Digestive Disease Institute
9500 Euclid Avenue, Cleveland, OH 44195
clevelandclinic.org
15-OUT-340
2014
Outcomes
Measuring Outcomes Promotes Quality Improvement
This project would not have been possible without
the commitment and expertise of a team led by
Laura Buccini, DrPH, MPH; and Charmaine Jones, MBA.
Graphic design and photography were provided by
Cleveland Clinic’s Center for Medical Art and Photography.
© The Cleveland Clinic Foundation 2015
Measuring and understanding outcomes of medical treatments promotes
quality improvement. Cleveland Clinic has created a series of Outcomes
books similar to this one for its clinical institutes. Designed for a physician
audience, the Outcomes books contain a summary of many of our surgical
and medical treatments, with a focus on outcomes data and a review of
new technologies and innovations.
The Outcomes books are not a comprehensive analysis of all treatments
provided at Cleveland Clinic, and omission of a particular treatment does
not necessarily mean we do not offer that treatment. When there are no
recognized clinical outcome measures for a specific treatment, we may
report process measures associated with improved outcomes. When process
measures are unavailable, we may report volume measures; a relationship
has been demonstrated between volume and improved outcomes for many
treatments, particularly those involving surgical and procedural techniques.
In addition to these institute-based books of clinical outcomes, Cleveland
Clinic supports transparent public reporting of healthcare quality data. The
following reports are available to the public:
• Joint Commission Performance Measurement Initiative
(qualitycheck.org)
• Centers for Medicare and Medicaid Services (CMS) Hospital
Compare (HospitalCompare.hhs.gov), and Physician Compare
(medicare.gov/PhysicianCompare)
• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR)
Our commitment to transparent reporting of accurate, timely information
about patient care reflects Cleveland Clinic’s culture of continuous
improvement and may help referring physicians make informed decisions.
We hope you find these data valuable, and we invite
your feedback. Please send your comments and
questions via email to:
[email protected] or scan here.
To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.
Dear Colleague:
Welcome to this 2014 Cleveland Clinic Outcomes
book. Every year, we publish Outcomes books for 14
clinical institutes with multiple specialty services. These
publications are unique in healthcare. Each one provides
an overview of medical or surgical trends, innovations,
and clinical data for a particular specialty over the past
year. We are pleased to make this information available.
Cleveland Clinic uses data to manage outcomes across
the full continuum of care. Our unique organizational
structure contributes to our success. Patient services at
Cleveland Clinic are delivered through institutes, and
each institute is based on a single disease or organ
system. Institutes combine medical and surgical services,
along with research and education, under unified
leadership. Institutes define quality benchmarks for their
specialty services and report on longitudinal progress.
All Cleveland Clinic Outcomes books are available in
print and online. Additional data are available through
our online Quality Performance Report (clevelandclinic.
org/QPR). The site offers process measure, outcome
measure, and patient experience data in advance of
national and state public reporting sites.
Our practice of releasing annual outcomes books has
become increasingly relevant as healthcare transforms
from a volume-based to a value-based system.
We appreciate your interest and hope you find this
information useful and informative.
Sincerely,
Delos M. Cosgrove, MD
CEO and President
2
Outcomes 2014
what’s inside
Chairman’s Letter
04
Institute Overview
05
Quality and Outcomes Measures
Procedure and Outcomes Overview
06
Esophageal and Gastric Disease
11
Small Bowel Disease and Intestinal Transplantation
18
Nutrition
27
Large Bowel Disease
30
Trauma and Acute Care Surgery
48
Pancreaticobiliary Disease
50
Liver Disease and Liver Transplantation
53
Obesity and Metabolic Disease
69
Breast Disease
80
Cleveland Clinic Florida
88
Institute Quality Improvement
100
Surgical Quality Improvement
104
Institute Patient Experience
108
Cleveland Clinic –
Implementing Value-Based Care
110
Innovations
116
Contact Information
122
we’ll remove you from the hard copy mailing list
About Cleveland Clinic
124
and email you when next year’s books are online.
Resources
126
Prefer an e-version?
Visit clevelandclinic.org/OutcomesOnline, and
Digestive Disease Institute
3
Chairman’sLetter
Letter
Chairman
I am pleased to present the 2014 Outcomes book for Cleveland Clinic’s
Digestive Disease Institute. This is the 13th year that we have shared
our clinical outcomes and innovations with referring physicians, alumni,
patients, and other individuals around the nation interested in digestive
diseases. The book reflects our ongoing goal to provide patients with
care of the highest quality and the deepest compassion.
This past year, the Digestive Disease Institute had many exciting
achievements, including:
• Receiving Centers for Medicare & Medicaid Services’ approval for
the liver and kidney transplant programs at our Weston, Florida,
campus, and approval from the United Network for Organ Sharing
for our heart transplant program
• Forming an affiliation with Doctors Hospital at Renaissance in
South Texas to consult on best practices in bariatric medicine
and surgery, including patient and safety initiatives, clinical
pathways, and protocols
• Hosting the first US TARGIT Academy — a training course on
treating breast tumors using intraoperative radiotherapy
• Contributing the largest single-center enrollment in the clinical
trial of the bioartificial Extracorporeal Liver Assist Device (ELAD®
System) for management of acute alcoholic hepatitis
We welcome your feedback, questions, and ideas for collaboration.
Please contact me via email at [email protected]
and reference the Digestive Disease Institute in your message.
Sincerely,
John Fung, MD, PhD
Chairman, Digestive Disease Institute
Medical Director, Allogen Laboratories
Professor of Surgery, Cleveland Clinic Lerner College of Medicine
4
Outcomes 2014
Institute Overview
Cleveland Clinic’s Digestive Disease Institute is regarded as one of the
top digestive disease centers in the nation and unites all specialists
within one unique, fully integrated model of care aimed at optimizing
the patient experience. Through the years, Digestive Disease Institute
physicians have pioneered many technologies and procedures for
treating digestive disorders. This rich history of innovation continues
today, whether through the development of new surgical techniques,
participation in clinical trials, or operation of outcomes research
databases or registries. U.S. News & World Report’s “Best Hospitals”
survey has ranked the institute’s digestive disease services as No. 2 in
the nation since 2003.
The institute is located on Cleveland Clinic’s main campus as well
as in 25 additional locations and includes the Departments of
Gastroenterology and Hepatology, Colorectal Surgery, and General
Surgery (including hepatopancreatobiliary surgery, transplant surgery,
and breast surgery); the Bariatric and Metabolic Center; and the Center
for Human Nutrition. The institute’s 174 staff physicians, 132 residents
and fellows, and 236 nurses offer the most advanced, safe, and proven
treatments performed in the most effective and patient-friendly way.
2014 | Statistics
Total admissions
Patient days
9196
61,041
Evaluation and management visits
26
Locations
Research studies
488
Publications
463
Physicians
174
Inpatient nurses
174
Ambulatory nurses
Fellows
Residents
The Digestive Disease Institute staff authored
463
113,782
62
66
66
publications in
2014.
For a complete list, go to clevelandclinic.org/outcomes.
Digestive Disease Institute
5
Procedure and Outcomes Overview
Endoscopic and Surgical Procedure Overview
Endoscopic Procedures
2012 – 2014
2012
2013
2014
Digestive Disease Institute (total)
57,353
61,142
62,576
Colonoscopy
26,397
27,952
27,641
Esophagogastroduodenoscopy/other esophagoscopy
16,729
18,496
21,297
Endoscopic retrograde cholangiopancreatography
1123
1289
1190
Endoscopic ultrasound
1367
1548
1675
Pouchoscopy
1339
1420
1493
Sigmoidoscopy and proctosigmoidoscopy
2840
2766
2741
Upper and lower motility
3945
4504
3769
Othera
3613
3167
2770
aIncludes
6
anoscopy, capsule endoscopy, and small bowel endoscopy
Outcomes 2014
Inpatient Surgical Visits by Department/Section
2012 – 2014
2012
2013
2014
7154
7594
8030
582
556
571
Colorectal
2966
2987
2919
General surgery
3606
4051
4540
2012
2013
2014
9345
10,393
10,086
381
335
292
Breast
1415
1789
1533
Colorectal
1683
1836
1695
General surgery
5866
6433
6566
2012
2013
2014
5463
6163
6607
Bariatric
831
811
795
Colorectal
840
850
840
3792
4502
4972
Digestive Disease Institute (total)
Bariatric
Outpatient Surgical Visits by Department/Section
2012 – 2014
Digestive Disease Institute (total)
Bariatric
Minimally Invasive Surgical Procedures by Department/Sectiona
2012 – 2014
Digestive Disease Institute (total)
General surgery
aIncludes
inpatient and outpatient laparoscopic and robotic surgical procedures
Digestive Disease Institute
7
Procedure and Outcomes Overview
Surgical Outcomes Overview
Breast Surgerya Mean Length of Stay
2012 – 2014
Days
5
Observed
Expected
4
3
2
1
0
N=
2012
2013
2014
417
429
426
Includes all Cleveland Clinic regional hospitals (excludes Cleveland Clinic Florida)
aSurgical procedures include other skin, subcutaneous tissue breast procedures with complication or comorbidity (cc) and without cc/major cc (mcc)
and mastectomies for malignancy with and without cc/mcc.
These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu
Bariatric Surgerya Mean Length of Stay
2012 – 2014
Days
4
Observed
Expected
3
2
1
0
N=
2012
2013
2014
595
662
649
Includes Cleveland Clinic main campus and Fairview Hospital, a Cleveland Clinic regional hospital
aSurgical
procedures include OR procedures for obesity with mcc, OR procedures for obesity with cc, and OR procedures for obesity without cc/mcc.
These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu
8
Outcomes 2014
Colorectal Surgerya Mean Length of Stay
2012 – 2014
Days
10
Observed
Expected
8
6
4
2
0
N=
2012
2013
2014
2650
2702
2779
aSurgical
procedures are defined as all major small/large bowel, minor small/large bowel, anal, and stomal procedures; rectal resection procedures; and
other digestive system OR procedures.
These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu
Colorectal Surgerya In-Hospital Mortality
2012 – 2014
Percent
2.0
Observed
Expected
1.6
1.2
0.8
0.4
0
N=
2012
2013
2014
2650
2702
2779
aSurgical
procedures are defined as all major small/large bowel, minor small/large bowel, anal, and stomal procedures; rectal resection procedures; and
other digestive system OR procedures.
These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu
Digestive Disease Institute
9
Procedure and Outcomes Overview
General Surgerya Mean Length of Stay
2012 – 2014
Days
8
Observed
Expected
6
4
2
0
N=
aSurgical
2012
2013
2014
1446
1509
1442
procedures are defined as all hernia, pancreas, and cholecystectomy procedures.
Includes all Cleveland Clinic regional hospitals (excludes Cleveland Clinic Florida)
These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu
General Surgerya In-Hospital Mortality
2012 – 2014
Percent
2.0
Observed
Expected
1.6
1.2
0.8
0.4
0
N=
aSurgical
2012
2013
2014
1446
1509
1442
procedures are defined as all hernia, pancreas, and cholecystectomy procedures.
Includes all Cleveland Clinic regional hospitals (excludes Cleveland Clinic Florida)
These data are prepared using the University HealthSystem Consortium (UHC) Comparative Database, 2012–2014 discharges. uhc.edu
10
Outcomes 2014
Esophageal and Gastric Disease
Esophageal Adenocarcinoma
The incidence of esophageal adenocarcinoma is rising rapidly, and this is now the predominant esophageal cancer type in
the United States.
Accurate T staging for esophageal cancer is necessary to ensure patients receive the optimal treatment. Radiologic imaging
alone is unable to accurately determine T staging for esophageal cancer. Endoscopic ultrasound (EUS) allows for detailed
examination of the esophageal wall to determine depth of tumor involvement. The Digestive Disease Institute performs
many endoscopic ultrasounds for the preoperative evaluation of esophageal cancer treatment. Comparing the surgical
pathology with preoperative endoscopic ultrasound staging in a representative sample of patients shows 100% accuracy for
EUS staging of T2 and T3 tumors. Errors were limited to differentiating stages T1a from T1b, which is a known limitation of
EUS. These results demonstrate the benefits of EUS preoperative staging of esophageal cancer.
Accuracy of Tumor Staging by Endoscopic Ultrasound: Percent Agreement With Pathology (N = 33)
2012 – 2014
Percent
100
80
60
40
20
0
Overall Mean
Accuracy
T1a
T1b
T2
T3
Mean Accuracy by Tumor Stage
Digestive Disease Institute
11
Esophageal and Gastric Disease
Hiatal Hernia Surgery
Hiatal hernias are graded according to severity and are often associated with gastroesophageal reflux disease. For patients
with severe symptoms, surgery may be indicated. Patients who are offered a minimally invasive approach — the standard
of care at Cleveland Clinic — benefit from decreased pain, shorter length of stay, and better overall recovery.
Median Length of Stay, Laparoscopic Hiatal Hernia Repair
2012 – 2014
Days
5
4
3
2
1
0
N=
2012
2013
2014
64
65
75
30-Day Readmission Rate, Laparoscopic Hiatal Hernia
2012 – 2014
Percent
20
15
10
5
0
N=
12
2012
2013
2014
64
65
75
Outcomes 2014
Gastroparesis Surgery
Gastroparesis, also called delayed gastric emptying, is a disorder that slows the movement of food from the stomach
to the small intestine. It often occurs in people with type 1 or type 2 diabetes. Patients often seek hospital treatment
for complications of the disease such as malnutrition, dehydration, and pain. Treatment ranges from dietary changes
and/or medications to surgery requiring the removal of most of the stomach and more recently the insertion of gastric
neurostimulators.
Median Length of Stay, Post-Neurostimulator Surgery
2013 – 2014
Days
2.5
2.0
1.5
1.0
0.5
0
N=
2013
2014
22
19
30-Day Readmission Rate, Post-Neurostimulator Surgery
2013 – 2014
Percent
20
15
10
5
0
N=
2013
2014
22
19
With increased awareness of disease symptoms, the institute’s multidisciplinary program has been able to identify and treat
patients preemptively and decrease the overall hospital readmission rate.
Digestive Disease Institute
13
Esophageal and Gastric Disease
Median Arcuate Ligament Syndrome
Median arcuate ligament (MAL) syndrome, also known as celiac artery compression syndrome, is a
rare condition resulting in postprandial abdominal pain and weight loss. Cleveland Clinic has formed a
collaborative team of gastroenterologists, minimally invasive surgeons, and vascular surgeons to evaluate
and treat MAL syndrome. Treatment consists of releasing the MAL. Since 2012, the yearly volumes of
MAL release have tripled. Likewise, conversion to open procedure has decreased from 25% to < 10%.
Conversion From Minimally Invasive to Open MAL Release Surgical Procedure
2012 – 2014
Percent
40
Cleveland Clinic
Benchmarka
30
20
10
0
N=
0
2012
2013
2014
5
12
15
aJimenez JC, Harlander-Locke M, Dutson EP. Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc
Surg. 2012 Sep;56(3):869-873.
14
Outcomes 2014
Median Length of Stay, MAL Release Surgical Procedure
2012 – 2014
Days
4
3
2
1
0
2012
2013
2014
5
12
15
N=
Celiac Artery Velocity (N = 32)
2012 – 2014
Median Velocity (cm/s)
400
2012
2013
2014
300
200
100
0
Preoperative
Postoperative
Decreased celiac artery velocity is a marker for successful release of the ligament
and occurred in 82.6% of the Digestive Disease Institute’s patient population.
Digestive Disease Institute
15
Esophageal and Gastric Disease
Esophageal Surgery Volume and In-Hospital Mortality
2014 Volume (N = 192)
2010 – 2014
Mortality (%)
Observed
Expected
4
Volume
400
300
3
200
2
100
1
0
2010
2011
2012
2013
2014
0
Cleveland Clinic thoracic
surgeons performed 192
procedures in 2014 and
achieved a lower-thanexpected in-hospital mortality
rate (1.56% vs 3%).
Source: Data from the UHC Clinical Data Base/Resource ManagerTM used by permission of UHC. All rights reserved.
Esophagectomy In-Hospital and 30-Day Mortality
2014
Percent
Expected
4
3
Both the in-hospital and 30-day mortality rates for
esophagectomy were 0% at Cleveland Clinic in 2014.
The expected rates were 3.10% and 2.8%, respectively.
2
1
0
0%
0%
In-Hospital
30-Day
Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database 2014.
16
Outcomes 2014
Esophagectomy for Esophageal Cancer, Combined Morbidity and Mortality
July 2011 – June 2014
Eligible procedures
142
Unadjusted rate
Risk-adjusted
rate (95% CI)
Standardized incidence
ratio (95% CI)
21.1%
22.0% (16.1-28.9)
0.80 (0.58-1.05)
Cleveland Clinic
Min
0.52
25th
0.94
Median 75th
1.04 1.17
= STS standardized incidence ratio
Max
1.81
Source: STS General Thoracic Surgery
Database, July 2010–June 2013
Cleveland Clinic surgeons performed 142 esophagectomy procedures for patients with esophageal cancer from July 2011
to June 2014. The combined morbidity and mortality risk-adjusted rate was better than the national average.
Distribution of Esophageal Surgeries by Indication (N = 192)
2014
29% Cancer (N = 55)
100%
28% Paraesophageal hernia repair (N = 53)
23% Achalasia (N = 45)
The majority of esophageal surgeries at
Cleveland Clinic in 2014 were to treat
patients with esophageal cancer and
complex paraesophageal hernias who have
had multiple failed operations.
8% Esophageal reconstruction (N = 15)
7% Reflux (N = 14)
5% Other (N = 10)
Digestive Disease Institute
17
Small Bowel Disease and Intestinal Transplantation
Capsule Endoscopy
The Digestive Disease Institute’s Center for Capsule
Endoscopy has extensive experience with the SmartPill®.
The SmartPill is an ingestible capsule that measures
pressure, pH levels, and temperature as it passes through
the GI tract. It is used to diagnose motility disorders such
as gastroparesis and colonic inertia. The SmartPill has been
used at Cleveland Clinic since 2009.
SmartPill Procedures
2012 – 2014
Number
120
100
80
60
40
20
0
N=
18
2012
2013
2014
47
105
107
Outcomes 2014
The Center for Capsule Endoscopy routinely performs video capsule endoscopy, a now well-established method to
detect and diagnose lesions of the small bowel in patients with suspected bleeding of the GI tract, inflammatory
conditions such as Crohn’s disease, and small bowel neoplasms and tumors.
Video Capsule Procedures
2012 – 2014
Number
800
600
400
200
0
N=
2012
2013
2014
566
513
668
The Center for Capsule Endoscopy has continued the IntelliCap® program, which allows institute physicians to review and
interpret small bowel video capsule endoscopy performed at other medical centers.
Remote Video Capsule Reads
2012 – 2014
Number
160
120
80
40
0
N=
2012
2013
2014
27
105
158
Digestive Disease Institute
19
Small Bowel Disease and Intestinal Transplantation
Crohn’s Disease
The surgical volume for Crohn’s disease is high, with a particular focus on techniques that conserve the small bowel.
The multidisciplinary team includes surgeons, gastroenterologists, nutritionists, pathologists, and radiologists.
Crohn’s Disease Organ Space Surgical Site Infection Rate
2012 – 2014
Percent
10
Open
Laparoscopic
8
6
4
2
0
N=
0
2012
296
2013
60
295
2014
82
238
101
Crohn’s Disease Postoperative Outcomes
2012 – 2014
2012
2013
2014
Open
(N = 296)
Lap
(N = 60)
Open
(N = 295)
Lap
(N = 82)
Median length of stay, days
9
7
8
7
8
6
30-day readmission rate, %
10
8
11
20
12
7
In-hospital mortality rate, %
0
0
0
0
0
0
Surgical site infection rate, %
Superficial
Deep
5
1
3
0
7
1
5
0
3
0
3
0
Urinary tract infection rate, %
3
7
2
1
1
1
Venous thromboembolism rate, %
4
3
4
2
1
3
Postoperative Outcomes
Open
Lap
(N = 238) (N = 101)
Lap = laparoscopic
20
Outcomes 2014
Small Bowel Obstruction
Mechanical small-bowel obstruction (SBO) is the most frequently encountered surgical disorder of the small intestine.
Cleveland Clinic’s annual SBO admissions have increased over the past 3 years. The section of Acute Care Surgery is
developing an SBO clinical care path that will standardize nonoperative and operative SBO management.
Median Length of Stay, Inpatient Small Bowel Obstruction Proceduresa
2012 – 2014
Days
8
Operative
Nonoperative
6
4
2
0
0
N=
2012
169
aProcedures
2013
99
102
2014
185
135
200
represent those conducted by the Department of General Surgery only.
30-Day Readmission Rate, Inpatient Small Bowel Obstruction Proceduresa
2012 – 2014
Percent
25
Operative
Nonoperative
20
15
10
5
0
0
N=
2012
169
aProcedures
111
2013
185
114
2014
200
165
represent those conducted by the Department of General Surgery only.
Digestive Disease Institute
21
Small Bowel Disease and Intestinal Transplantation
Management of Carcinomatosis
Hyperthermic intraoperative peritoneal chemotherapy (HIPEC) is a surgical procedure used to treat cancers that have
spread to the lining of the abdominal cavity, such as cancers arising in the appendix, colon, stomach, and ovaries, as well
as pseudomyxoma peritonei and peritoneal mesothelioma. This is a 2-step surgical procedure, which includes debulking
of visible disease (tumor), followed by HIPEC. HIPEC delivers heated chemotherapy directly into the abdomen, which
circulates for 90 minutes, treating the microscopic disease that may remain.
Median Length of Stay for HIPEC Patients
2011 – 2014
Days
10
8
6
4
2
0
2011
2012
2013
2014
20
11
16
18
N=
Cancer Type for Patients Undergoing HIPEC Procedure (N = 65)
2011 – 2014
22
Cancer Type
Patients
Percent
Colon cancer
15
23.1
Appendix carcinoma
12
Pseudomyxoma peritonei
Cancer Type
Patients
Percent
Retroperitoneal cancer
2
3.1
18.5
Gastric cancer
1
1.5
8
12.3
Adenocarcinoma unknown primary
1
1.5
Ovarian cancer
8
12.3
Breast carcinoma
1
1.5
Peritoneal mesothelioma
6
9.2
Desmoplastic round cell tumor
1
1.5
Peritoneal carcinomatosis
5
7.7
Small bowel cancer
1
1.5
Undefined
3
4.6
Thyroid cancer
1
1.5
Outcomes 2014
Hernia Center
Surgeons from Cleveland Clinic’s Hernia Center perform more than 1700 hernia repairs each year, from the routine
to the most complex cases. The center is designed so that patients receive individualized care, undergoing a
comprehensive evaluation to determine the best surgical procedure for their specific type of hernia.
Median Length of Stay, Inpatient Inguinal Hernia Repairs
2012 – 2014
Days
1.2
Open
Laparoscopic
1.0
0.8
0.6
0.4
0.2
0
N=
2012
83
2013
18
79
2014
24
93
27
The indications for inpatient inguinal hernia repairs are limited to patients with serious concomitant medical illnesses.
Digestive Disease Institute
23
Small Bowel Disease and Intestinal Transplantation
Median Length of Stay, Inpatient Incisional/Ventral Hernia Repairs
2012 – 2014
Days
2.5
Open
Laparoscopic
2.0
1.5
1.0
0.5
0
2012
160
N=
114
2013
188
121
2014
177
106
30-Day Reoperation Rate, Inpatient/Outpatient Post Hernia Repair
2012 – 2014
2012 (N)
2013 (N)
2014 (N)
Open
1.5 (957)
1.9 (1012)
0.7 (986)
Laparoscopic
1.0 (411)
0.7 (552)
0.3 (596)
Open
2.9 (481)
3.7 (485)
2.9 (485)
Laparoscopic
1.2 (161)
2.6 (192)
1.5 (202)
Inguinal (%)
Incisional/ventral (%)
24
Outcomes 2014
Center for Gut Rehabilitation and Transplantation
The Center for Gut Rehabilitation and Transplantation was established as a continuation of Cleveland Clinic’s efforts to
enhance the multidisciplinary team approach for the management of patients with acute and chronic gut failure. The center
accepts all patients with acute intestinal ischemia, with the intent to restore blood flow to the intestine and other abdominal
organs by using combined radiologic and surgical techniques. With chronic gut failure, all efforts are made to restore gut
function with medical and surgical modalities including autologous surgical reconstruction and bowel lengthening. Intestinal
and multivisceral transplantations continue to be used as rescue therapies for those who fail intravenous nutritional therapy.
Nontransplant Intestinal Reconstruction
2013 – 2014
Percent
100
2013 (N = 98)
2014 (N = 114)
80
60
40
20
0
Midgut Reconstruction
Bowel Lengthening
Procedure
Foregut Gastric
Reconstruction
Bowel Lengthening With Serial Transverse Enteroplasty Procedure
Digestive Disease Institute
25
Small Bowel Disease and Intestinal Transplantation
Intestinal Transplantation 1-Year Patient Survivala (N = 8)
July 2011 – December 2013
Percent Survival
100
80
60
40
20
0
0
aScientific
100
200
300
Days After Transplantation
Registry of Transplant Recipients national average for 1-year graft survival = 70.87% srtr.org
Intestinal Transplantation 1-Year Graft Survivala,b (N = 11)
July 2011 – December 2013
Percent Survival
100
80
60
40
20
0
0
aScientific
bIncludes
26
100
200
300
Days After Transplantation
Registry of Transplant Recipients national average for 1-year graft survival = 70.87% srtr.org
3 intestinal retransplants
Outcomes 2014
Nutrition
The Center for Human Nutrition evaluates, educates, and treats disease-related nutrition problems in addition to providing
preventive, sports, and wellness counseling. Specialty focus nutrition teams work closely with healthcare providers in the
Center for Gut Rehabilitation and Transplantation to support the nutritional needs of critically ill, organ transplant, and
severe-gastrointestinal-failure patients. As part of the overall care, the center offers intensive diet counseling, tube feeding,
and oral rehydration techniques, along with medication, growth factor therapy, and restorative surgery.
1-Year Readmission Rate for Patients Discharged on Home Parenteral Nutrition
2012 – 2014
Percent
40
30
20
10
0
N=
2012
2013
2014
737
755
801
Complication Rate of Home Parenteral Nutrition-Related Readmissions per Year
2012 – 2014
Percent
60
2012 (N = 109)
2013 (N = 82)
2014 (N = 221)
45
30
15
0
CRBSI
Dehydration
Othera
CRBSI = catheter-related bloodstream infection
aOther
complications include noninfectious catheter complications, electrolyte disturbances, and venous thrombosis.
Home parenteral nutrition frequently results in hospital readmission. The most common reason for readmissions is CRBSI.
Digestive Disease Institute
27
Nutrition
Safety (Adverse Events) of Cycling Parenteral Nutrition From 24 to 12 Hours in 1 Step in Patients Requiring Long-Term
Therapy (N = 63)
2013 – 2014
This Cleveland Clinic study aimed to test the hypothesis that patients without diabetes mellitus or major organ dysfunction
requiring long-term parenteral nutrition could be cycled from 24 hours to 12 hours in 1 step without increasing the risk of
parenteral nutrition-related adverse events compared with the standard 2-step process. In the 63 patients studied, the most
prevalent parenteral nutrition-related adverse event was hyperglycemia, occurring in 24% of patients in the fast-track (1-step)
group and 30% of patients in the standard (2-step) group. Overall, no significant difference was seen in the prevalence of
parenteral nutrition-related minor adverse events between fast-track (33%) and standard (53%) groups (P = 0.5).1
Day 0
Average Glucose (mg/dL)
200
Day 1
Average Glucose (mg/dL)
200
180
180
160
160
140
140
120
120
100
12 am
6 am
11 am
5 pm
100
12 am
6 am
11 am
Time
Time
Day 2
Average Glucose (mg/dL)
200
Day 3
Average Glucose (mg/dL)
200
180
180
160
160
140
140
120
120
100
12 am
6 am
11 am
Time
5 pm
100
12 am
6 am
11 am
1-step
2-step
5 pm
5 pm
Time
Fast-track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring
long-term parenteral nutrition. Fast-track cycling could potentially expedite hospital discharge, resulting in decreased
healthcare costs and improved patient satisfaction.
1Austhof
S, Dechicco B, Cresci G, Corrigan M, Suryadevara S, Parisian K, Sourianarayanane A, Kumaravel A, Lopez R, Steiger E. Cycling
parenteral nutrition from 24 to 12 hours in one step is safe in patients requiring long-term therapy. Abstract presented at American Society of
Parenteral and Enteral Nutrition, Clinical Nutrition Week, Savannah, GA: Jan. 20, 2014.
28
Outcomes 2014
Wound Prevention Outcomes Based on Nutrition Therapy
2014
Wound/
Not Developed
(N = 84)
Wound Developed/
Healed
(N = 9)
Wound Developed/
Not Healed
(N = 12)
Wound Status
Unknown
(N = 7)
Oral diet with oral supplements, %
36
22
8
29
Oral diet with no oral supplements, %
16
0
8
0
Enteral feeding, %
27
56
50
14
Enteral feeding plus oral supplements, %
17
22
8
14
Parenteral nutrition, %
2
0
25
0
Unknown mode, %
2
0
0
43
Nutrition Therapy
These data show the impact of the registered dietitian nutritionist’s involvement, including assessing existing
nutrition status, developing nutrition care plans for patients, and preventing wound development among a sample of
hospitalized patients who were identified as at risk for wound development based on criteria in a new pressure ulcer
prevention care path.
Digestive Disease Institute
29
Large Bowel Disease
Colonoscopy
Colonoscopy is a common endoscopic procedure, with more than 3 million examinations performed in the United
States annually. The efficacy of colonoscopy to prevent colorectal cancer is dependent on the quality of the procedure.
National benchmarks have been established as minimal targets to meet or exceed in order to maximize the benefit of the
colonoscopy. Three important metrics include the percentage of procedures in which the endoscopist reaches the cecum
(cecal intubation rate), the time spent looking at the colon mucosa on withdrawal of the colonoscope (withdrawal time),
and the polyp detection rate, which is a surrogate for the adenoma detection rate.
Cecal Intubation Rate for Colonoscopy
2012 – 2014
Percent
100
Cleveland Clinic
Benchmarka
80
60
40
20
0
N=
2012
2013
2014
26,397
27,952
27,641
aRex
DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb GJ, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S,
Weinberg DS. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110:72-90.
30-Day Colonoscopy-Related Complications
2012 – 2014
Percent
1.0
0.8
0.6
0.4
0.2
0.0
N=
30
2012
2013
2014
26,397
27,952
27,641
Outcomes 2014
Mean Scope Withdrawal Time for Colonoscopies Without Maneuvers
2012 – 2014
Minutes
12
Cleveland Clinic
Benchmarka
9
6
3
0
N=
2012
2013
2014
2941
6774
9527
aRex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb GJ, Park WG,
Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS. Quality indicators for
colonoscopy. Am J Gastroenterol. 2015;110:72-90.
Polyp Detection Rate During Screening Colonoscopy
2012 – 2014
Percent
50
Cleveland Clinic
Benchmarka
40
30
20
10
0
N=
2012
2013
2014
4257
4590
6368
aGohel TD, Burke CA, Lankaala P, Podugu A, Kiran RP, Thota PN, Lopez R, Sanaka MR.
Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender,
and endoscopist. Clin Gastroenterol Hepatol. 2014 Jul;12(7):1137-1142.
Digestive Disease Institute
31
Large Bowel Disease
Colon Cancer
In 2014, more than 200 patients underwent surgery for tumors of the colon by the Department of Colorectal Surgery.
Despite increasing patient acuity (average American Society of Anesthesiologists score 2.9), surgeons in the Department of
Colorectal Surgery achieved a 30-day mortality rate of 0% for patients undergoing laparoscopic resection and 1% for those
having an open colectomy.
Mean Lymph Nodes Harvested
2012 – 2014
Number
40
Open
Laparoscopic
AJCC/NCI benchmarka
30
aAmerican
Joint Committee on Cancer (AJCC) and
National Cancer Institute (NCI) recommend harvesting
for examination at least 12 lymph nodes in patients with
colon cancer to confirm the absence of nodal involvement
by tumor.
20
10
0
N=
2012
104
104
2013
90
2014
98
114
104
The average lymph node harvest remained almost 3 times higher than the 12-node minimum that has become a national
benchmark for quality of surgery and pathology assessment.
Colon Cancer Organ Space Superficial Infection Rate
2012 – 2014
Percent
12
10
8
6
4
2
0
N=
Open
Laparoscopic
2012
104
104
2013
90
98
2014
114
104
Through the implementation of a surgical site infection bundle, the Department of Colorectal Surgery has been able to drastically reduce
surgical site infections for all its cancer patients.
32
Outcomes 2014
Colon Cancer Postoperative Outcomes
2012 – 2014
Postoperative Outcomes
2012
2013
2014
Open
Lap
Open
Lap
Open
Lap
N=
104
104
90
98
114
104
ASA scorea, mean
2.9
2.8
2.9
2.8
3.1
2.8
Median length of stay, days
11
8
9
8
11
6
30-day readmission rate, %
13
10
14
16
11
7
In-hospital mortality rate, %
2
1
1
0
1
0
5
0
4
0
7
1
8
0
3
0
3
1
Urinary tract infection rate, %
2
3
7
8
3
0
Venous thromboembolism rate, %
8
5
4
3
4
3
Surgical site infection rate, %
Superficial
Deep
Multidisciplinary
Tumor Conference
Patients with colorectal cancer are
reviewed by a multidisciplinary
tumor board consisting of
caregivers from anatomic
pathology, colorectal surgery,
medical oncology, radiation
oncology, gastroenterology,
genomic medicine, hepatobiliary
surgery, and radiology.
ASA = American Society of Anesthesiologists, Lap = laparoscopic
a
ASA score is a subjective assessment of a patient’s severity of illness based on five classes (1–5)
where 1 represents a completely healthy/fit patient and 5 represents a moribund patient not expected
to live more than 24 hours.
Colon Cancer Survival by Stage
2000 – 2013
Survival (%)
100
Stage
Stage
Stage
Stage
80
60
I (N = 362)
II (N = 538)
III (N = 486)
IV (N = 275)
40
During tumor board conferences,
patients’ pathology and radiologic
images are reviewed for
diagnosis and clinical staging; an
individualized treatment plan is
then formulated. Cleveland Clinic’s
colorectal cancer multidisciplinary
tumor board strives to discuss
100% of patients presenting to
the clinic with a new diagnosis of
colorectal cancer.
20
0
0
12
24
36
Time (Months)
48
60
Stage-specific, 5-year disease-free survival rates for Cleveland Clinic-treated
patients with colon cancer continue to exceed national averages: stage I (74%),
stage II (59%), stage III (46%), and stage IV (6%).
Digestive Disease Institute
33
Large Bowel Disease
Rectal Cancer
In 2014, nearly 180 patients underwent surgery for cancer of the rectum. Despite a referral pattern consisting of a
preponderance of lower rectal tumors, more than 70% of patients were successfully treated without a permanent
colostomy. This restorative procedure rate compares favorably with data from a large internationally recognized trial
conducted in Europe.
Restorative and Nonrestorative Procedures (Na = 89)
2014
Percent
100
Cleveland Clinic
Benchmarkb
80
60
40
20
0
aRepresents
Restorative
Non Restorative
a subset of all rectal cancer surgical patients
bKapiteijn
E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH,
Leer JW, van de Velde CJ; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for
resectable rectal cancer. N Engl J Med. 2001 Aug;345(9):638-646.
34
Outcomes 2014
One of the major factors influencing rectal cancer survival is the surgeon’s
ability to remove the tumor with a clear margin of surrounding normal tissue.
Achieving a clear circumferential resection margin (CRM) is highly predictive
of survival after rectal cancer surgery and serves as a useful indicator of
surgical quality.
Circumferential Resection Margin Status (Na = 89)
2014
Percent
100
Cleveland Clinic
Benchmarkb
80
60
40
20
0
Involved
Uninvolved
Cleveland Clinic’s rate of clear CRM (96%) exceeds the national
recognized rate of 84%.
aRepresents
a subset of all rectal cancer surgical patients
bMarijnen
CA, Nagtegaal ID, Kapiteijn E, Kranenbarg EK, Noordijk EM, van Krieken JH,
van de Velde CJ, Leer JW; Cooperative investigators of the Dutch Colorectal Cancer
Group. Radiotherapy does not compensate for positive resection margins in rectal
cancer patients: report of a multicenter randomized trial. Int J Radiat Oncol Biol Phys.
2003;55(5):1311-1320.
Digestive Disease Institute
35
Large Bowel Disease
Total mesorectal excision (TME) refers to the en bloc surgical removal of the rectum, attached lymph
node-containing mesorectum, and the surrounding connective tissue envelope. TME surgery has
become the contemporary standard of care for patients with rectal cancer. While circumferential
resection margin (CRM) is the most significant predictor of local recurrence, the completeness of the
TME also contributes to the reduction of local recurrence and is another important quality metric.
Incomplete TME for rectal cancer is associated with increased local and overall recurrences.
Completeness of Total Mesorectal Excision (Na = 88)
2014
Percent
100
Cleveland Clinic
Benchmarkb
80
60
40
20
0
Complete
Near Complete
Incomplete
Cleveland Clinic’s rate of completeness (96%) exceeds the nationally recognized rate of 57%. As
well, the rates of near complete and incomplete TMEs are significantly lower than the nationally
recognized rates of 19% and 24%, respectively.
aRepresents
a subset of all rectal cancer surgical patients
bNagtegaal
ID, van de Velde CJ, van der Worp E, Kapiteijn E, Quirke P, van Krieken JH; Cooperative Clinical
Investigators of the Dutch Colorectal Cancer Group. Macroscopic evaluation of rectal cancer resection specimen:
clinical significance of the pathologist in quality control. J Clin Oncol. 2002;20(7):1729-1734.
36
Outcomes 2014
Rectal Cancer Organ Space Superficial Infection Rate
2012 – 2014
Percent
15
Open
Laparoscopic
12
9
6
3
0
2012
N=
134
31
2013
126
2014
47
140
39
Rectal Cancer Postoperative Outcomes
2012 – 2014
Postoperative Outcomes
2012
2013
2014
Open
Lap
Open
Lap
Open
Lap
134
31
126
47
140
39
2.9
2.7
2.8
2.7
3.0
2.7
Median length of stay, days
9
8
9
8
9
6
In-hospital mortality rate, %
1
0
0
0
1
0
9
1
0
0
5
0
2
0
2
0
5
0
Urinary tract infection rate, %
4
0
6
2
1
5
Venous thromboembolism rate, %
2
3
3
2
4
5
N=
ASA
scorea,
mean
Surgical site infection rate, %
Superficial
Deep
ASA = American Society of Anesthesiologists, Lap = laparoscopic
aASA
score is a subjective assessment of a patient’s severity of illness based on five classes (1–5) where 1 represents a completely healthy/fit
patient and 5 represents a moribund patient not expected to live more than 24 hours.
Digestive Disease Institute
37
Large Bowel Disease
Rectal Cancer Survival by Stage
2000 – 2013
Survival (%)
100
Stage
Stage
Stage
Stage
80
60
I (N = 683)
II (N = 415)
III (N = 507)
IV (N = 233)
40
20
0
0
12
24
36
Time (Months)
48
60
Stage-specific, 5-year, disease-free survival rates for Cleveland Clinic-treated patients with rectal cancer
continue to exceed national averages: stage I = 74%, stage II = 52%, stage III = 45%, and stage IV = 6%.
38
Outcomes 2014
Hereditary Colon Cancer
The Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia was established in 2008. It is staffed by a
multidisciplinary team dedicated to the care of patients affected by hereditary colorectal cancer syndromes. It houses the
David G. Jagelman Inherited Colorectal Cancer Registries, which were established in 1979. The mission of the Jagelman
Registries and the Weiss Center is to prevent death from cancer and maintain quality of life through excellent patient care,
effective education, and clinically relevant research. The Weiss Center is the largest and one of the most well-established
registries of its type in the world.
To help reduce the risk of inherited colon cancer, the team follows generations of families. The graph below shows the rate
at which cancer is detected in patients with familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal
cancer (HNPCC) according to the generations to which they belong. The data show decreasing cancer detection rates
across three generations.
Cancer Detection Rate Over 3 Generations
1979 – 2014
Percent
50
Generation 1
Generation 2
Generation 3
40
30
20
10
0
.12
FAP (N = 98)
Digestive Disease Institute
HNPCC (N = 112)
39
Large Bowel Disease
Cancer Detection Rate in Lynch Syndrome Under Surveillance
2012 – 2014
Percent
10
8
6
4
2
0
2012
2013
2014
45
63
86
N=
The graph above depicts the rate of cancer diagnosis in patients affected by Lynch syndrome who are undergoing
a yearly colonoscopy. Note that the number of patients under surveillance is increasing, but the rate of cancer
diagnosis is decreasing. Most cancers are diagnosed at the patient’s first colonoscopy.
Polyp Removal Rate in Patients With Lynch Syndrome
2012 – 2014
Percent
60
40
20
0
N=
2012
2013
2014
51
51
29
The process of carcinogenesis is accelerated in patients with Lynch syndrome. Many patients form new adenomas within
1 year of their prior colonoscopy. Continued surveillance and polyp removal are essential to preventing cancer.
40
Outcomes 2014
Weiss Center Families Enrolled in the Familial Adenomatous Polyposis and Hereditary Nonpolyposis
Colorectal Cancer Registry
2012 – 2014
Number
2400
1800
1200
600
0
N=
2012
2013
2014
1849
1952
2075
In addition to treating patients with hereditary nonpolyposis colorectal cancer and familial adenomatous
polyposis syndromes, the Weiss Center cares for patients and families with other less common hereditary
syndromes associated with a high risk for colorectal and other cancers. These include Peutz-Jeghers syndrome,
juvenile polyposis syndrome, MYH-associated polyposis, and serrated polyposis syndrome.
Families Treated by the Weiss Center for Less Common Polyposis Syndromes
2012 – 2014
2012
2013
2014
Number
200
160
120
80
40
0
N=
aIncludes
Peutz-Jeghers
Syndrome
35
36
37
Juvenile Polyposis
Syndrome
MYH-Associated
Polyposis
Serrated Polyposis
Syndrome
51
44
115
54
59
49
52
122
136
Othera
85
185
190
Cowden syndrome, Cronkhite-Canada syndrome, and oligopolyposis
Digestive Disease Institute
41
Large Bowel Disease
Ulcerative Colitis
Cleveland Clinic is a referral center for patients diagnosed with ulcerative colitis. Minimally invasive laparoscopic surgical
approaches as well as the ability to salvage problematic pouches are available for those patients requiring surgery.
Ulcerative Colitis Organ Space Surgical Site Infection Rate
2012 – 2014
Percent
10
Open
Laparoscopic
8
6
4
2
0
2013
2012
N=
315
142
326
2014
116
224
149
Ulcerative Colitis Postoperative Outcomes
2012 – 2014
Postoperative Outcomes
2012
2013
2014
Open
Lap
Open
Lap
Open
Lap
315
142
326
116
224
149
Median length of stay, days
5
5
5
5
5
4
30-day readmission rate, %
14
11
14
21
10
13
In-hospital mortality rate, %
0
0
0
0
0
0
5
0
6
0
4
0
7
0
2
1
1
0
Urinary tract infection rate, %
3
2
5
3
4
3
Venous thromboembolism rate, %
4
7
3
6
3
5
N=
Surgical site infection rates
Superficial
Deep
Lap = laparoscopic
42
Outcomes 2014
Continent Ileostomy
Cleveland Clinic’s Department of Colorectal Surgery is one of the few sites in the world that performs continent ileostomies.
The continent ileostomy (Kock pouch) is an internal reservoir that allows patients to avoid wearing an external stomal
appliance. The pouch is emptied by inserting a soft catheter through the stoma. A continent ileostomy can be constructed
from an existing end ileostomy and, in some cases, from failed pelvic J pouches.
Continent Ileostomy Volume
2011 – 2014
Number
80
60
40
20
0
N=
Creation
Revision
16
67
Digestive Disease Institute
43
Large Bowel Disease
Center for Ileal Pouch Disorders
The Center for Ileal
Pouch Disorders
is the world’s
first and largest
multidisciplinary
pouch center,
which sees
more than 1200
patients each year.
Pouch disorders are classified
and managed based on the
following categories:
• Surgical/mechanical
• Inflammatory/infectious
• Functional
• Neoplastic
• Systemic/metabolic
Cleveland Clinic is one of the highest-volume centers in the US and for more than
3 decades, has offered restorative proctocolectomy with ileal J pouch surgery as an
alternative to permanent stoma. The Center for Ileal Pouch Disorders was established to
treat pouch disorders and remains at the forefront of new approaches to the management
of pouch complications.
Surgical Pouch Construction
2012 – 2014
Number
200
160
120
80
40
0
N=
2012
2013
2014
172
195
190
Cleveland Clinic gastroenterologists have helped pioneer endoscopic therapy for various
pouch-associated complications, which have been the major cause of pouch failure. The
Digestive Disease Institute is the only medical center in the world that treats such pouch
complications with less invasive endoscopic techniques.
Novel Endoscopic Therapy for Pouch Leak and Stricture
2013 – 2014
Number of Patients
20
2013
2014
15
10
5
0
N=
44
Needle Knife Stricturotomy
for Pouch Stricture
4
7
Endoscopic Closure
of the Tip of “J” Leak
7
12
Needle Knife Sinusotomy
of Anastomotic Leak
11
18
Outcomes 2014
Diverticulitis
Diverticulitis is a condition resulting from inflammation and infection in 1 or more diverticula. Surgery becomes necessary
when antibiotics fail to eradicate the infection and when a large abscess, perforation, peritonitis, or continued rectal
bleeding is present.
The percentage of diverticulitis surgical cases completed via a minimally invasive laparoscopic approach has increased over
the past 3 years. The colorectal department has a national and international referral base for highly complex cases.
Diverticulitis Organ Space Surgical Site Infection Rate
2012 – 2014
Percent
15
Open
Laparoscopic
12
9
6
3
0
2012
N=
76
113
2013
80
2014
132
140
137
Diverticulitis Postoperative Outcomes
2012 – 2014
Postoperative Outcomes
2012
2013
2014
Open
Lap
Open
Lap
Open
Lap
76
113
80
132
140
137
Median length of stay, days
7
5
7
5
8
4
30-day readmission rate, %
11
13
11
13
15
8
In-hospital mortality rate, %
0
0
0
0
3
0
7
0
4
1
7
0
4
1
16
0
5
0
Urinary tract infection rate, %
7
1
7
1
6
2
Venous thromboembolism rate, %
3
3
3
3
1
1
N=
Surgical site infection rates
Superficial
Deep
Lap = laparoscopic
Digestive Disease Institute
45
Large Bowel Disease
Stoma Therapy
Cleveland Clinic’s R.B.
Turnbull, Jr., MD, School
of Wound, Ostomy, and
Continence Nursing (WOCN)
was established as the first
WOCN school in the world
50 years ago. More than
3000 WOCN specialists
have graduated from the
The Digestive Disease Institute has an active Wound Ostomy Care (WOC)
program that helps patients with the practical, social, and psychological
issues related to bowel diversion. WOC nurses are board-certified by their
professional organization and care for patients each day in the inpatient setting
and outpatient clinic. For patients with an ileostomy or a colostomy, having the
support of an experienced enterostomal therapy nurse (ETN) is critical. The
institute’s ETNs conducted more than 17,000 inpatient and outpatient visits
in 2014, making them some of the most experienced ETNs in the country.
This depth and breadth of experience allows them to manage even the most
complex issues related to the care of ostomy patients.
Total Inpatient and Outpatient Visits for Stoma Therapy
2013 – 2014
Number of Visits
15,000
9000
program and are practicing
6000
throughout the world.
3000
The program prepares nurses to:
Inpatient
Outpatient
12,000
0
N=
2013
11,544
2014
3813
12,842
3915
• Manage ostomies pre- and postoperatively
• Prevent and treat pressure ulcers, fistulas,
and other skin disorders
• Care for patients with urinary and
fecal incontinence
46
Outcomes 2014
Pelvic Floor Disorders
The pelvic floor team is a multidisciplinary group of physicians that focuses on female pelvic floor disorders and
is one of the most experienced groups of such specialists in the region. Specialists treat the entire spectrum of
bowel disorders, including fecal incontinence, chronic constipation, and other difficulties. They also treat anal pain,
hemorrhoids, fissures, anal and rectovaginal fistulas, and rectal prolapse. The National Association for Continence
has designated the Section of Female Pelvic Medicine and Reconstructive Surgery in Cleveland Clinic’s Ob/Gyn &
Women’s Health and Digestive Disease Institutes as a Center of Excellence for Continence Care in Women.
Ventral Rectopexy by Procedure Type
2008 – 2014
Number
60
50
40
30
20
10
0
N=
Robotic
Laparoscopic
Open
Converted
58
20
11
6
Complications of Ventral Rectopexy
2008 – 2014
Number
80
60
40
20
0
N=
SBO
Ileus
Respiratory
Wound
Urinary
UTI
Other
None
4
4
4
6
6
8
22
75
SBO = small bowel obstruction
Digestive Disease Institute
47
Trauma and Acute Care Surgery
Trauma
The Department of General Surgery provides coverage for trauma care. The Northeast Ohio Trauma System, created in
2010, is a partnership between Cleveland Clinic Health System and MetroHealth Medical Center. Together they provide
integrated trauma care to the citizens of Northeast Ohio. Since its inception, the collaboration has proved successful in
controlling length-of-stay and mortality rates.
Mean Length of Stay, Trauma Casesa
2013 – 2014
Days
8
2013
2014
6
4
2
0
N=
No Injuries or
Noncodeable
99
196
Minor
(ISS 1 – 9)
1538 1578
Moderate
(ISS 10 – 15)
129
135
Severe
(ISS 16 – 24)
77
70
Critical
(ISS ≥ 25)
40
39
ISS = injury severity score
aData
48
from Hillcrest Hospital, a Cleveland Clinic regional hospital, a level II trauma center
Outcomes 2014
Acute Care Surgery
The acute care surgery section located at Cleveland Clinic main campus consists of surgeons who are fellowship trained in
surgical critical care. The team manages a wide range of emergent and complex general surgery patients who are admitted
through the Emergency Department or transferred to Cleveland Clinic from outside hospitals. As board-certified intensivists,
the team also practices in the surgical ICU at Cleveland Clinic main campus.
APR DRG Severity of Illness at Admissiona for Acute Care Surgeryb
2012 – 2014
Percent
40
Minor
Moderate
Major
Extreme
30
In 2014, the acute care surgery
team was involved in the care
of more than 900 patients.
Most presented with moderate
to major severity of illness.
20
10
0
N=
2012
2013
2014
1055
1295
952
aAPR
DRG severity of illness at admission is defined as the extent of physiologic decompensation or loss of organ system function.
bData
represent Cleveland Clinic main campus only.
Source: The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and
risk of mortality. solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG-Software
In-Hospital Mortality
2012 – 2014
Percent
10
Observed
Expected
8
6
4
2
0
N=
2012
2013
2014
1055
1295
952
Digestive Disease Institute
These data are prepared using the University
HealthSystem Consortium (UHC) Clinical
Database. uhc.edu
49
Pancreaticobiliary Disease
Endoscopic Retrograde Cholangiopancreatography
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose and treat disorders of the bile
and pancreatic ducts.
Post-ERCP Acute Pancreatitis, Adult and Pediatric
2012 – 2014
Percent
10
8
6
4
2
0
N=
2012
2013
2014
1123
1289
1190
ERCP = endoscopic retrograde cholangiopancreatography
Placement of a prophylactic pancreatic duct stent in high-risk patients has been shown to reduce the risk for pancreatitis
following ERCP.
Pancreatic Stent Placement, Adult and Pediatric
2012 – 2014
Percent
15
10
5
0
N=
50
2012
2013
2014
1123
1289
1190
Outcomes 2014
Management of Gallbladder Disease
Cholecystectomy is one of the most common general surgical procedures for the treatment of symptomatic gallstones
and other gallbladder conditions. The majority of these operations are performed laparoscopically.
Median Length of Stay, Open and Laparoscopic Inpatient Cholecystectomies
2012 – 2014
Days
8
Open
Laparoscopic
6
4
The indications for inpatient cholecystectomy are limited
to patients with concomitant medical illnesses or in
whom complications from gallstones require immediate
cholecystectomy.
2
0
N=
2012
2013
2014
58 820
68 895
51 799
30-Day Readmission Rate, Open and Laparoscopic Inpatient Cholecystectomies
2012 – 2014
Percent
20
Open
Laparoscopic
16
12
8
4
0
N=
2012
2013
2014
58 820
68 895
51 799
30-Day Mortality Rate, Open and Laparoscopic Inpatient Cholecystectomies
2012 – 2014
Open, % (N)
Laparoscopic, % (N)
Digestive Disease Institute
2012
2013
2014
3.4 (58)
1.5 (68)
2.0 (51)
0.2 (820)
0.3 (895)
0.1 (799)
51
Pancreaticobiliary Disease
Management of Pancreatic Disease
Cleveland Clinic’s Pancreas Disorder Clinic cares for patients across the spectrum of pancreatic disease, both benign and
malignant, and offers multidisciplinary care teams for pancreatic cancer and chronic pancreatitis.
Median Length of Stay, Pancreatectomy Procedures
2012 – 2014
Days
10
2012
2013
2014
8
6
4
2
0
N=
Open
Whipple
104 107 124
Lap Distal
Pancreatectomy
31
34
25
Open Distal
Whipple
4
4
7
Lap/Robotic
Pancreatectomy
8
17
13
Total
Pancreatectomy
29
11
11
Lap = laparoscopic
30-Day Readmission Rate, Pancreatectomy Procedures
2012 – 2014
Percent
30
2012
2013
2014
25
20
15
10
5
0
N=
52
0
Open
Whipple
104 107 124
Lap Distal
Pancreatectomy
31
34
25
Open Distal
Whipple
4
4
7
Lap/Robotic
Pancreatectomy
8
17
13
Total
Pancreatectomy
29
11
11
Outcomes 2014
Liver Disease and Liver Transplantation
Liver Biopsy
Severe Adverse Events Following Outpatient Liver Biopsya (N = 775)
The cumulative frequency of severe adverse events (SAEs) during 2012–2014 outpatient liver biopsies was 1.8% (14 of 775).
This surgical complication rate compares favorably with the reported frequency of these events in the medical literature.1
2012 – 2014
Type of SAE
Number of SAEs
SAE Rate (%)
Bleedinga
7
0.9
Severe pain
7
0.9
Hypotension
0
0.0
Pneumothorax
0
0.0
14
1.8
Total
aIncludes
outpatient liver biopsies performed by the hepatology service only
1Rockey
DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD; American Association for the Study of Liver Diseases. Liver biopsy.
Hepatology. 2009 Mar;49(3):1017-1044.
Digestive Disease Institute
53
Liver Disease and Liver Transplantation
Paracentesis
Paracentesis is a diagnostic and therapeutic procedure. Large volume paracentesis is the first-line treatment for
cirrhotic patients with tense and/or refractory ascites.
Severe Adverse Events Following Paracentesis
2012 – 2014
Percent
4
3
2
1
0
N=
2012
2013
2014
1371
1290
1548
Of the 4209 procedures performed between 2012 and 2014, 76 (1.81%) resulted in an Severe Adverse Events,
defined as death within 72 hours or hemoperitoneum.
30-Day Readmission Rate for Paracentesis
2012 – 2014
Percent
80
60
40
20
0
N=
2012
2013
2014
228
238
290
Of the 756 patients who underwent paracentesis procedures in the hospital between 2012 and 2014,
41% were readmitted within 30 days related to severity of underlying liver failure.
54
Outcomes 2014
Patients with community-acquired spontaneous bacterial peritonitis (SBP) have outpatient paracentesis with an ascitic
fluid neutrophil count > 250 cells/mm3. The prevalence of SBP in outpatients with ascites evaluated at Cleveland Clinic
between 2012 and 2014 was 1.01%. This compares with previous reports indicating rates of SBP in outpatients with
ascites of 1.5%–3.5%.1
Spontaneous Bacterial Peritonitis
2012 – 2014
Percent
4
1
Evans LT, Kim WR, Poterucha JJ, Kamath PS. Spontaneous bacterial
peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology.
2003 Apr;37(4):897-901.
3
2
1
0
N=
2012
2013
2014
847
764
860
Coronal multiplanar
reconstruction of CT of the
abdomen with contrast
that demonstrates contrast
opacification of existing left
portal vein to middle hepatic
vein shunt corresponding
to patent Transjugular
Intrahepatic Portosystemic
Shunt (TIPS). The stent
extends inferiorly in the main
portal vein.
Digestive Disease Institute
Portogram: Direct
portogram obtained through
transjugular approach that
demonstrates contrast
opacification of the main
portal vein and patent TIPS.
55
Liver Disease and Liver Transplantation
Transjugular Intrahepatic Portosystemic Shunt
Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat portal hypertension-related complications, such as
bleeding esophageal or gastric varices, refractory ascites, and hepatic hydrothorax. Cleveland Clinic is among the top
institutions in the nation in the number of TIPS procedures it performs. A multidisciplinary approach, which includes
hepatologists and radiologists, is employed in the selection of candidates best suited for TIPS procedures.
Admissions or Readmissions Within 30 Days of TIPS
2012 – 2014
Percent
40
30
20
10
0
2012
2013
2014
82
127
84
N=
Readmissions include need for management of all complications related to severity of underlying liver disease.
Indications for TIPS
2012 – 2014
Percent
60
50
40
30
20
10
0
N=
56
Hepatic hydrothorax
Ascites
Variceal bleeding
2012
2013
2014
82
127
84
Outcomes 2014
Nonalcoholic Steatohepatitis
Cardiovascular disease is the main cause of death in patients with nonalcoholic steatohepatitis (NASH). Statin
therapy has proved safe in NASH patients and improves cardiovascular outcomes. Renal-angiotensin system blockade
with angiotensin receptor blockers (ARBs) has an antihypertensive effect, and current evidence suggests it has a role
in inhibiting liver fibrosis.
Nonalcoholic Steatohepatitis Patients Receiving Drug Therapy
2012 – 2014
Percent
60
50
40
30
20
10
0
N=
Digestive Disease Institute
Statins
ARBs
Diabetic
Nondiabetic
643
1490
57
Liver Disease and Liver Transplantation
Hepatitis C
There are 30,000 new cases of hepatitis C virus (HCV) in the US each year. It is the leading reason for liver transplantation.
HCV Patients Treated With Antiviral Medications
2012 – 2014
Number
200
160
120
80
40
0
N=
2012
2013
2014
164
69
101
In 2013 there was a significant reduction in the number of patients treated with antiviral medications as the
institute was awaiting approval of direct-acting antiviral agents. The number of patients increased in 2014 because
these agents were approved.
Sustained Virologic Response in Patients With and Without Cirrhosisa
2012 – 2014
Percent
100
Cirrhotic
Noncirrhotic
80
60
40
20
0
N=
aIncludes
2012
56
76
2013
21
33
2014
50
51
patients with liver biopsy or radiologic imaging
In 2014, the number of patients who achieved sustained virologic response significantly increased in comparison with
previous years, reflective of treatment with new direct-acting antiviral agents such as sofosbuvir and simeprevir.
58
Outcomes 2014
Liver Tumor Clinic
Cleveland Clinic’s Liver Tumor Clinic uses a multidisciplinary approach to treat benign and
malignant liver tumors. Treatment options include surgical resection (open, laparoscopic, and
robotic) and nonsurgical treatment (chemoembolization, radioembolization, external beam
radiation, radiofrequency ablation). The team includes medical and radiation oncologists,
interventional radiologists, hepatologists, and transplant/hepatobiliary surgeons.
Median Number of Days From Initial Visit to Intervention
2012 – 2014
Days
40
30
20
10
0
2012
2013
2014
207
157
189
N=
Median Length of Stay, Liver Resection
2012 – 2014
Days
8
6
4
2
0
a
N =
aData
2012
2013
2014
92
113
149
not available for all patients who underwent liver resection
Digestive Disease Institute
59
Liver Disease and Liver Transplantation
30-Day Readmission Rate, Liver Resection
2012 – 2014
Percent
20
15
10
5
0
a
N =
aData
60
2012
2013
2014
92
113
149
not available for all patients who underwent liver resection
Outcomes 2014
Liver Transplantation
Cleveland Clinic performed its first adult liver transplantation on Nov. 8, 1984, and has completed 2094 liver
transplantations to date, including 2001 liver transplantations alone and 93 multiorgan transplantations: 73 liver/kidney,
5 liver/heart, 4 liver/lung, 4 liver/pancreas, 6 liver/intestine/pancreas and 1 liver/intestine/pancreas/kidney.
Liver Transplant Patients and Short-Term Outcomes
Patients Referred, Evaluated, and Listed
2012 – 2014
Number of Patients
800
Referred
Evaluated
Listed
600
400
200
0
2013
2012
N=
619
393
214
611
405
2014
178
579
331
164
Patient Removals From the Wait-List
2012 – 2014
Number of Patients
100
Removalsa
Deathsb
80
60
40
20
0
2012
N=
73
30
2013
57
14
2014
65
24
aIncludes
bPatient
all removals for reasons other than death and transplantation
deaths while on the liver transplant wait-list
Digestive Disease Institute
61
Liver Disease and Liver Transplantation
Solitary Liver Transplantation
2012 – 2014
Number of Transplantations
200
160
120
80
40
0
N=
2012
2013
2014
143
128
132
Transplant rate is calculated in person-years (days converted to fractional years): the number of days from Jan. 1 or
from the date of first wait-listing until death, transplantation, 60 days after recovery, transfer, or Dec. 31. The expected
transplant rate is adjusted for age, blood type, medical urgency status, time on the wait-list, and previous transplantation.
Transplant Rate for Patients Waiting for Liver Transplantation
2011 – 2013
Rate per 100 Person Years
80
Observeda
Expectedb
60
40
20
0
July 2011 – June 2012
July 2012 – June 2013
July 2013 – June 2014
139
130
136
N=
aObserved
bScientific
62
rates for 2011, 2012, and 2013 were all statistically significantly higher than the expected rates (P < 0.01).
Registry of Transplant Recipients (SRTR). srtr.org
Outcomes 2014
Liver Transplantation Median Length of Stay
2009 – 2014
MELDa
30
Days
18
12
20
6
10
0
2009
2010
2011
2012
2013
2014
135
128
119
134
124
127
Nb =
Days
MELD Score
0
MELD = model for end-stage liver disease
aCalculated MELD scores do not reflect exception MELD points.
bData not available for all liver transplant patients
Cleveland Clinic’s liver transplant team started a project in 2010 to streamline the postoperative clinical care pathways,
which resulted in an immediate reduction in length of stay.
30-Day Liver Transplantation Readmission Rate
2012 – 2014
Percent
40
30
20
10
0
N=
2012
2013
2014
143
128
132
Monthly monitoring and review of readmissions resulted in a reduction in the rate of readmissions from 32% in 2012 to
26% in 2014.
Digestive Disease Institute
63
Liver Disease and Liver Transplantation
Patient and Graft Survival, All Donor Types
1-Year Adult Patient Survival
2012 – 2014
Percent
100
Observed
Expected
80
60
40
20
0
N=
2012
2013
2014
277
293
295
Scientific Registry of Transplant Recipients (SRTR) srtr.org
Each reporting year reflects transplants performed over a 2.5 year period
3-Year Adult Patient Survival
2012 – 2014
Percent
100
Observed
Expected
80
60
40
20
0
N=
2012
2013
2014
304
302
277
Scientific Registry of Transplant Recipients (SRTR) srtr.org
Each reporting year reflects transplants performed over a 2.5 year period
64
Outcomes 2014
1-Year Adult Graft Survival
2012 – 2014
Percent
100
Observed
Expected
80
60
40
20
0
N=
2012
2013
2014
289
293
302
Scientific Registry of Transplant Recipients (SRTR) srtr.org
Each reporting year reflects transplants performed over a 2.5 year period
3-Year Adult Graft Survival
2012 – 2014
Percent
100
Observed
Expected
80
60
40
20
0
N=
2012
2013
2014
316
327
319
Scientific Registry of Transplant Recipients (SRTR) srtr.org
Each reporting year reflects transplants performed over a 2.5 year period
Digestive Disease Institute
65
Liver Disease and Liver Transplantation
Patient and Graft Survival by Donor Types
1-Year Patient Survival: Adult Primary Liver Transplantation Only
2012 – 2014
Survival (%)
100
DBD (N = 274)
DCD (N = 42)
Living donor (N = 34)
80
60
40
20
0
0
60
240
300
120
180
Days After Transplantation
360
DBD = donation after brain death, DCD = donation after cardiac death
Scientific Registry of Transplant Recipients (SRTR). National Average for 1-Year Patient Survival = 90.83%. srtr.org
3-Year Patient Survival: Adult Primary Liver Transplantation Only
2012 – 2014
Survival (%)
100
DBD (N = 274)
DCD (N = 42)
Living donor (N = 34)
80
60
40
20
0
0
200
600
800
400
Days After Transplantation
1000
DBD = donation after brain death, DCD = donation after cardiac death
Scientific Registry of Transplant Recipients (SRTR). National Average for 3-Year Patient Survival = 81.24%. srtr.org
66
Outcomes 2014
1-Year Graft Survival: Adult Primary Liver Transplantation Only
2012 – 2014
Survival (%)
100
DBD (N = 274)
DCD (N = 42)
Living donor (N = 34)
80
60
40
20
0
0
60
240
300
120
180
Days After Transplantation
360
DBD = donation after brain death, DCD = donation after cardiac death
Scientific Registry of Transplant Recipients (SRTR). National Average for 1-Year Graft Survival = 88.26%. srtr.org
3-Year Graft Survival: Adult Primary Liver Transplantation Only
2012 – 2014
Survival (%)
100
DBD (N = 274)
DCD (N = 42)
Living donor (N = 34)
80
60
40
20
0
0
200
600
800
400
Days After Transplantation
1000
DBD = donation after brain death, DCD = donation after cardiac death
Scientific Registry of Transplant Recipients (SRTR). National Average for 3-Year Graft Survival = 77.97%. srtr.org
Digestive Disease Institute
67
Liver Disease and Liver Transplantation
Liver Transplantation for Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is the 5th most common cancer in men and the 7th most common cancer in women.
Liver transplantation is the standard of care for patients with HCC complicated by cirrhosis and portal hypertension. In
order to be acceptable candidates for liver transplantation, patients must have HCC lesions within the Milan criteria.
Locoregional therapy has been used to downstage HCC in selected patients who fall outside the Milan criteria in order to
proceed to liver transplantation.
3-Year Patient Survival, Within and Beyond Milan Criteria
2009 – 2014
Survival (%)
100
Within Milan (N = 187)
Beyond Milan (N = 64)
80
60
40
20
0
0
200
600
800
400
Days After Transplantation
1000
3-Year Graft Survival, Within and Beyond Milan Criteria
2009 – 2014
Survival (%)
100
Within Milan (N = 187)
Beyond Milan (N = 64)
80
60
40
20
0
68
0
200
600
800
400
Days After Transplantation
1000
Outcomes 2014
Obesity and Metabolic Disease
Bariatric Surgery
In 2014, Cleveland Clinic’s Bariatric and Metabolic Institute marked its 9th anniversary and continued to be accredited
as a designated Bariatric Surgery Center of Excellence by the American Society for Metabolic & Bariatric Surgery and the
American College of Surgeons. This designation is awarded to programs that meet high quality standards and perform a
minimum of 125 procedures annually.
Bariatric Surgery Cases by Type
2007 – 2014
Othera
Cases
Revision
Banding
Sleeve
Bypass
800
600
400
200
0
N=
2007
438
2008
589
2009
561
2010
692
2011
609
2012
647
2013
724
2014
680
aOther includes other bariatric procedures such as gastric plication +/- band, duodenal switch, distal bypass,
and band removal.
In 2014, laparoscopic Roux-en-Y
gastric bypass accounted for 56%
of all cases and was the most
frequently performed bariatric
procedure at Cleveland Clinic.
Laparoscopic sleeve gastrectomy
continued to grow and was the
2nd most commonly performed
procedure (36% of all cases).
Due to patient preference,
laparoscopic adjustable gastric
banding has shown large declines
over the past several years.
Nine percent, or 72 cases, were
performed at a Cleveland Clinic
regional hospital.
SINCE 2012, 92 BARIATRIC CASES WERE PERFORMED ROBOTICALLY.
More Common Procedures
Bypass
Digestive Disease Institute
Sleeve
Duodenal Switch
Less Common Procedures
Ringed Bypass
Banded Plication
Gastric Plication
Band
69
Obesity and Metabolic Disease
Comorbidities at Baseline Among Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass
2014
Percent
100
80
Cleveland Clinic (N = 357)
MBSCa (N = 2949)
60
40
20
0
0.3 0.2
Obstructive Hypertension
Sleep
Apnea
Diabetes
Mellitus
Hyperlipidemia
Smoking
Venous
Thromboembolism
Renal
Failure
Comorbidities at Baseline Among Patients Undergoing Laparoscopic Sleeve Gastrectomy
2014
Percent
100
80
Cleveland Clinic (N = 219)
MBSCa (N = 2949)
60
40
20
0
aMBSC
2.3 0.3
Obstructive Hypertension
Sleep
Apnea
Hyperlipidemia
Diabetes
Mellitus
Smoking
Venous
Thromboembolism
Renal
Failure
= Michigan Bariatric Surgery Collaborative
Source: Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, Schram JL, Kole KL, Finks JF, Birkmeyer JD, Share D,
Birkmeyer NJ; Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and
adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791-797.
70
Outcomes 2014
Laparoscopic Sleeve Gastrectomy and Roux-en-Y Length of Stay
2012 – 2014
Days
5
4
3
Cleveland Clinic
Top ranked U.S. News hospitalsa
2
1
0
2012
551
N=
aThese
2013
589
2014
559
data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
30-Day Complication Rate for All Bariatric Cases
2014
Percent
8
6
Cleveland Clinica (N = 619)
MBSCb (N = 2929)
4
2
0
Intestinal
Obstruction
1.2
Anastomotic
Leak
1.2
Bleeding
0.5
Deep Vein
Thrombosis
0.7
Respiratory Wound Infection/
Failure
Evisceration
0.5
0.2
aCleveland
bMBSC
Clinic data are non-risk-adjusted.
= Michigan Bariatric Surgery Collaborative
Source: Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, Schram JL, Kole KL, Finks JF, Birkmeyer JD, Share D, Birkmeyer NJ;
Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures
for the treatment of morbid obesity. Ann Surg. 2013;257(5):791-797.
Digestive Disease Institute
71
Obesity and Metabolic Disease
Robotic Bariatric Surgery Roux-en-Y Complications (N = 92)
2012 – 2014
In-Hospital Types of Complication
Number
Complications (%)
82
89.0
Atrial fibrillation
3
3.3
Nausea/vomiting
2
2.2
Hypoxia
2
2.2
Othera
3
3.3
30-day all-cause readmissions
6
6.5
None
a
Other includes bleed, superficial wound infection, delirium, and urinary tract infection.
Percentage of Patients Requiring Intensive Care Unit Admission:
Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy
2012 – 2014
Percent
8
6
Cleveland Clinic
UHC Top Hospitalsa
4
2
0
N=
2012
551
2013
589
2014
559
*These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database. uhc.edu
72
Outcomes 2014
30-Day Mortality Rates for Bariatric Surgery
2014
Type
Cleveland Clinic
BOLD
All bariatric surgeries, % (N)
0.0 (680)
0.1 (186,567)a
Laparoscopic Roux-en-Y gastric bypass, % (N)
0.0 (382)
0.14 (136,036)
Laparoscopic sleeve gastrectomy, % (N)
0.0 (244)
0.08 (15,964)
BOLD = Bariatric Outcomes Longitudinal Database, a database of the American Society for Metabolic & Bariatric Surgery
aNational
Comparisons of Bariatric Surgery Safety and Efficacy: Findings from the BOLD Database 2007–2010. Paper presented at: 29th
Annual Meeting of the American Society for Metabolic & Bariatric Surgery; June 17–22, 2012; San Diego, CA. Abstract PL-104.
Source: Inabet WB 3rd, Winegar DA, Sherif B, Sarr MG. Early outcomes of bariatric surgery in patients with metabolic syndrome: an analysis
of the bariatric outcomes longitudinal database. J Am Coll Surg. 2012;214(4):550-556.
Comorbidity Resolution at 3-Year Follow-Up for All Bariatric Surgery Cases
2008 – 2014
Percent
100
75
50
25
0
N=
Sleep Apnea
161
Digestive Disease Institute
Diabetes
178
Hyperlipidemia
192
Hypertension
273
73
Obesity and Metabolic Disease
Mean Percent Weight Lossa Toward Ideal Body Mass Index at Follow-Up (All Case Types)
2008 – 2014
Percent
80
60
40
20
0
N=
a
Year 1
2220
Year 2
1399
Year 3
764
Year 4
412
Year 5
213
Weight loss formula: (baseline BMI – follow-up BMI) / (baseline BMI – ideal BMI [25]) x 100
For cases followed ≤ 5 years, the weight loss toward ideal BMI was 51%. The laparoscopic Roux-en-Y
gastric bypass at 5 years had the highest percentage of weight loss toward ideal BMI at 59%.
74
Outcomes 2014
Bariatric Surgery for Diabetes
Mean Body Mass Index Before and After Bariatric Surgery for Obese Diabetic Patients With Baseline
HbA1c Values > 6.5% (N = 394)
2004 – 2014
BMI (kg/m2)
50
45
40
(P < .001)
35
30
25
Before Surgery
Over the past 11 years, approximately 77% of obese diabetic
patients had laparoscopic Roux-en-Y gastric bypass, 11% had
sleeve gastrectomy, and 8% had gastric banding. The mean
body mass index (BMI) difference before and after surgery was
statistically significant with baseline BMI at 46.6 and follow-up
at 35.4. The mean follow-up duration was 5.5 years.
After Surgery
Mean Hemoglobin A1c Values Before and After Bariatric Surgery for Diabetic Patients With Baseline
A1c Values > 6.5% (N = 394)
2004 – 2014
Percent
10
9
8
7
(P < .001)
6
5
Before Surgery
Digestive Disease Institute
After Surgery
Since 2004, Cleveland Clinic has performed bariatric surgery on
1914 obese diabetic patients. Of these patients, 1011 (58%)
had baseline HbA1c values > 6.5%. Of the 1011 patients, 39%
(N = 394) had recent HbA1c values available at least 90 days
postsurgery. Improvement from baseline values was statistically
significant, with a mean A1c baseline of 8.3% before surgery and
most recently available A1c of 6.5% after surgery. The average time
between pre- and postoperative HbA1c values was 16 months.
75
Obesity and Metabolic Disease
Bariatric Behavioral Health
Bariatric Surgery Outcomes in Patients With Psychotic Disorders
2008 – 2014
Parameter
Psychosis Cohort (N = 11)
Nonpsychosis Control Cohort (N = 33)
Age, mean, years
45.8
46.1
Gender, % male
36.4
36.4
57.8
57.3
3.7
3.0
18.2
12.0
9
6
44.6
50.1
BMI, mean,
kg/m2
Length of stay, mean, days
60-day morbidity
Readmission rate, %
Excess weight loss, mean %
Patients with psychiatric disorders that include psychotic features (e.g., delusions and auditory or visual
hallucinations) are at high risk of morbid obesity. Most bariatric surgery programs do not consider these patients
as surgical candidates. The institute assessed outcomes in bariatric surgery patients with well-stabilized
psychotic disorders, comparing a study cohort with a matched control group of bariatric patients without
psychotic disorders.
All study cohort patients were on psychiatric medications (median of 3), with 91% taking antipsychotic
medications and 46% with a previous suicide attempt. Two patients had perioperative complications (18%),
namely, respiratory failure and rhabdomyolysis, and 1 patient had a marginal ulcer 2 years after Roux-en-Y
gastric bypass. No statistical differences occurred between the groups in length of stay, 60-day morbidity, late
complications, or readmission. Although not all patients with psychotic features are candidates for bariatric
surgery, appropriately screened candidates, with intensive multidisciplinary assessment, can cope successfully
with weight-loss surgery.
76
Outcomes 2014
Impact of a History of Eating Disordered Behaviors on Weight Loss and
Early Adjustment After Bariatric Surgery (N = 221)
2010 – 2014
Percent
18
16
14
12
Positive history
Negative history
10
8
P < 0.001
6
P < 0.09
4
2
0
Fear of Failure
Grieving the Loss of Food
Eating disorders (ED) (e.g., loss of control over eating, grazing, and vomiting
to control weight) after bariatric surgery may be common. Staff examined the
prevalence of purging behaviors and past treatment of ED in 870 bariatric surgery
candidates and the impact of this history on 1-month psychological adjustment and
BMI loss in the 1st year in a subset of 221 patients.
A reported history of purging and/or eating disorders treatment was rare (8.9%).
Women and African Americans were more likely to have an ED history. Baseline
scores on a measure of binge eating and clinician ratings of ED pathology were
significantly higher for those with an ED history. No differences were found in
weight loss at any time. Patients with an ED history indicated greater fear of failure
and greater grieving over the loss of food at their 1-month follow-up visit. Although
weight loss in the 1st year was equivalent, those with an ED history may have
greater difficulty with the early postoperative psychological adjustment.
Digestive Disease Institute
77
Obesity and Metabolic Disease
Psychosocial Factors Between First-Time Bariatric Patients and Revisional Bariatric Patients
2010 – 2014
Psychosocial Factor
First-Time Bariatric Surgery (%)
Revisional Bariatric Surgery (%)
(N = 1311)
(N = 57)
Past alcohol abuse
12.9
21.1
Past substance abuse
13.7
20
Use of psychotropic medicines
56.3
76.2
Inpatient psychiatric treatment
11.3
14.3
Use of laxatives/diuretics
6.3
6.7
History of vomiting
4.4
6.7
Number of psychotropic medicines
0.7
2.0
Patients presenting for revisional bariatric surgery because of inadequate weight loss were compared with
first-time bariatric candidates. Groups did not differ on BMI, gender, ethnicity, or history of outpatient
psychiatric treatment. However, patients seeking a revision of previous bariatric surgery may have more
complicated psychiatric histories than bariatric populations as a whole.
78
Outcomes 2014
Brief 4-Session Cognitive Behavioral Training Group Increases Knowledge and Coping Skills in
a High-Risk Bariatric Surgery Population (N = 77)
March 2013 – March 2014
Quiz # Correct
12
(P < .001)
10
8
Pre
Post
6
4
2
0
GET SET Quiz
The effectiveness of a brief, 4-session group called “Getting Expertise Today for a Successful Experience Tomorrow”
(GET SET) was examined for bariatric surgery candidates deemed to have limited knowledge or coping skills. Pre- and
post-group measures were completed by participants to evaluate knowledge using a 15-item quiz. Participants also
completed the Brief COPE, a measure used to assess a range of coping strategies.
Brief COPE Significant Subscales Pre- and Post-Test Scores (N = 77)
2013 – 2014
Subscale Score
8
P < 0.05
7
6
Pre
Post
P < 0.05
P < 0.001
P < 0.001
5
4
3
2
1
0
Self-Distraction
Active Coping
Emotional Support
Positive Reframing
Participants’ mean knowledge quiz scores increased, and several subscales of the Brief COPE also demonstrated
significant change.
Digestive Disease Institute
79
Breast Disease
Cleveland Clinic’s Comprehensive Breast Cancer Program offers a multidisciplinary team of highly skilled specialists
who provide comprehensive care to patients with breast cancer. A full array of services ranges from initial screening and
diagnosis to high-risk genetic counseling to innovative breast cancer treatment and supportive therapies. Cleveland Clinic
has 5 multidisciplinary comprehensive breast center locations: Fairview Hospital, Hillcrest Hospital, Beachwood Family
Health Center, Strongsville Family Health Center, and Cleveland Clinic main campus. The Breast Centers at Cleveland
Clinic’s main campus, Fairview Hospital, and Beachwood Family Health Center have been accredited by the American
College of Surgeons’ National Accreditation Program for Breast Centers.
Percentage of Screening Mammograms Resulting
in Callback
2012 – 2014
Core Biopsy Rate (Needle Core Biopsy/Fine Needle
Aspirate Biopsy Prior to Surgical Treatment of
Breast Cancer)
2012 – 2014
Percent
20
10.7% Not performed (N = 85)
15
10
5
0
N=
100%
2012
2013
2014
7914
8985
8909
Cleveland Clinic offers a diagnostic callback program for
patients with abnormal screening mammograms.
89.3% Performed (N = 711)
Data from Cleveland Clinic tumor registry for main campus and family
health center locations
Cleveland Clinic’s performance was 89.3% (711 of 796
patients) from 2012–2013 for this Commission on Cancer
(CoC) standard of care quality measure (95% confidence
interval [CI], 87.2–91.5). Cleveland Clinic performs within
the acceptable range for biopsy prior to surgical treatment
of breast cancer.
80
Outcomes 2014
Breast Conservation Surgery for Breast Cancer
(Lumpectomy)
Breast Surgery for Breast Cancer (Mastectomy)a
2012 – 2014
2012 – 2014
Percent
60
Percent
60
45
45
30
30
15
15
0
2012
2013
2014
664
815
570
N=
0
N=
2012
2013
2014
534
605
587
aIncludes
all breast cancers plus prophylactic mastectomy with
breast reconstruction
Immediate Breast Reconstruction
2012 – 2014
Percent
40
30
More than 30% of breast cancer surgeries in 2014
included immediate reconstruction performed by a
plastic surgeon specializing in breast reconstruction.
20
10
0
N=
2012
2013
2014
1198
1420
1157
Digestive Disease Institute
81
Breast Disease
5-Year Overall Survival of Female Patients With All Stages of Breast Cancer (N = 5694)
2006 – 2013
Survival (%)
100
80
60
40
American Joint Committee on Cancer (AJCC)
stage I–IV breast cancer
20
0
0
1
Percent Survival
(Number at Risk) =
5
2
3
4
Years After Diagnosis
98.6
96.5
94.6
93.1
91.3
(5227) (4201) (3328) (2620) (1984)
5-Year Overall Survival of Female Patients With All Stages of Breast Cancer by Racea (N = 5528)
2006 – 2013
Survival (%)
100
Black (N = 870)
White (N = 4658)
80
60
40
20
0
0
1
5
2
3
4
Years After Diagnosis
Percent Survival and (Number at Risk) by Racea
Years After Diagnosis
Race
1
2
3
4
5
Black
97.3 (735)
93.8 (582)
90.4 (438)
88.7 (330)
86.9 (249)
White
98.9 (4354)
97.0 (3517)
95.3 (2809)
93.9 (2221)
92.1 (1679)
aSelf-reported
82
Outcomes 2014
5-Year Overall Survival by ER, PR, and HER2 Status for Breast Cancer Patients (N = 4022)
2006 – 2013
Survival (%)
100
ER or PR positive (N = 2765)
HER2 positive (N = 715)
Triple negative (N = 542)
80
60
40
20
0
0
1
2
3
4
Years After Diagnosis
5
Percent Survival and (Number at Risk) by Receptor HER2 Status
Years After Diagnosis
Status
1
2
3
4
5
99.1 (2557)
97.5 (2038)
96.0 (1584)
94.5 (1278)
92.0 (1041)
HER2 positive
98.6 (669)
97.3 (534)
94.4 (414)
92.2 (326)
90.0 (268)
Triple negative
95.5 (489)
87.6 (373)
83.4 (279)
80.8 (220)
79.2 (193)
ER or PR positive
ER = estrogen receptor, HER2 = human epidermal growth factor receptor 2, PR = progesterone receptor
Digestive Disease Institute
83
Breast Disease
5-Year Overall Survival of Female Patients With Stage 0 and I Breast Cancer (N = 3234)
2006 – 2013
Survival (%)
100
Stage
Stage
Stage
Stage
80
60
0 CC (N = 953)
0 AJCC
I CC (N = 2281)
I AJCC
40
20
0
0
1
5
2
3
4
Years After Diagnosis
Percent Survival and (Number at Risk) by Stage
Years After Diagnosis
Stage
1
2
3
4
5
0
99.5 (864)
98.9 (694)
98.2 (563)
97.8 (458)
97.3 (338)
I
99.7 (2121)
99.1 (1725)
98.2 (1394)
97.6 (1116)
96.2 (869)
CC = Cleveland Clinic
AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College
of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG,
Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
84
Outcomes 2014
5-Year Overall Survival of Female Patients With Stage II Breast Cancer (N = 1556)
2006 – 2013
Survival (%)
100
Stage
Stage
Stage
Stage
80
60
IIA
IIA
IIB
IIB
CC (N = 1055)
AJCC
CC (N = 501)
AJCC
40
20
0
0
1
2
3
4
Years After Diagnosis
5
Percent Survival and (Number at Risk) by Stage
Years After Diagnosis
Stage
1
2
3
4
5
IIA
99.3 (990)
98.1 (797)
97.4 (647)
96.4 (509)
93.7 (395)
IIB
99.0 (469)
95.7 (365)
93.6 (274)
90.5 (197)
89.4 (143)
CC = Cleveland Clinic
AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College
of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG,
Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
Digestive Disease Institute
85
Breast Disease
5-Year Overall Survival of Female Patients With Stage IIIA and IIIB Breast Cancer (N = 442)
2006 – 2013
Survival (%)
100
Stage
Stage
Stage
Stage
80
60
IIIA
IIIA
IIIB
IIIB
CC (N = 341)
AJCC
CC (N = 101)
AJCC
40
20
0
0
1
2
3
4
Years After Diagnosis
5
Percent Survival and (Number at Risk) by Stage
Years After Diagnosis
Stage
1
2
3
4
5
IIIA
97.6 (307)
93.5 (257)
89.1 (199)
86.1 (158)
82.3 (108)
IIIB
99.0 (95)
86.4 (67)
72.0 (43)
66.5 (33)
64.2 (23)
CC = Cleveland Clinic
AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College
of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG,
Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
86
Outcomes 2014
5-Year Overall Survival of Female Patients With Late Stage Breast Cancer (N = 330)
2006 – 2013
Survival (%)
100
Stage
Stage
Stage
Stage
80
60
IIIC CC (N = 128)
IIIC AJCC
IV CC (N = 202)
IV AJCC
40
20
0
0
1
2
3
4
Years After Diagnosis
5
Percent Survival and (Number at Risk) by Stage
Years After Diagnosis
Stage
1
2
3
4
5
IIIC
95.2 (114)
84.7 (92)
76.2 (60)
73.4 (46)
68.2 (35)
IV
82.4 (150)
72.8 (109)
60.6 (66)
49.7 (45)
44.7 (31)
CC = Cleveland Clinic
AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College
of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG,
Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
Digestive Disease Institute
87
Cleveland Clinic Florida
Upper and Lower GI Diagnostic Procedures
Cecal Intubation Rate for Colonoscopy
2013 – 2014
Percent
100
Cleveland Clinic
Benchmarka
80
60
40
20
0
N=
2013
2014
6535
7174
aRex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb GJ, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S,
Weinberg DS. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110(1):72-90.
Polyp Detection Rate During Screening Colonoscopy
2013 – 2014
Percent
50
Cleveland Clinic
Benchmarka
40
30
20
10
0
N=
2013
2014
3262
3639
aGohel TD, Burke CA, Lankaala P, Podugu A, Kiran RP, Thota PN, Lopez R, Sanaka MR. Polypectomy rate: a surrogate for adenoma detection
rate varies by colon segment, gender, and endoscopist. Clin Gastroenterol Hepatol. 2014 Jul;12(7):1137-1142.
88
Outcomes 2014
Postendoscopic Retrograde Cholangiopancreatography Pancreatitis, Adult and Pediatric
2012 – 2014
Percent
10
8
6
4
2
0
N=
2012
2013
2014
272
323
219
Pancreatic Stent Placement, Adult and Pediatric
2012 – 2014
Percent
10
8
6
4
2
0
N=
2012
2013
2014
272
323
219
Placement of a prophylactic pancreatic duct stent in high-risk patients has been shown to reduce the risk for
postendoscopic retrograde cholangiopancreatography pancreatitis.
Digestive Disease Institute
89
Cleveland Clinic Florida
Upper and Lower GI Surgical Procedures
Median Length of Stay, Inpatient Incisional/Ventral Hernia Repairs
2012 – 2014
Days
6
Open
Laparoscopic
4
2
0
N=
2012
88
26
2013
2014
114 35
145 36
Rectal Cancer Postoperative Outcomes
2013 – 2014
Rectal Cancer Surgical Procedures
2013
2014
85
94
Median length of stay, days
9
7.8
30-day readmission rate, %
19
12.7
0
0
2013
2014
51
44
Median length of stay, days
9
8.7
30-day readmission rate, %
15
9.1
0
0
N
In-hospital mortality, %
Ulcerative Colitis Postoperative Outcomes
2013 – 2014
Ulcerative Colitis Surgical Procedures
N
In-hospital mortality, %
90
Outcomes 2014
Median Length of Stay, Laparoscopic Inpatient Cholecystectomy
2012 – 2014
Days
3
2
1
0
N=
2012
2013
2014
113
113
69
Median Length of Stay, Pancreatectomy Proceduresa
2012 – 2014
Days
10
8
6
4
2
0
N=
a
2012
2013
2014
176
173
180
Includes open Whipple, laparoscopic distal pancreatectomy, laparoscopic/robotic Whipple, and total pancreatectomy procedures
Digestive Disease Institute
91
Cleveland Clinic Florida
Liver Transplantation
In August 2012, the Agency for Health Care Administration approved Cleveland Clinic Florida’s Certificate of Need to
provide liver and kidney transplanta services. In March 2013, the United Network for Organ Sharing granted approval
to Cleveland Clinic Florida’s liver transplant program. The program was launched in April 2013 and received CMS
(Medicare) approval in June 2014. A multidisciplinary team participates in the evaluation, management, treatment,
and follow-up of the transplant patients.
Patients Referred, Evaluated, Listed, and Transplanted
2013 – 2014
Number of Patients
200
2013
2014
160
120
80
40
0
N=
Referred
Evaluated
103 160
48
64
Listed
34
41
Transplanted
9
24
Liver Transplantation, 1-Year Patient Survival (N = 9)
July 2011 – December 2013
Percent
100
Observed
Expecteda
80
60
40
20
0
aExpected
events based on risk adjustment model published by Scientific Registry of Transplant Recipients (SRTR).
Scientific Registry of Transplant Recipients (SRTR) srtr.org
92
Outcomes 2014
Liver Transplantation, 1-Year Graft Survival (N = 9)
July 2011 – December 2013
Percent
100
Observed
Expecteda
80
60
40
20
0
aExpected
events based on risk adjustment model published by Scientific Registry of Transplant Recipients (SRTR).
Scientific Registry of Transplant Recipients (SRTR) srtr.org
Digestive Disease Institute
93
Cleveland Clinic Florida
Obesity and Metabolic Disease
The Bariatric and Metabolic Center (BMC) at Cleveland Clinic Florida is dedicated to the care and well being of
surgical and morbidly obese patients. The American Society for Metabolic and Bariatric Surgeons, the American
College of Surgeons, and the Fellowship Council have named BMC and the section of Minimally Invasive Surgery
a Center of Excellence. For the past 14 years, BMC at Cleveland Clinic Florida has delivered high-quality care and
research in the field of bariatric surgery.
Bariatric Surgery Cases
2012 – 2014
Number of Cases
350
300
250
200
150
100
50
0
2012
N=
267
Band
Bypass
Sleeve
Revision
2013
2014
310
297
Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass, Median Length of Stay
2012 – 2014
Days
6
Laparoscopic sleeve gastrectomy
Laparoscopic Roux-en-Y
4
2
0
N=
94
2012
2013
2014
135 87
200 46
211 33
Outcomes 2014
30-Day Complication Rate for All Bariatric Cases (N = 874)
2012 – 2014
Percent
4
Cleveland Clinic
MBSC
3
2
1
0
0
Respiratory
Failure
Deep Vein
Thrombosis
Bleeding
Intestinal
Obstruction
Wound Infection/ Anastomotic
Evisceration
Leak
MBSC = Michigan Bariatric Surgery Collaborative
Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, Schram JL, Kole KL, Finks JF, Birkmeyer JD, Share D, Birkmeyer NJ; Michigan
Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the
treatment of morbid obesity. Ann Surg. 2013 May;257(5):791-797.
Reduction of Comorbidities 6 Months After Surgical Procedure
2014
Percent
80
Laparoscopic sleeve gastrectomy (N = 116)
Laparoscopic Roux-en-Y (N = 10)
60
40
20
0
Sleep Apnea
GERD
Hyperlipidemia
Hypertension
Diabetes
GERD = gastroesophageal reflux disease
Digestive Disease Institute
95
Cleveland Clinic Florida
Breast Disease
Screening Mammograms Resulting in Callback
2012 – 2014
Percent
20
15
10
5
0
N=
2012
2013
2014
9865
11,756
13,379
Cleveland Clinic Florida offers a diagnostic callback program for
patients with abnormal screening mammograms.
Breast Conservation Surgery for Breast Cancer (Lumpectomy)
2011 – 2013
Percent
75
50
25
0
N=
96
2011
2012
2013
59
65
86
Outcomes 2014
Breast Surgery for Breast Cancer (Mastectomy)
2011 – 2013
Percent
75
50
25
0
2011
2012
2013
43
48
72
N=
Core Needle Biopsy Rate
2011 – 2013
Percent
100
Cleveland Clinic
National Quality Foruma benchmark
75
50
25
0
N=
aNational
2011
2012
2013
125
135
175
Quality Forum (NQF) qualityforum.org
Digestive Disease Institute
97
Cleveland Clinic Florida
Radiation Therapy After Lumpectomy
2011 – 2013
Percent
100
Cleveland Clinic
ACoS/CoC CP3Ra benchmark
75
50
aThe
American College of Surgeons Commission on Cancer’s Cancer
Program Practice Profile Report (ACoS/CoC CP3R) benchmark is 90%.
25
0
N=
2011
2012
2013
31
29
42
Breast cancer patients < 70 years of age who had lumpectomy also had radiation therapy within 1 year.
98
Outcomes 2014
Tamoxifen or Third Generation Aromatase Inhibitor Within 1 Year of Diagnosis
2011 – 2013
Percent
100
Cleveland Clinic
ACoS/SoS CP3Ra benchmark
75
50
a
The American College of Surgeons Commission on Cancer’s
Cancer Program Practice Profile Report (ACoS/CoC CP3R)
benchmark is 90%.
25
0
N=
2011
2012
2013
36
45
54
Tamoxifen or third generation aromatase inhibitors were administered within 1 year of diagnosis for > 70% of women
with AJCC T1c or stage II or III hormone receptor positive breast cancer.
Combination Chemotherapy Within 4 Months of Diagnosis
2011 – 2013
Percent
100
Cleveland Clinic
ACoS/SoS CP3Ra benchmark
75
50
25
0
N=
aThe
2011
2012
2013
9
11
10
ACoS/CoC CP3R benchmark is 90%.
The ACoS/CoC CP3R combination chemotherapy was administered within 4 months for women < 70 years of age
with AJCC T1c or stage II or III hormone receptor negative breast cancer.
Digestive Disease Institute
99
Institute Quality Improvement
Digestive Disease Institute Patient Safety Indicators
The Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) are used to measure
patient safety in hospitals. The Digestive Disease Institute has made great improvements in identifying potential
complications or adverse events through efforts that align clinical care with documentation.
Digestive Disease Institute Postoperative Hemorrhage or Hematoma (PSI 9)
January 2010 – November 2014
Rate per 1000 Patients
16
Digestive Disease Institute performance
Cleveland Clinic targeta
12
8
4
0
2010
2011
2012
2013
2014
PSI = Patient Safety Indicator
aThe Cleveland Clinic target is 4.64 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC)
Clinical Database. (uhc.edu)
The Digestive Disease Institute’s postoperative hemorrhage or hematoma rate (AHRQ PSI 9) has steadily
improved since 2010.
100
Outcomes 2014
Digestive Disease Institute Postoperative Respiratory Failure (PSI 11)
January 2010 – November 2014
Rate per 1000 Patients
20
Digestive Disease Institute performance
Cleveland Clinic targeta
15
10
5
0
2010
2011
2012
2013
2014
aThe Cleveland Clinic target is 5.61 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC)
Clinical Database. (uhc.edu)
Collaboration with the Intensive Care Unit staff has resulted in a 30% decrease in postoperative respiratory
failure rate (AHRQ PSI 11).
Digestive Disease Institute Postoperative Pulmonary Embolism or Deep Vein Thrombosis (PSI 12)
January 2010 – November 2014
Rate per 1000 Patients
16
Digestive Disease Institute performance
Cleveland Clinic targeta
12
8
4
0
2010
2011
2012
2013
2014
a
The Cleveland Clinic target is 5.5 per 1000 patients. These data are prepared Data from the University HealthSystem Consortium
(UHC) Clinical Database. (uhc.edu)
Reducing the incidence of postoperative pulmonary embolism or deep vein thrombosis (AHRQ PSI 12)
continues to be an area of focus and a priority for improvement. There was a 27% decrease in the rate per
1000 patients from 2012 to 2014.
Digestive Disease Institute
101
Institute Quality Improvement
Digestive Disease Institute Postoperative Sepsis (PSI 13)
January 2010 – November 2014
Rate per 1000 Patients
30
Digestive Disease Institute performance
Cleveland Clinic targeta
24
18
12
6
0
2010
2011
2012
2013
2014
aThe Cleveland Clinic target is 4.27 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC) Clinical
Database. (uhc.edu)
Digestive Disease Institute Postoperative Wound Dehiscence (PSI 14)
January 2010 – November 2014
Rate per 1000 Patients
2.0
Digestive Disease Institute performance
Cleveland Clinic targeta
1.5
1.0
0.5
0
2010
2011
2012
2013
2014
a
The Cleveland Clinic target is 0 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC) Clinical Database.
(uhc.edu)
The Digestive Disease Institute’s postoperative wound dehiscence rate (AHRQ PSI 14) is low at 1 per 1000 patients,
despite performing complex primary and reoperative abdominal and colorectal surgical procedures.
102
Outcomes 2014
Digestive Disease Institute Accidental Puncture or Laceration (PSI 15)
January 2010 – November 2014
Rate per 1000 Patients
50
Digestive Disease Institute performance
Cleveland Clinic targeta
40
30
20
10
0
2010
2011
2012
2013
2014
aThe Cleveland Clinic target is 1.21 per 1000 patients. These data are prepared using the University HealthSystem Consortium (UHC) Clinical
Database. (uhc.edu)
In spite of a large number of reoperative cases, the accidental puncture or laceration rate (AHRQ Patient Safety Indicator
15) has dramatically decreased since 2010 and remained below 5 per 1000 patients in 2014.
Digestive Disease Institute Readmissions
Digestive Disease Institute All-Cause 30-Day Readmissions by Department
2011 – 2014
Percent
40
Bariatrics
Colorectal Surgery
Gastroenterology & Hepatology
General Surgery
30
20
10
0
2011
2012
2013
2014
Readmission rates by department have been consistent since 2011. A process to review all unplanned readmissions was
implemented to gain insight and identify improvement opportunities.
Digestive Disease Institute
103
Surgical Quality Improvement
American College of Surgeons National Surgical Quality Improvement Program
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) objectively measures
and reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. These outcomes
data reflect Cleveland Clinic’s overall general surgery ACS NSQIP performance benchmarked against 458 participating
sites and overall colorectal surgery benchmarked against 451 participating sites.
General Surgery Outcomes
July 2013 – June 2014
Outcome
30-day mortality
30-day morbidity
Observed Rate (%)
Expected Rate (%)
1145
1.31
1.82
1145
22.10a
1.09
18.30
Cardiac event
1145
1.22a
Pneumonia
1143
2.80
2.68
Unplanned intubation
1143
3.32a
2.40
1137
3.43a
2.44
Deep vein thrombosis/pulmonary embolism
1145
5.59a
2.16
Renal failure
1143
1.14
1.36
Urinary tract infection
1161
1.98
1.75
1138
13.44a
10.77
Sepsis
1102
10.89a
4.73
Return to operating room
1145
4.37
5.23
1145
14.24a
11.99
Ventilator > 48 hours
Surgical site infection
Readmission
aIdentified
104
N
as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model
Outcomes 2014
Colorectal Surgery Outcomes
July 2013 – June 2014
Outcome
30-day mortality
N
Observed Rate (%)
Expected Rate (%)
693
1.59
2.00
30-day morbidity
693
21.36
19.10
Length of stay
511
29.94a
17.81
Pneumonia
691
2.17
1.97
Unplanned intubation
692
2.46
1.88
Ventilator > 48 hours
688
2.76
2.16
Deep vein thrombosis/pulmonary embolism
693
5.92a
2.38
Renal failure
691
1.16
1.54
692
3.76a
2.63
11.05
Urinary tract infection
Surgical site infection
689
11.61
Sepsis
662
10.42a
4.63
Return to operating room
693
4.33
5.39
Readmission
693
13.56
13.52
aIdentified
as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model
Digestive Disease Institute
105
Surgical Quality Improvement
In addition to overall general surgery and colorectal surgery ACS NSQIP outcomes data, data specific to the following
procedures are provided (with number of sites participating in benchmarking outcomes shown in parentheses):
hepatectomy (79), pancreatectomy (100), colectomy (451), and proctectomy (123).
Hepatectomy Outcomes
July 2013 – June 2014
Outcome
N
Observed Rate (%)
Expected Rate (%)
30-day mortality
73
1.37
1.43
30-day morbidity
73
32.88
19.60
73
26.03a
12.29
Surgical site infection
aIdentified
as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model
Pancreatectomy Outcomes
July 2013 – June 2014
Outcome
N
Observed Rate (%)
Expected Rate (%)
30-day mortality
127
1.57
0.88
30-day morbidity
127
36.22
27.10
127
28.35a
17.26
Surgical site infection
aIdentified
106
as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model
Outcomes 2014
Colectomy Outcomes
July 2013 – June 2014
Outcome
N
Observed Rate (%)
Expected Rate (%)
486
1.85
2.18
30-day morbidity
486
20.99a
16.76
Cardiac event
486
1.03
1.08
Pneumonia
484
2.27
1.89
Unplanned intubation
485
2.68
2.26
Ventilator > 48 hours
481
3.53
2.71
Deep vein thrombosis/pulmonary embolism
486
5.76a
2.63
Renal failure
484
1.45
1.66
Urinary tract infection
485
2.47
2.45
Surgical site infection
483
12.01a
8.20
Return to operating room
486
4.12
5.15
Readmission
486
13.17
12.60
Anastomotic leak
486
5.14
3.14
486
24.90a
16.32
30-day mortality
Prolonged NPO/nasogastric tube use
aIdentified
as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model
Proctectomy Outcomes
July 2013 – June 2014
Outcome
30-day morbidity
Surgical site infection
aIdentified
N
Observed Rate (%)
Expected Rate (%)
207
22.22
19.87
206
10.68a
12.51
as a low statistical outlier (lower than expected) by the ACS NSQIP hierarchical model
Digestive Disease Institute
107
Patient Experience — Digestive Disease Institute
Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the
best possible experience for patients and their families. Reported patient experiences
are shared with caregivers and used to identify opportunities to improve care. Cleveland
Clinic’s Office of Patient Experience supports caregivers through education and guidance
to help them deliver consistent, patient-centered care.
Outpatient Office Visit Survey — Digestive Disease Institute
CG-CAHPS Assessmenta
2013 – 2014
Best Response (%)
100
2013 (N = 2981)
2014 (N = 6843)
80
CG-CAHPS 2013
database average
(all practices)b
60
40
20
0
Appointment
Access
(% Always)c
Doctor
Communication
(% Yes, Definitely)d
Doctor Rating
Clerical Staff
(% 9 or 10)
0 – 10 Scale
(% Yes, Definitely)d
Test Results
Communication
(% Yes)e
a
In 2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS),
standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for
use in the physician office setting to measure patients’ perspectives of outpatient care.
bBased on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 2013
c
Response options: Always, Usually, Sometimes, Never
dResponse options: Yes, definitely; Yes, somewhat; No
eResponse options: Yes, No
Source: Press Ganey, a national hospital survey vendor
108
Outcomes 2014
Inpatient Survey — Digestive Disease Institute
HCAHPS Overall Assessment
2013 – 2014
Best Response (%)
100
80
2013 (N = 1939)
2014 (N = 1970)
60
National average
all patientsa
40
20
0
Hospital Rating
(% 9 or 10)
0 – 10 Scale
Recommend Hospital
(% Definitely Yes)b
aBased on national survey results of discharged patients, January 2013 – December 2013,
from 4067 US hospitals. medicare.gov/hospitalcompare
bResponse options: Definitely yes, Probably yes, Probably no, Definitely no
Source: Press Ganey, a national hospital survey vendor
The Centers for Medicare
& Medicaid Services
requires United States
hospitals that treat Medicare
patients to participate
in the national Hospital
Consumer Assessment
of Healthcare Providers
and Systems (HCAHPS)
survey, a standardized tool
that measures patients’
perspectives of hospital
care. Results collected
for public reporting are
available at medicare.gov/
hospitalcompare.
HCAHPS Domains of Carea
2013 – 2014
Best Response (%)
100
2013 (N = 1939)
2014 (N = 1970)
National average all patientsb
80
60
40
20
0
Discharge
Information
% Yes
aExcept
Doctor
Nurse
Communication Communication
Pain
Management
Room
New Medications Responsiveness
Clean
Communication
to Needs
% Always
(Options: Always, Usually, Sometimes, Never)
Quiet at
Night
for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions.
Source: Press Ganey, a national hospital survey vendor
bBased
on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare
Digestive Disease Institute
109
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 2014 focus areas in pursuit of
this 3-part aim. Throughout this section, “Cleveland Clinic” refers to the academic medical center or “main campus,”
and those results are shown.
Real-time dashboard data are leveraged in each Cleveland Clinic location to drive performance improvement. Although
not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels
and support improved care in all clinical locations.
Improve the Patient Experience of Care
Cleveland Clinic Overall Mortality
Observed/Expected Ratio
Cleveland Clinic Central Line-Associated Bloodstream
Infection — ICU Rate per 1000 Line Days
2013 – 2014
2013 – 2014
O/E Ratio
1.0
Rate per 1000 Line Days
2.5
0.8
2.0
0.6
1.5
0.4
0.0
1.0
Cleveland Clinic
Cleveland Clinic target
0.2
Q1
Q2
Q3
2013
Q4
Q1
0.5
Q2
Q3
Q4
2014
Source: Data from the UHC Clinical Data Base/Resource
ManagerTM used by permission of UHC. All rights reserved.
Cleveland Clinic’s observed/expected (O/E) mortality ratio
outperformed its internal target derived from the University
HealthSystem Consortium (UHC) 2014 risk model. Ratios
less than 1.0 indicate mortality performance “better than
expected” in UHC’s risk adjustment model.
110
Cleveland Clinic
Cleveland Clinic target
0.0
Q1
Q2
Q3
2013
Q4
Q1
Q2
Q3
Q4
2014
Cleveland Clinic has implemented several strategies to
reduce central line-associated bloodstream infections
(CLABSI), including a central-line bundle of insertion,
maintenance, and removal best practices. Focused reviews
of every CLABSI occurrence support reductions in CLABSI
rates in the high-risk critical care population.
Outcomes 2014
Cleveland Clinic Postoperative Pulmonary Embolism
or Deep Vein Thrombosis Risk Adjusted Rate
per 1000 Eligible Patients
2013 – 2014
Cleveland Clinic Hospital-Acquired Pressure Ulcer
Prevalence (Adult)
2013 – 2014
Percent
5
Rate per 1000 Patients
10
4
8
3
6
2
4
Cleveland Clinic
Cleveland Clinic target
2
0
0
Q1
Q2
Q3
2013
Q4
Q1
Cleveland Clinic
NDNQI 50th percentile
(academic medical centers)
1
Q2
Q3
Q4
Q1
Q2
Q3
2013
Q4
Q1
Q2
Q3
Q4
2014
2014
Source: Data from the UHC Clinical Data Base/Resource
ManagerTM used by permission of UHC. All rights reserved.
Source: Data reported from the National Database for Nursing Quality
Indicators® (NDNQI®) with permission from Press Ganey.
Improved screening, risk adjustment, and prevention
strategies have supported Cleveland Clinic’s continued
improvement with respect to perioperative pulmonary
embolism and deep vein thrombosis (AHRQ Patient
Safety Indicator 12). Embolism/thrombosis prevention
remains a safety priority for Cleveland Clinic in 2015.
A pressure ulcer is an injury to the skin that can be caused
by pressure, moisture, or friction. These sometimes occur
when patients have difficulty changing position on their
own. Cleveland Clinic caregivers have been trained to
provide appropriate skin care and regular repositioning help
while taking advantage of special devices and mattresses
to reduce pressure for high-risk patients. In addition, they
actively look for hospital-acquired pressure ulcers and treat
them quickly if they occur.
Digestive Disease Institute
111
Cleveland Clinic — Implementing Value-Based Care
Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the
best possible experience for patients and their families. Reported patient experiences
are shared with caregivers and used to identify opportunities to improve care. Cleveland
Clinic’s Office of Patient Experience supports caregivers through education and guidance
to help them deliver consistent, patient-centered care.
Outpatient Office Visit Survey — Cleveland Clinic
CG-CAHPS Assessmenta
2013 – 2014
2013 (N = 64,792)
2014 (N = 124,521)
Best Response (%)
100
CG-CAHPS 2013 database average
(all practices)b
80
60
40
20
0
Appointment
Access
(% Always)c
Primary Care
Specialty Care
Doctor Communication
(% Always)c
(% Yes, Definitely)d
Doctor Rating
Clerical Staff
(% 9 or 10)
0 – 10 Scale
(% Yes, Definitely)d
Test Results
Communication
(% Yes)e
aIn
2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS),
standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for
use in the physician office setting to measure patients’ perspectives of outpatient care.
bBased on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 2013
cResponse options: Always, Usually, Sometimes, Never
dResponse options: Yes, definitely; Yes, somewhat; No
eResponse options: Yes, No
Source: Press Ganey, a national hospital survey vendor
112
Outcomes 2014
Inpatient Survey — Cleveland Clinic
HCAHPS Overall Assessment
2013 – 2014
Best Response (%)
100
80
2013 (N = 10,730)
2014 (N = 10,369)
60
National average
all patientsa
40
20
0
Hospital Rating
(% 9 or 10)
0 – 10 Scale
Recommend Hospital
(% Definitely Yes)b
aBased on national survey results of discharged patients, January 2013 – December 2013,
from 4067 US hospitals. medicare.gov/hospitalcompare
bResponse options: Definitely yes, Probably yes, Probably no, Definitely no
Source: Press Ganey, a national hospital survey vendor
The Centers for Medicare
& Medicaid Services
requires United States
hospitals that treat Medicare
patients to participate
in the national Hospital
Consumer Assessment
of Healthcare Providers
and Systems (HCAHPS)
survey, a standardized tool
that measures patients’
perspectives of hospital
care. Results collected
for public reporting are
available at medicare.gov/
hospitalcompare.
HCAHPS Domains of Carea
2013 – 2014
Best Response (%)
100
2013 (N = 10,730)
2014 (N = 10,369)
National average all patientsb
80
60
40
20
0
Discharge
Information
% Yes
aExcept
Doctor
Nurse
Communication Communication
Pain
Management
Room
New Medications Responsiveness
Clean
Communication
to Needs
% Always
(Options: Always, Usually, Sometimes, Never)
Quiet at
Night
for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions.
Source: Press Ganey, a national hospital survey vendor
bBased
on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare
Digestive Disease Institute
113
Cleveland Clinic — Implementing Value-Based Care
Focus on Value
Cleveland Clinic is developing and implementing new models of care that focus on “Patients First” and aim to deliver
on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new
models of Value-Based Care is a 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
Home
Retail Venues
Community-Based
Organizations
Care System
Outpatient Clinics
Post-Acute
(other)
Emergency
Independent
Physician
Offices
Skilled Nursing
Facilities
M y Ch a r t
Ambulatory
Diagnosis & Treatment
Hospitals
Rehabilitation
Facilities
• 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.
114
Outcomes 2014
Improve Population Health
Reduce the Cost of Care
Select Accountable Care Organization
Performance Measures
Cleveland Clinic All-Cause 30-Day Readmission Rate
to Any Cleveland Clinic Hospital
Measure
Cleveland Clinic 2014
Performance (%)
Cleveland Clinic
Goala (%)
Pneumococcal
vaccination
84.9
100
Colorectal
cancer screening
72.3
100
Mammography
screening
77.5
≥ 99.6
Hemoglobin
A1c > 9%
20.5
≤ 10b
Hypertension
control
a2015
bLower
69.3
≥ 79.7
ACO 90th percentile
is better
As part of Cleveland Clinic’s commitment to population
health and in support of its newly certified Accountable
Care Organization (ACO), these primary care ACO
measures have been prioritized for monitoring and
improvement. Cleveland Clinic is improving performance
in these measures through enhanced care coordination,
optimizing technology and information systems, and
engaging primary care physicians and specialists directly
in the improvement work. These pursuits are part of
Cleveland Clinic’s overall strategy to transform care in
order to improve health and make care more affordable.
Digestive Disease Institute
2013 – 2014
Percent of Discharges
Case Mix Index
18
3.0
15
12
9
6
3
0
Na =
1.5
Cleveland Clinic rate
Cleveland Clinic CMI
UHC academic medical centers CMI
Q1
Q2
Q3
2013
52,104
Q4
Q1
Q2
Q3
Q4
0.0
2014
50,755
CMI = case mix index
aTotal discharges
Source: Data from the UHC Clinical Data Base/Resource ManagerTM
used by permission of UHC. All rights reserved.
Cleveland Clinic monitors 30-day readmission rates for
any reason to any of its system hospitals. Unplanned
readmissions are actively reviewed for improvement
opportunities. Strategies associated with communication,
education, and follow-up have been implemented for
several high-risk conditions, including heart failure and
pneumonia. These practices are being expanded and
enhanced to reduce overall avoidable readmissions.
Sicker, more complex patients are more susceptible
to readmission. Case mix index (CMI) reflects patient
severity of illness and resource utilization. Cleveland
Clinic’s CMI remains one of the highest among American
academic medical centers.
115
Innovations
Bariatric Surgery Provides Long-Term Control of
Type 2 Diabetes
Capnographic Monitoring in Colonoscopy Fails to
Reduce Incidence of Hypoxemia
Cleveland Clinic researchers demonstrated that bariatric
surgery is a highly effective and durable treatment for type
2 diabetes in obese patients, enabling nearly all surgical
patients to be free of insulin, and many more to be free of
all diabetic medications 3 years after surgery. The Surgical
Therapy and Medications Potentially Eradicate Diabetes
Efficiently (STAMPEDE) trial also showed that bariatric
surgery patients experienced an improvement in quality
of life and a reduction in the need for cardiovascular
medications to control blood pressure and cholesterol,
compared with those receiving medical therapy.
A randomized controlled trial of capnographic monitoring for
the reduction of hypoxemia in patients undergoing routine
colonoscopy with moderate sedation showed no statistical
difference between the incidence of hypoxemia in patients
titrated with capnography and patients who underwent
standard care. The results of this trial were presented at
the presidential plenary session of the American College of
Gastroenterology’s annual meeting.
Celecoxib Prevents Polyp Progression in Pediatric Familial Adenomatous Polyposis Patients
A worldwide trial conducted at Cleveland Clinic and
directed in part by Cleveland Clinic staff assessed the
impact of celecoxib, an anti-inflammatory drug, on
colorectal polyp disease progression in children with
familial adenomatous polyposis. The research showed
that 13% of children receiving celecoxib met the endpoint of developing more than 20 polyps larger than 2
mm at an annual colonoscopy, compared with 26% of
the placebo group. The median time to the polyposis
progression end-point was 2.1 years in the patients
receiving celecoxib and 1.1 years in the patients
receiving placebo. Although celecoxib is not a cure, the
trial demonstrated that it is a reasonable adjunct to
yearly colonoscopy to prevent polyp progression, and
it may allow children to delay their surgery to a more
suitable time.
116
Results
Time to > 20 Polyps, > 2 mm on Single Colonoscopy
Cumulative Event Rate (%)
100
90
80
70
60
50
40
30
20
10
0
Celecoxib
0
1
Placebo
2
3
4
5
6
28
11
Time (y)
Subjects evaluated
106
97
73
51
Outcomes 2014
Cirrhotic Patients May Benefit From Routine Screening for
Celiac Disease
Researchers at Cleveland Clinic found that celiac disease is more
than twice as common in people with cirrhosis of the liver as it
is in the general population, indicating that routine screening for
celiac disease may be warranted for cirrhotic patients. They also
found that patients who have levels of celiac serology antibodies
at least 5 times higher than the upper levels of normal values may
be diagnosed with celiac disease with no need for a small biopsy.
Forgoing an upper endoscopy or small bowel biopsy would be more
cost-effective and avoid risk of complications in the elderly or those
with advanced cirrhosis.
Wakim-Fleming J, Pagadala MR, McCullough AJ, Lopez R,
Bennett AE, Barnes DS, Carey WD. Prevalence of celiac disease
in cirrhosis and outcome of cirrhosis on a gluten free diet: a
prospective study. J Hepatol. 2014 Sep;61(3):558-563.
High-Definition Video Cholangioscopes Aid Diagnosis
Cleveland Clinic is optimizing evaluation of biliary disorders using
high-definition video cholangioscopes with narrow-band imaging
capability. It is among a handful of centers in the world with
experience using this technology for various biliary disorders.
High-definition endoscopes are now thin enough for insertion into
the bile duct, allowing detection of smaller and more obscure
lesions. Patients with biliary strictures will benefit from this new
technology because it allows earlier detection of neovascularization
and helps identify benign vs malignant lesions.
Digestive Disease Institute
Direct Peroral Cholangioscopy for
Difficult-to-Remove Biliary Stones
Cleveland Clinic gastroenterologists are
utilizing direct peroral cholangioscopy
for shockwave treatment of difficultto-remove biliary stones. Direct
visualization minimizes risk for damage
to bile duct walls, including perforation,
and can help patients avoid complicated
surgeries. Many patients with difficultto-remove stones are elderly with
comorbidities that put them at greater
risk for surgery.
117
Innovations
Variable Width, Extreme
Angulation Colonoscope May
Prove Helpful
Cleveland Clinic Florida’s Digestive
Disease Center staff conducted a
study to assess the effectiveness
of the PENTAX E-340TLi Video
Colonoscope (RetroView™), the newly
available variable-width colonoscope
with extreme tip angulation capability.
Based on colonoscopies of 16
patients, staff members found that
the RetroView colonoscope may help complete colonoscopies made difficult by colon tortuosity
and angulations. More data regarding the device’s performance, especially compared with other
colonoscopes, are needed.
Lara LF, Erim T, Schneider A, Palekar N, Jimenez B, Murchie B, Pimentel RR, Charles RJ.
Initial experience with a variable width and extreme tip angulation colonoscope.
Tech Coloproctol. 2014 Dec;18(12):1173-1175.
Study of Overtube-Assisted Enteroscopy Adverse Events Prompts Change in Practice
A retrospective study conducted at Cleveland Clinic Florida’s Digestive Disease Center of 432
overtube-assisted enteroscopies identified 14 resulting in emergency resuscitation efforts. Based
on the frequency of adverse events, and in consultation with anesthesia providers, endoscopists
conducted all antegrade overtube-assisted enteroscopies with general anesthesia with no
adverse events. The review prompted a change in practice. All patients undergoing antegrade
overtube-assisted enteroscopy at Cleveland Clinic now have endotracheal intubation, which has
dramatically decreased the rate of respiratory adverse events. The impact of endoscopic quality
measurements on practices, procedures, and outcomes will be of further interest.
Lara LF, Ukleja A, Pimentel R, Charles RJ. Effect of a quality program with adverse events
identification on airway management during overtube-assisted enteroscopy. Endoscopy. 2014
Nov;46(11):927-932.
118
Outcomes 2014
Glucose Spray Used to Control Gastric Variceal, Peptic Ulcer Bleeding
Management of nonvariceal and nonulcerative bleeding in the gastrointestinal tract,
such as that associated with radiation enteritis with active and extensive oozing, has
been challenging. Conventional treatments, such as endoclips, electric cauterization,
argon plasma coagulation, radiofrequency ablation, and epinephrine injection, may
not be feasible or effective. Cleveland Clinic gastroenterologists reported the first case
in the literature using hypertonic glucose spray in radiation enteritis-associated diffuse
mucosal bleeding. The spray of hypertonic glucose (50% dextrose) was shown to be
safe and effective in controlling bleeding from diffuse radiation enteritis. Cleveland Clinic
gastroenterologists have also successfully used this technique as a single therapy or an
adjuvant therapy to treat bleeding associated with radiation proctitis, postendoscopic
dilation, Mallory-Weiss tears, and peptic ulcers.
Tian C, Mehta P, Shen B. Endoscopic therapy of bleeding from radiation enteritis with
hypertonic glucose spray. ACG Case Rep J. 2014;1(4):181-183.
Metabolomics Studies Identify Novel Prognostic Indicators in
Patients With End-Stage Liver Disease, Alcoholic Hepatitis
3-Month OLT-Free Survival
Sensitivity
1.0
0.8
0.6
0.4
AUC (95% CI)
MELD: 0.82 (0.69, 0.95)
Tyrosine: 0.91 (0.74, 1.0)
MELD & Tyrosine: 0.92 (0.76, 1.0)
0.2
0.0
0.0
0.2
0.4
0.6
0.8
1.0
1-Specificity
Sensitivity
1.0
0.8
0.6
0.4
AUC (95% CI)
citrulline & betaine: 0.84 (0.75, 0.98)
citrulline: 0.76 (0.61, 0.91)
betaine: 0.73 (0.59, 0.88)
0.2
0.0
0.0
Cleveland Clinic’s hepatology staff, in collaboration with the Department
of Cellular and Molecular Medicine, has developed a novel method
to evaluate prognosis of patients with liver cirrhosis awaiting liver
transplantation, as well as diagnosis of alcoholic hepatitis and the severity
of liver disease in these patients. They conducted a study using mass
spectrometry to identify and measure 29 metabolomics compounds in
plasma samples. Using various statistical analyses to compare clinical
characteristics and plasma levels of compounds among groups, the
research group evaluated the correlation between levels of compounds and
severity of liver disease. Specific plasma metabolomics compounds were
found to be associated with transplant-free survival in patients with liver
cirrhosis. Similarly, specific plasma metabolomics compounds were found
to be associated with the presence of alcoholic hepatitis and severity of
liver disease.
0.2
0.4
0.6
0.8
1.0
1-Specificity
Digestive Disease Institute
119
Innovations
Multidisciplinary Clinic Uses
Chromoendoscopy to Screen for
Anal Dysplasia
Cleveland Clinic staff representing colorectal
surgery, gastroenterology, and infectious
disease have formed a multidisciplinary clinic
to treat patients with anal dysplasia, a human
papillomavirus-associated premalignant condition
of the anal transitional zone and anal canal. The
team uses chromoendoscopy to detect lesions
that may become precancerous squamous
intraepithelial lesions. Abnormalities such as
punctuation (black arrow) and mosaicism (white
arrow) suggest that squamous intraepithelial
dysplasia may be present. These lesions are
biopsied and ablated endoscopically or surgically.
Transanal Total Mesorectal Excision Offers Less Invasive
Approach to Rectal Cancer
Surgical outcomes of rectal cancer are optimized by performance
of high-quality total mesorectal excision (TME) including tumor-free
circumferential radial margins (CRM)s. Thus far, despite evaluation
of data on hundreds of thousands of patients worldwide, there are
no significant differences in the quality of TME or tumor-free
status after CRMs among open, laparoscopic, and robotic
methods of surgery. To improve these outcomes, the Colorectal
Surgery Department at Cleveland Clinic Florida’s Digestive Disease
Center has started performing transanal TME. This “down to up”
technique offers the potential for a less invasive procedure with
ease of dissection in the most challenging cancer patients.
A two-team approach facilitates the procedure with an abdominal
team working concurrently with the pelvic team, potentially
allowing for shorter operative times. The lower pelvic dissection
is done transanally with improved visualization, which facilitates
a more complete TME and the potential for improved oncologic
outcomes. Increasing evidence demonstrates superior CRMs.
Evidence from peer-reviewed publications has shown that
transanal TME may be oncologically superior to all other
commonly employed methods.
Endoscopic Full-Thickness Resection
Reduces Complications
Endoscopic full-thickness resection (EFTR) reduces complications
in resection of colonic lesions that require advanced endoscopic
techniques. Currently, with few exceptions, gastroenterologists
refer large, benign, sessile colonic polyps to surgeons for segmental
colorectal resections. EFTR allows en bloc resection of polyps
and large intraluminal lesions, permitting precise pathological
assessments of resection. Digestive Disease Institute colorectal
surgeons successfully performed EFTR in more than 12 patients,
with insignificant complications. Initial experience proves that
EFTR is feasible and effective and can avoid unnecessary oncologic
segmental bowel resections.
120
Outcomes 2014
Fluorescent Cholangiography Provides Effective Alternative to Intraoperative Cholangiography
Despite the standardization of laparoscopic cholecystectomy, the rate of bile duct injury (BDI) has risen from 0.2% to
0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of
evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as
an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. Staff at
Cleveland Clinic Florida’s Digestive Disease Center prospectively collected the data of all patients undergoing laparoscopic
cholecystectomy. A total of 43 patients (21 males and 22 females) were analyzed during the study period. In this study, FC
was effective in delineating important anatomic structures. It required less time and expense than IOC and was perceived
by the surgeons to be easier to perform and at least as useful as IOC. Further prospective studies are warranted to evaluate
the effectiveness of FC in decreasing BDI.
Dip FD, Asbun D, Rosales-Velderrain A, Lo Menzo E, Simpfendorfer CH, Szomstein S, Rosenthal RJ. Cost analysis and
effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in
patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2014 Jun;28(6):1838-1843.
Gastric Bypass Effective Treatment for
Refractory Gastroparesis
Barbed Sutures Offer Effective Alternative to
Traditional Hiatal Hernia Repair
Cleveland Clinic staff conducted a study aimed at
presenting their experience with laparoscopic gastric
bypass and gastric electrical stimulation (GES) as a safe
and efficacious procedure for gastroparesis patients.
They retrospectively reviewed data from 72 medical
records between 2003 and 2013, using descriptive
analysis. Out of 72 patients, 68 patients underwent
either a gastric bypass or GES. As a newer application
of this technique, laparoscopic gastric bypass is a safe
treatment option in this patient population. GES can
also be safely employed to treat this cohort as previously
established in literature. Though 54% of the combined
group had symptom improvement in early follow-up,
longer-term studies and postoperative gastric emptying
studies are needed to objectively delineate efficacy of
these procedures.
Hiatal hernia repair (HHR) is considered a technically
challenging procedure in an anatomically difficult
location. The method of hiatal hernia closure has a
substantial impact on the course of postoperative
recovery. Cleveland Clinic Florida’s Digestive Disease
Center staff retrospectively reviewed the surgical
cases of patients who had undergone HHR using
unidirectional barbed sutures between January 2010
and December 2012. The researchers found that
adopting continuous unidirectional barbed sutures
provided a safe, efficient, and effective alternative to
traditional techniques. The findings warrant further
studies to establish the long-term efficacy of using
barbed sutures during laparoscopic HHR.
Digestive Disease Institute
121
Contact Information
Colorectal Surgery, Gastroenterology
and Hepatology, and General Surgery
Appointments/Referrals
800.223.2273, ext. 47000
Bariatric Surgery
Appointments/Referrals
Staff Listing
For a complete listing of Cleveland
Clinic’s Digestive Disease Institute
staff, please visit clevelandclinic.org/
staff.
216.445.2224 or
800.223.2273, ext. 52224
Breast Center
Appointments/Referrals
800.223.2273, ext. 43024
Publications
Digestive Disease Institute staff
authored 474 publications in 2014.
For a complete list, go to
clevelandclinic.org/outcomes.
Center for Human Nutrition
Appointments/Referrals
800.223.2273, ext. 43046
Cleveland Clinic Florida
Appointments
877.463.2010
On the Web at
clevelandclinic.org/digestive and
clevelandclinic.org/bariatric
122
Locations
For a complete listing of Digestive
Disease Institute locations, please visit
clevelandclinic.org/digestive.
Outcomes 2014
Additional Contact Information
General Patient Referral
24/7 hospital transfers or physician
consults
Global Patient Services/
International Center
Complimentary assistance for international
patients and families
800.553.5056
001.216.444.8184 or visit
clevelandclinic.org/gps
General Information
Medical Concierge
216.444.2200
Complimentary assistance for out-of-state
patients and families
Hospital Patient Information
216.444.2000
800.223.2273, ext. 55580, or
email [email protected]
General Patient Appointments
Cleveland Clinic Abu Dhabi
216.444.2273 or 800.223.2273
clevelandclinicabudhabi.ae
Referring Physician Center and Hotline
Cleveland Clinic Canada
855.REFER.123 (855.733.3712)
888.507.6885
Or email [email protected] or visit
clevelandclinic.org/refer123
Cleveland Clinic Florida
Request for Medical Records
866.293.7866
216.444.2640 or
800.223.2273, ext. 42640
Cleveland Clinic Nevada
Same-Day Appointments
For address corrections or changes,
please call
216.444.CARE (2273)
702.483.6000
800.890.2467
Digestive Disease Institute
123
About Cleveland Clinic
Overview
The Cleveland Clinic Model
Cleveland Clinic is an academic medical center offering
patient care services supported by research and education in
a nonprofit group practice setting. More than 3200 Cleveland
Clinic staff physicians and scientists in 130 medical
specialties and subspecialties care for more than 5.9 million
patients across the system, performing more than 192,000
surgeries and conducting more than 497,000 emergency
department visits. Patients come to Cleveland Clinic from all
50 states and more than 147 nations.
Cleveland Clinic was founded in 1921 by 4 physicians
who had served in World War I and hoped to replicate
the organizational efficiency of military medicine. The
organization has grown through the years by adhering to
the model set forth by the founders. All Cleveland Clinic
staff physicians receive a straight salary with no bonuses
or other financial incentives. The hospital and physicians
share a financial interest in controlling costs, and profits
are reinvested in research and education.
Cleveland Clinic is an integrated healthcare delivery
system with local, national, and international reach. The
main campus in midtown Cleveland, Ohio, has a 1400bed hospital, outpatient clinic, specialty institutes, labs,
classrooms, and research facilities in 42 buildings on 165
acres. Cleveland Clinic’s CMS case-mix index is the second
highest in the nation. Cleveland Clinic encompasses more
than 90 northern Ohio outpatient locations, including 18
full-service family health centers, 8 regional hospitals, an
affiliate hospital, and a rehabilitation hospital for children.
Cleveland Clinic also includes Cleveland Clinic Florida;
Cleveland Clinic Nevada, which includes the Lou Ruvo Center
for Brain Health in Las Vegas, and urology and nephrology
services; Cleveland Clinic Canada; and Sheikh Khalifa
Medical City (management contract). Cleveland Clinic Abu
Dhabi is a full-service hospital and outpatient center in the
United Arab Emirates (UAE), which began offering services in
spring 2015. Cleveland Clinic is the second-largest employer
in Ohio, with more than 42,500 employees. It generates
$12.6 billion of economic activity a year.
The Cleveland Clinic health system began to grow in
1987 with the founding of Cleveland Clinic Florida and
expanded in the 1990s with the development of 18
family health centers across Northeast Ohio. Fairview
Hospital, Hillcrest Hospital, and 6 other regional
hospitals have joined Cleveland Clinic over the past 2
decades, offering Cleveland Clinic institute services in
heart and neurological care, physical rehabilitation, and
more. Clinical and support services were reorganized
into 27 patient-centered institutes beginning in 2007.
Institutes combine medical and surgical specialists
for specific diseases or organ systems under unified
leadership and in a shared location to provide optimal
team care for every patient. Institutes work with the
Office of Patient Experience to give every patient the best
outcome and experience.
Cleveland Clinic Global Solutions supports physician
education, training and consulting, and patient services
around the world through offices in Canada, China, the
Dominican Republic, El Salvador, Guatemala, Honduras,
Panama, Peru, Saudi Arabia, Turkey, UAE, and the
United Kingdom.
124
A Clinically Integrated Network
Cleveland Clinic is committed to providing value-based
care, and it has grown the Cleveland Clinic Quality
Alliance into the nation’s second-largest and Northeast
Ohio’s largest clinically integrated network. The network
comprises more than 5400 physician members,
both employed and independent physicians from the
community. Led by its physician members, the Quality
Alliance strives to improve quality and consistency of
care; reduce costs and increase efficiency; and provide
access to expertise, data, and experience.
Outcomes 2014
Cleveland Clinic Lerner College of Medicine
Lerner College of Medicine is known for its small class sizes,
unique curriculum, and full-tuition scholarships for all students.
Each new class accepts 32 students who are preparing to
be physician investigators. Cleveland Clinic is building a
multidisciplinary Health Education Campus as the new home
of the Case Western Reserve University (CWRU) School of
Medicine and Cleveland Clinic’s Lerner College of Medicine,
as well as the CWRU School of Dental Medicine, the Frances
Payne Bolton School of Nursing, and physician assistant and
allied health training programs.
Graduate Medical Education
In 2014, nearly 1800 residents and fellows trained at
Cleveland Clinic and Cleveland Clinic Florida, which is part of a
continuing upward trend.
U.S. News & World Report Ranking
Cleveland Clinic is consistently ranked among the top hospitals
in America by U.S. News & World Report. It is ranked No. 1 in
urology and has ranked No. 1 in heart care and heart surgery
since 1995. In 2014, 4 of its programs were ranked No. 2 in
the nation: diabetes and endocrinology, gastroenterology and GI
surgery, nephrology, and rheumatology.
For more information about Cleveland Clinic, please visit
clevelandclinic.org.
Cleveland Clinic Physician Ratings
At Cleveland Clinic, we believe in transparency. We also believe
in the positive influence of the physician-patient relationship on
healthcare outcomes. To continue to meet the highest standards
of patient satisfaction, we now publish Cleveland Clinic
physician ratings, based on nationally recognized Press Ganey
patient satisfaction surveys, online at clevelandclinic.org/staff.
Digestive Disease Institute
125
Resources
Referring Physician Center and Hotline
Medical Records Online
Call 24/7 for access to medical services or to
schedule patient appointments: 855.REFER.123
(855.733.3712), email [email protected], or go to
clevelandclinic.org/Refer123. The free Cleveland Clinic
Physician Referral App, available for mobile devices,
gives you 1-click access. Available at the App Store
or Google Play.
Patients can view portions of their medical record, receive
diagnostic images and test results, make appointments, and
renew prescriptions through MyChart, a secure online portal.
All new Cleveland Clinic patients are automatically registered
for MyChart. clevelandclinic.org/mychart
Remote Consults
Anybody anywhere can get an online second opinion
from a Cleveland Clinic specialist through our MyConsult
service. For more information, go to clevelandclinic.
org/myconsult, email eclevelandclinic.org, or call
800.223.2273, ext. 43223.
Request Medical Records
216.444.2640 or 800.223.2273, ext. 42640
Track Your Patients’ Care Online
Cleveland Clinic offers an array of secure online services
that allow referring physicians to monitor their patients’
treatment while under Cleveland Clinic care, as well as
access test results, medications, and treatment plans.
my.clevelandclinic.org/online-services
DrConnect (online access to patients’ treatment progress
while under referred care): 877.224.7367; drconnect@
ccf.org
MyPractice Community (affordable electronic medical
records system for physicians in private practice):
866.320.4573
eRadiology (teleradiology consultation provided
nationwide by board-certified radiologists with specialty
training, within 24 hours or stat): 216.986.2915;
[email protected]
126
Critical Care Transport Worldwide
Cleveland Clinic’s fleet of ground and air transport vehicles
is ready to transfer patients at any level of acuity anywhere
on earth. Specially trained crews provide Cleveland Clinic
care protocols from first contact. To arrange a transfer for
STEMI (ST-elevation myocardial infarction), acute stroke, ICH
(intracerebral hemorrhage), SAH (subarachnoid hemorrhage),
or aortic syndrome, call 877.379.CODE (2633). For all other
critical care transfers, call 216.444.8302 or 800.553.5056.
CME Opportunities: Live and Online
Cleveland Clinic’s Center for Continuing Education operates
the largest CME program in the country. Live courses are
offered in Cleveland and cities around the nation and the
world. The center’s website (ccfcme.org) is an educational
resource for healthcare providers and the public. It has a
calendar of upcoming courses, online programs on topics
in 30 areas, and the award-winning virtual textbook of
medicine, The Disease Management Project.
Clinical Trials
Cleveland Clinic is running more than 2100 clinical trials
at any given time for conditions including breast and liver
cancer, coronary artery disease, heart failure, epilepsy,
Parkinson disease, chronic obstructive pulmonary disease,
asthma, high blood pressure, diabetes, depression, and
eating disorders. Cancer Clinical Trials is a mobile app that
provides information on the more than 100 active clinical
trials available to cancer patients at Cleveland Clinic.
clevelandclinic.org/cancertrialapp.
Outcomes 2014
Healthcare Executive Education
Cleveland Clinic has programs to teach people
from outside the organization how it operates
a major medical center. The Executive Visitors’
Program is an intensive 3-day behind-the-scenes
view of the Cleveland Clinic organization for the
busy executive. The Samson Global Leadership
Academy is a 2-week immersion in challenges
of leadership, management, and innovation
taught by Cleveland Clinic leaders,
administrators, and clinicians. Curriculum
includes coaching and a personalized 3-year
leadership development plan. Learn more at
clevelandclinic.org/executiveeducation.
Consult QD Physician Blog
A singular blog for physicians and healthcare
professionals from Cleveland Clinic. Discover the
latest research insights, innovations, treatment
trends, and more for all specialties. Join the
conversation: consultqd.clevelandclinic.org.
Social Media
Cleveland Clinic uses social media to help
caregivers everywhere provide better patient
care. Millions of people currently like, friend, or
link to Cleveland Clinic social media — including
leaders in medicine.
Facebook for Medical Professionals
facebook.com/CMEclevelandclinic
Follow us on Twitter
@cleclinicMD
Connect with us on LinkedIn
Clevelandclinic.org/Mdlinkedin
Digestive Disease Institute
127
Notes
Measuring Outcomes Promotes Quality Improvement
This project would not have been possible without
the commitment and expertise of a team led by
Laura Buccini, DrPH, MPH; and Charmaine Jones, MBA.
Graphic design and photography were provided by
Cleveland Clinic’s Center for Medical Art and Photography.
© The Cleveland Clinic Foundation 2015
Digestive Disease Institute
9500 Euclid Avenue, Cleveland, OH 44195
clevelandclinic.org
15-OUT-340
2014
Outcomes