the prevention, evaluation and treatment of cardiovascular disease. The department offers patients advanced diagnosis, innovative treatments and comprehensive management by expert cardiologists collaborating among their areas of specialization to achieve excellent treatment outcomes and improved quality of life for our patients. All Cleveland Clinic cardiologists are subspecialty trained to effectively evaluate patients with specific cardiovascular concerns. Additionally, the department includes a section of Vascular Medicine. Vascular surgical specialists provide comprehensive surgical treatments in collaboration with cardiovascular medicine. The Robert and Suzanne Tomsich Department of Cardiothoracic Surgery also offers state-of-the-art cardiac and thoracic surgical treatment. Cleveland Clinic Florida 5

Surgery Risk Adjusted Operative Mortality (Isolated CABG) 21 In 21, Cleveland Clinic Florida surgeons performed 65 isolated coronary artery bypass grafting (CABG) procedures. The mortality rate associated with this group was percent. This is well below The Society of Thoracic Surgeons (STS) benchmark of 1.9.* Percent 2. 1.5 1..5 % Mortality STS Benchmark *Source: STS period ending 6/3/21 Risk Adjusted Inhospital Mortality (Isolated CABG) 21 Percent 2. 1.5 1..5 % Mortality STS Benchmark 6 Outcomes 21

Case Volumes 21 4% CABG Only 13% AV Replacement 9% AV Replacement + CABG 4% MV Repair 3% MV Repair + CABG 1% MV Replacement + CABG 3% MV Replacement Only 27% Other Arterial Grafts 21 Arterial grafts, with their excellent long term patency, remain the conduit of choice for coronary revascularization. In 21, 1% of all CABG patients received at least one arterial graft. 74.2% Left ITA 1.6% Right ITA 24.2% Left & Right ITA Isolated CABG 21 Percent 2. 1.5 CCF Florida STS Benchmark 1..5 Risk Adjusted Infection Rate Readmission to ICU Cleveland Clinic Florida 7

Heart Failure Heart Failure National Hospital Quality Measures 21 Heart failure care performance measures are available online at hospitalcompare.hhs.gov, a consumer-oriented website hosted by Centers for Medicare & Medicaid Services (CMS). Process Measures (often referred to as core measures): Hospitals submit heart failure process-of-care data that show how consistently recommended care was provided to adult patients, irrespective of payer. Cleveland Clinic Florida s National Hospital Quality Measure heart failure data are shown here. 8 Outcomes 21

Cleveland Clinic Florida Benchmark* Adult Smoking Cessation Advice Provided ACE/ARB Given for LVSD N = 19 N = 94 Left Ventricular Systolic Function Evaluated N = 279 Discharge Instructions Provided N = 255 2 4 6 8 1 Percent of Patients Cleveland Clinic benchmark: hospitalcompare.hhs.gov Visit clevelandclinic.org/qpr to view Cleveland Clinic s current Quality Performance Report. National average for discharges, January 21 through December 21, hospitalcompare.hhs.gov Abbreviations: ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker Cleveland Clinic Florida 9

Heart Failure Heart Failure Outcome Measures CMS calculates two heart failure outcome measures: all-cause mortality and all-cause readmission rates, each based on Medicare claims and enrollment information. Cleveland Clinic Florida s performance appears below. Heart Failure All-Cause 3-Day Mortality (N = 285) Discharges July 27 June 21 Percent 3 Heart Failure All-Cause 3-Day Readmission (N = 39) Discharges July 27 June 21 Percent 3 25 25 24.5 24.8 2 2 15 15 1 5 8.8 11.3 1 5 Cleveland Clinic * Source: hospitalcompare.hhs.gov National Average Cleveland Clinic National Average 1 Outcomes 21

Cleveland Clinic Florida s heart failure risk-adjusted 3-day mortality rate is below the national average. Our heart failure risk-adjusted readmission rate is at the national average. In an effort to reduce the readmission rate, transition-ofcare strategies are being developed and deployed. These include pre-discharge needs assessment, improved discharge processes (patient education, relay of discharge information to receiving providers), and post-discharge follow-up including continued clinical management support. For patients suffering from refractory heart failure, transplantation and mechanical circulatory support are alternative strategies offering relief from symptoms and excellent survival. The seamless integration with the Section of Heart Failure in Cleveland allows patients access to the full spectrum of therapies for this complex disease. Board Certified Heart Failure Transplant Cardiologists provide care. Cleveland Clinic Florida 11

Interventional Cardiology Risk Factors Among Patients Undergoing PCI Procedures (N = 27) 21 Percent 1 Cleveland Clinic Florida Comparable ACC-NCDR hospitals 8 6 4 2 Age (>8 years) Current/Recent Smoker Hypertension Dyslipidemia Prior CABG Current Dialysis Cerebrovascular Disease Peripheral Arterial Disease Chronic Lung Disease Diabetes Mellitus Patients who underwent PCI procedures at Cleveland Clinic Florida in 21 had similar medical co-morbidities to comparable hospitals. 12 Outcomes 21

Use of Adjunctive Medications After PCI (N = 26) 21 Percent 1 8 6 4 2 Aspirin ACE (EF <4%) β-blockers Statins Thienopyridines At Discharge Cleveland Clinic Florida Comparable ACC-NCDR hospitals Appropriate adjunctive medications before and after PCI procedures is considered a key performance measure by the ACC. Abbrevations: ACE, angiotensin converting enzyme. Cleveland Clinic Florida 13

Interventional Cardiology PCI Complications (N = 1,911 cases) 21 Percent 3 2 Cleveland Clinic Comparable ACC-NCDR hospitals 1 Mortality Emergency CABG The rates of mortality, unplanned bypass surgery, cardiac tamponade, dialysis, and bleeding among patients undergoing PCI procedures at Cleveland Clinic Florida were at or below the 21 national averages, as reported by the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). Abbreviation: CABG, coronary artery bypass grafting. %.3% %.1% %.3% Cardiac Tamponade New Requirement of Dialysis Bleeding at Access Site w/in 72hrs Median Time to PCI for STEMI 21 Minutes 1 8 6 4 2 Cleveland Clinic Florida Comparable ACC-NCDR Hospitals Benchmark It is recommended by the American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines that patients with ST-elevation acute myocardial infarction (STEMI) receive PCI balloon inflation within 9 minutes of arrival in the Emergency Department to reduce mortality and morbidity. 14 Outcomes 21

Acute Myocardial Infarction (AMI) National Hospital Quality Measures (continued) Acute Myocardial Infarction Outcome Measures CMS calculates two AMI outcome measures: all-cause mortality and all-cause readmission rates, each based on Medicare claims and enrollment information. Cleveland Clinic s performance appears below. AMI All-Cause 3-Day Mortality (N = 96) Discharges July 27 June 21 AMI All-Cause 3-Day Readmission (N = 14) Discharges July 27 June 21 Percent Percent 3 3 25 25 28.2 24.8 2 2 15 1 14 15.9 15 1 5 5 Cleveland Clinic National Average Cleveland Clinic National Average Cleveland Clinic Florida s AMI risk-adjusted all-cause 3-day mortality rate is below the national average; our AMI risk-adjusted readmission rate is higher than the national average.to reduce this rate, transition-of-care strategies are being developed and deployed at Cleveland Clinic. These include pre-discharge needs assessment, improved discharge processes (patient education, relay of discharge information to receiving providers) and post-discharge follow up, including continued clinical management support. *Source: www.hospitalcompare.hhs.gov Cleveland Clinic Florida 15

Interventional Cardiology Acute Myocardial Infarction (AMI) National Hospital Quality Measures Process Measures (often referred to as core measures): Hospitals submit AMI process-of-care data that show how consistently recommended care was provided to adult patients, irrespective of payer. Cleveland Clinic s AMI National Hospital Quality Measure data appear below. National Hospital Quality Measure (NHQM) volumes are based on NHQM inclusion/exclusion criteria and sampling methodologies; they may differ from case volumes shown elsewhere in this Outcomes book. AMI Care Performance Measures are available online at hospitalcompare.hhs.gov, a consumer-oriented website hosted by the Centers for Medicare & Medicaid Services (CMS). 16 Outcomes 21

Acute Myocardial Infarction Process Measures ( Core Measures) & Appropriateness of Care 21 Cleveland Clinic Florida Benchmark* Aspirin Given at Arrival N = 351 Aspirin Prescribed at Discharge N = 855 ACE/ARB Given for Left Ventricular Systolic Dysfunction N = 182 Adult Smoking Cessation Advice Provided N = 295 Beta Blocker Prescribed at Discharge N = 811 PCI Received within 9 Mins Hospital Arrival N = 22 2 4 6 8 1 Percent of Patients * Benchmark source: www.hospitalcompare.hhs.gov Abbreviations: ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker. Visit clevelandclinic.org/qpr to view Cleveland Clinic s current Quality Performance Report.National average for discharges, January 21 through December 21 hospitalcompare.hhs.gov Cleveland Clinic Florida 17

Cardiac Rhythm Disorders EP Laboratory Procedures 21 Cleveland Clinic Florida electrophysiologists use specialized approaches to diagnose and treat a wide variety of arrhythmias. Procedures performed in 21 are shown below. The total number of procedures includes some that are not detailed in the graph below. Volume 35 3 25 2 15 1 5 Pacemakers ICDs Total Ablations Cardioversions Pulmonary Vein Antrum Isolation Procedures (PVAI) Pulmonary Vein Antrum Isolation (PVAI) essentially disconnects the pathway of the abnormal heart rhythm and prevents atrial fibrillation. Cleveland Clinic Florida continues to be a leading center in performing non-surgical catheterbased ablation therapies used to treat atrial fibrillation, atrial flutter and supraventricular tachycardia. Volume 2 15 1 5 27 28 29 21 18 Outcomes 21

ICD Procedures 21 Volume 15 1 5 27 28 29 21 Implantable cardioverter defibrillators (ICD) help prevent sudden cardiac death. Biventricular ICD devices help prevent cardiac death and assist in the management of heart failure. Volumes noted are for both types of devices. At Cleveland Clinic Florida, there has been no documented case of device pocket infection (either after initial implant, replacement, revision or upgrade) since 23, in approximately 18 cases. We believe this is a reflection of technique and the tight infection control measures in the hospital. Cleveland Clinic Florida 19

Cardiovascular Imaging The Echo Lab at Cleveland Clinic Florida provides transthoracic, transesophageal and stress echocardiograms. More than 9, echocardiogram procedures were performed in 21. 79% Transthoracic 4% Transesophageal 16% Exercise 1% Dobutmine Exercise Echocardiograms Volume 2, 1,5 1, 5 26 27 28 29 21 Dobutamine Echocardiograms Volume 25 2 15 1 5 26 27 28 29 21 2 Outcomes 21

Transthoracic Echocardiograms Volume 8, 6, 4, 2, 26 27 28 29 21 Transesophageal Echocardiograms Volume 5 4 3 2 1 26 27 28 29 21 Cleveland Clinic Florida 21

Vascular Noninvasive Vascular Ultrasound Volume The Vascular Lab at Cleveland Clinic Florida performs a high volume of various ultrasounds each year. Volume 4, 3, 2, 1, 27 28 29 21 22 Outcomes 21

Cleveland Clinic Florida s Vascular Medicine lab is accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL). The ICAVL is dedicated to promoting high quality noninvasive vascular diagnostic testing in the delivery of health care by providing a peer review process of laboratory accreditation. ICAVL Accreditation is offered in the following testing areas: Extracranial Cerebrovascular Intracranial Cerebrovascular Peripheral Arterial Peripheral Venous Visceral Vascular Screening Cleveland Clinic Florida 23

Patient Experience Patients First is the guiding principle of Cleveland Clinic. Patient experience is a key component of Cleveland Clinic s strategic plan to achieve a coordinated delivery model that integrates patient and family-centered care with clinical outcomes, quality, safety and employee experience. The Office of Patient Experience s mission is to ensure consistent, patientcentered care by partnering with caregivers to exceed the expectations of patients and families. Programs and services include: Expertise for critical initiatives throughout the organization to ensure the consistent delivery of patient-centered care Patient satisfaction data analysis, HCAHPS education and resources Identification and sharing of sustainable best practices Support of employee experience and recognition initiatives Customer service education programs, including the Respond with H.E.A.R.T. service recovery program, to positively impact the Cleveland Clinic culture and support caregivers in providing outstanding service to patients, families and colleagues Personalized, holistic Healing Services for patients, families and employees including light massage, Reiki, Healing Touch, reflexology, personal aromatherapy, guided imagery, spiritual support, Code Lavender firstresponse holistic care service and others Health literacy education and solutions Voice of the Patient Advisory Councils, an advisory resource that empowers patients and families to take an active role in improving the patient experience by providing real-time feedback and creative solutions to specific challenges Ombudsman Office, which serves as a centralized complaint center 24 Outcomes 21

Cardiology Overall Rating of Outpatient Care and Services During Outpatient Visit 21 Percent 1 8 6 4 2 Good & Fair Poor Very Poor Very Good Source: Press Ganey, a national hospital survey vendor Rating of Outpatient Care Provider 21 Percent 1 8 6 4 2 Good & Fair Poor Very Poor Very Good Source: Press Ganey, a national hospital survey vendor Cleveland Clinic Florida 25

Patient Experience Likelihood of Recommending Outpatient Care Provider 21 Percent 1 8 6 4 2 Good & Fair Poor Very Poor Very Good Source: Press Ganey, a national hospital survey vendor 26 Outcomes 21

HCAHPS Overall Assessment of Cleveland Clinic Florida Hospital (N = 1,75) Percent 1 8 % respondents choosing 9 or 1 % respondents choosing 'definitely yes' 6 4 2 Rate Hospital (-1 scale) Would Recommend HCAHPS Domains of Care % respondents choosing always or yes Volume 1 8 6 4 2 Discharge Infromation Doctor Nurse Communication New Medication Pain Management Room Clean Responsiveness to Needs Quiet at Night Cleveland Clinic Florida 27

Staff Directory Interim Chairman Randall C. Starling, MD, MPH Cardiac Imaging Gian Novaro, Director Echocardiography Michael Shen, Director Nuclear Cardiology Craig Asher Marianela Areces Darryl Miller Cardiac Pacing & Electrophysiology Sergio Pinski MD, Director Jose Baez-Escudero, MD Marcelo Helguera, MD Invasive and Interventional Cardiology Kenneth Fromkin MD, Director Howard Bush, MD Vascular Medicine Mehrdad Farid, MD Bernardo Fernandez, MD (CEO, Cleveland Clinic Florida) Carmel Celestin, MD Thoracic and Cardiovascular Surgery Edward Savage, MD, Chairman Vascular Surgery Mark K. Grove, MD Terry King, MD Heart Failure Viviana Navas, MD Clinical Cardiology Richard Adamick, MD David Wolinsky, MD 28 Outcomes 21

Contact Information www.clevelandclinic.org/florida 24/7 hospital transfer 954.689.515 General Patient Referal 954.689.515 General Patient Information 877.463.21 Referring Physician Center For help with service issues, information about clinical specialists and services, details about CME opportunities and more: 954.659.5162 physicianrelations@ccf.org Global Patient Services Patient Services Center 954.659.58 Toll-free: 877.463.21 flgps@ccf.org Cleveland Clinic Florida 29

Cleveland Clinic Florida Locations Weston Campus 295 Cleveland Clinic Blvd Weston, FL 33331 Clinic: 954.659.5 Hospital: 954.689.5 Family Health Center 1825 North Corporate Lakes Blvd. Weston, FL 33326 West Palm Beach CityPlace Tower 525 Okeechobee Blvd. West Palm Beach, FL 3341 Toll-free 1.877.463.21 Krupa Center 325 Meridian Parkway Weston, FL 33331 Global Patient Services Patient Services center 954.659.56 Toll-free at 1.877.463.21 Bahamas, Canada, Cayman Islands, Continental U.S., Puerto Rico and the U.S. Virgin Islands Toll-free 1.866.898.821 Dominican Republic Toll-free 1.888.156.286 Venezuela Toll-free 8.1..4538 3 Outcomes 21

About Cleveland Clinic Florida Cleveland Clinic Florida, the Florida campus of the world-renowned Cleveland Clinic, is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Located in Weston and West Palm Beach, Cleveland Clinic Florida has nearly 2 physicians with expertise in 35 specialties and subspecialties working collaboratively to achieve excellent results for patients. The medical campus is fully integrated and includes diagnostic centers, outpatient surgery and a 24-hour emergency department located in the state-of-the-art hospital, which was named one of the nation s 1 Top Hospitals by Thomson Reuters in 21. Our West Palm Beach location extends our reach, enabling us to serve the Palm Beach County community. In addition to clinical care, our services include and infusion suite, pulmonary function testing and procedure room, as well as diagnostic imaging suites. Cleveland Clinic Florida has been named one of the nation s 1 Top Hospitals for cardiovascular care for the last four years (27, 28, 29, 21) by Thomson Reuters. In 21, it was named one of America s Best Hospitals for gastroenterology and diabetes/endocrinology by U.S. News & World Report. Cleveland Clinic Florida is an integral part of Cleveland Clinic Ohio, where providing outstanding patient care is based upon the principles of cooperation, compassion and innovation. Established in 1988, Cleveland Clinic Florida has been committed to improvements in patient care and enhancements in medical education for more than 2 years. Cleveland Clinic Florida 31

Resources ecleveland Clinic ecleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second medical opinions to patients around the world; personalized medical record access for patients; patient treatment progress for referring physicians; and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org. DrConnect Weather you are referring from near or far, DrConnect can streamline communication from Cleveland Clinic physicians to your office. This online tool offers you secure access to your patient s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient s care using the secure DrConnect website. To establish a DrConnect account, visit eclevelandclinic.org or email drconnect@ccf.org. MyConsult MyConsult Remote Second Medical Opinion is a secure online service providing specialist consultations and remote second opinions for more than 6 lifethreatening and life-altering diagnoses. The MyConsult service is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, or call 8.223.2273, ext 43223 MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to Google TM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart. 32 Outcomes 21

Continuing Medical Education (CME) Opportunities Cleveland Clinic Florida is dedicated to advancing medical knowledge through continuing education. Our CME program provides educational opportunities of a high quality and a wide variety to physicians, nurses, and other healthcare professionals. Our mission is to develop educational programs of an appropriate scope and depth to satisfy the need for knowledge and skill development of the learner. CME activities include didactic lectures, live surgery presentations, hands on workshops and audience participation. Interactivity between faculty and participants is emphasized. All activities are designed to maintain, develop or increase knowledge, competence or professional performance with the intended result of improving patient care and reducing disease impact. For a program schedule and more information, visit: clevelandclinic.org/florida and click on Education at the top of the page.