Digestive Disease Institute by mikesanye



Digestive Disease Institute
Institute Overview

Surgical Overview
                              To promote quality improvement, Cleveland Clinic has created a series of
                              Outcomes books similar to this one for many of its institutes. Designed for a
                              physician audience, the Outcomes books contain a summary of our surgical and
                              medical trends and approaches, data on patient volume and outcomes, and a
                              review of new technologies and innovations.

                              Although we are unable to report all outcomes for all treatments provided at
                              Cleveland Clinic — omission of outcomes for a particular treatment does not
                              mean we necessarily do not offer that treatment — our goal is to increase

                              unavailable, we often report process measures associated with improved
                              outcomes. When process measures are unavailable, we may report volume
                              measures; a volume/outcome relationship has been demonstrated for many
                              treatments, particularly those involving surgical techniques.

                              In addition to our internal efforts to measure clinical quality, Cleveland Clinic
                              supports transparent public reporting of healthcare quality data and participates
                              in the following public reporting initiatives:



                              Our commitment to providing accurate, timely information about patient care will
                              also help patients and referring physicians make informed healthcare decisions.


Digestive Disease Institute                                                                                       1
    Dear Colleague,

    On behalf of Cleveland Clinic, I am pleased
    to present our 2008 Outcomes books. The
    primary purpose of our annual Outcomes
    book initiative is to promote quality
    improvement at Cleveland Clinic, thereby
    optimizing the care we provide to our

    accountability, transparency and results.

    requiring hospitals to report more and more
    quality and patient safety data. We view our
    Outcomes books as voluntary supplements
    to the required public reporting and an
    opportunity to share selected innovations
    with colleagues across the country.

    Designed for the physician reader, each
    book in the annual series focuses on care
    provided by one of our patient-centered

    content informative.

2                                       Outcomes 2008
                                            what’s inside

                              Institute Overview              05

                              Quality and Outcomes Measures

                                 Anorectal Disease            06

                                 Esophageal Cancer            28

                                 Nursing Quality              29

                              Contact Information             50

                              Cleveland Clinic Overview       52

Digestive Disease Institute                                        3
Chairman’s Letter

Thank you for your interest in the Cleveland Clinic Digestive Disease Institute (DDI) 2008 Outcomes. This is the seventh year
that we have shared our clinical outcomes and advanced technology with referring physicians, alumni, potential patients and
other individuals interested in digestive diseases around the country.

includes the liver transplant team, nutrition therapy, nutrition support,
intestinal rehabilitation and transplant nutrition, and upper gastrointestinal
surgery – along with the former Digestive Disease Center’s departments of
colorectal surgery and gastroenterology and hepatology.

reorganization as this close-knit team of healthcare providers draws on each

across the nation and from around the world. The institute is the largest
national referral center for repairing failed pelvic pouches and houses

and treatment of digestive diseases, which you can read about in
the pages that follow. It was also the year that

who I have mentored for many years here at Cleveland
Clinic, will carry on the department’s reputation of both
quality and compassion.

Digestive Disease Outcomes useful both as a reference as well
as a testimony to our commitment to continuously raise the
standards of our patient-centered care.

Chairman, Digestive Disease Institute

4                                                                                                                 Outcomes 2008
Institute Overview

                                                                                           2008 Statistics
                                                                                           Patient Days
                                                                                           Average Length of Stay
                                                                                           Total Visits
                                                                                           Surgical Cases
                                                                                           Endoscopic Cases

and hepatology, colorectal surgery, hepato-pancreato-biliary and transplant surgery, and
nutrition within one unique, fully integrated model of care – aimed at optimizing the

treatments performed in the most effective and patient-friendly way, including shorter
waits for appointments and more seamless interaction with all of our specialists. In
addition, our institute model enhances opportunities for cutting-edge research and
physician education.

U.S.News & World Report’s

Digestive Disease Institute                                                                                         5
 Anorectal Disease
Surgical Overview

                Diseases We Treat                         Techniques We Use
                •	Anal	Cancer	                            •	Combined	Modality	Therapy	for		
                                                          	 Anal	Cancer
                •	Polyps	
                                                          •	Transanal	Excision	and	TEM
                •	Abscess	
                                                          •	Fistula	Plug
                •	Fistula
                                                          •	Advancement	Flaps
                •	Fissure	
                                                          •	Seton	Insertion
                •	Hemorrhoids
                                                          •	Episioproctomy
                •	Pruritis	Ani
                                                          •	Sphincterotomy
                •	Bowen’s	Disease	
                                                          •	Botox	Injection
                •	Paget’s	Disease	
                                                          •	Stapled,	Doppler-Guided,	and		
                •	Anal	Intraepithelial	Neoplasia	
                                                          	 Conventional	Hemorrhoidectomy
                                                          •	High-Resolution	Anoscopy

                 Cleveland	Clinic’s	Digestive	Disease	Institute	offers	patients	all	available	techniques	
                 to	treat	hemorrhoids—from	banding	to	hemorrhoidal	arterial	ligation	to	staple	and	
                 conventional	surgical	techniques	proven	to	provide	good	outcomes.
                 Procedure Volumes and Percent Recurrence (1 year) for Treatment of Hemorrhoids
                      Volume                                                                Recurrence (%)
                  200                                                                                        4

                  150                                                                                        3

                  100                                                                                        2

                     50                                                                                      1

                      0                                                                                      0
                            Hemorrhoidal Hemorrhoidal          Stapled         Excisional
                              Banding    arterial ligation hemorrhoidectomy hemorrhoidectomy

6                                                                                                 Outcomes 2008
Anal Fistula and Rectovaginal Fistula           Procedure Volumes and Percent Recurrence (1 year) for Treatment of Anal
                                                and Rectovaginal Fistula
operative techniques that are determined
by the etiology and precise anatomy of                Volume                                              Recurrence (%)
                                                80                                                                        60
plug and other cutting edge treatments in
                                                60                                                                        45
the result of failed prior attempts at cures,
                                                40                                                                        30

                                                20                                                                        15
In many cases, despite the challenges of
                                                  0                                                                       0
                                                        Fistulotomy Fistulectomy  Anal and      Rectovaginal
                                                                      Complex    Rectovaginal Fistula Complex

Anal Fissures
                                                Procedure Volumes and Percent Recurrence (1 year) for Treatment of
60 percent when treated conservatively.         Anal Fissures
Cleveland Clinic’s Digestive Disease
Institute offers minimally invasive                    Volume                                        Recurrence (%)
and traditional surgical options to              80                                                                  16
increase healing rates in patients whose
                                                 60                                                                  12
treatment or have failed therapy at other
institutions. Careful patient selection          40                                                                  8
and a focus on changing bowel habits
can decrease the chances of recurrence.          20                                                                  4

                                                  0                                                                  0
                                                         Fissurectomy     Botox injection   Lateral internal

Digestive Disease Institute                                                                                                   7
Constipation, Rectal Prolapse, Fecal Incontinence


patients and their physicians. In 2008, we performed nearly 60 surgical procedures to treat
the different causes of severe constipation. The two most commonly performed procedures,

Constipation Patients with Symptom Improvements as a Result of Surgery (N = 60)
Percent Improvement




          Abdominal Colectomy IRA           Stoma
                       Surgical Procedure

specialized surgical procedure that preserves the colon and is used in select cases of severe

Constipation - Comparison of Pre- and Post Op Patients following ACE Procedure (N = 9)
Occurrences per Week



          Bowel      Laxatives      Retrograde          Fecal    Abdominal Pain
        Movements                    Enemas         Incontinence   (Episodes)

8                                                                                               Outcomes 2008
                              Rectal Prolapse
                              In 2007 through 2008, we performed 31 surgical procedures for rectal prolapse including
                              14 perineal procedures and 17 abdominal procedures. A laparoscopic approach was used
                              for the majority of the abdominal procedures. More than 80 percent of patients experienced
                              symptomatic improvement. At one year follow-up, 100 percent and 86 percent of patients
                              who underwent abdominal and perineal procedures respectively were free of recurrent prolapse.
                              Fecal Incontinence
                              Overlapping sphincteroplasty was used to treat fecal incontinence in 61 patients in 2007 and
                              2008. More than 80 percent of patients improved control following sphincteroplasty. Quality of
                              life related to control of bowel movements also was markedly improved after sphincteroplasty.
                              (Charts below)

                              FIQL: Comparison Between Pre- and Post-Sphincteroplasty (N = 61)
                              2007 – 2008
                               80                                                                            Worse


                                       Lifestyle Score   Coping/Behavior        Depression   Embarrassment
                                                                  FIQL scales
                              FIQL: Fecal Incontinence Quality of Life - Improvement noted in all domains

                              SF-12: Comparison Between Pre- and Post-Sphincteroplasty (N = 61)
                              2007 – 2008
                              60                                           Worse


                                          SF-12 scores

Digestive Disease Institute                                                                                               9
 Colon and Rectal Cancer

                   Cleveland Clinic’s Digestive Disease Institute is a leader in both prevention and
                   treatment of colon and rectal polyps and cancer. Using a multidisciplinary approach
                   Digestive Disease Institute provides world-class care through patient screening,
                   education, detection, and treatment.

                   Effect of Time of Colonoscopy on Adenoma Detection Rate (N = 3,619)
                   Percent Rate



                                         Adenoma Detection

                   A recent study from the Institute provided information that could lead to an

                   in 2006 at Cleveland Clinic. Detecting at least one adenoma was considered a
                   positive colonoscopy. Colonoscopies performed in the morning had a higher rate of
                   adenoma detection than those performed in the afternoon. The adenoma detection

                   group (p = 0.008). This study accounted for variability in bowel preparation and

                   p = 0.006]. This information has led to further studies as to why this phenomenon
                   was observed and how the detection rate may be improved.

10                                                                                         Outcomes 2008
5-Year Survival Curves (Kaplan-Meier) for Colon Cancer by Stage
Proportion DFS Survival


                                                         92.7%, Stage 1, N = 694
0.4                                                      79.7%, Stage 2, N = 982
                                                         60.5%, Stage 3, N = 823
0.2                                                      6.3%, Stage 4, N = 572

      0          10           20      30       40   50      60
                              Months from Surgery

Treating colon and rectal cancer is often a multimodal approach with surgery as the
cornerstone of care. The Cleveland Clinic’s Digestive Disease Institute treats one of
the highest volumes of colorectal cancer patients in the country. Institute surgeons

Digestive Disease Institute                                                             11
 Colon and Rectal Cancer

 Rectal Cancer
 Colostomy avoidance is one goal of rectal cancer surgery. Digestive Disease Institute colorectal surgeons were able to avoid a
 permanent colostomy in 67 percent, despite the complex presentation of many of our rectal cancer patients.

 Types of Surgery Performed for Rectal Cancer:

 Procedures (%)                     2001       2002      2003          2004            2005     2006   2007      2008
 Sphincter saving procedure          52          66        66               64          58       67     66        57
 Resection and Colostomy             23          25        20               22          28       25     22        33
 Local excision/treatment            14           8        12               12              9     9     12          8
 Other Treatments                      1          1           2             2               5     0      0          2

 5-Year Survival Curves (Kaplan-Meier) for Rectal Cancer by Stage
 Proportion DFS Survival


                                                      83.4%,   Stage   1,   N   =   1,176
 0.4                                                  70.6%,   Stage   2,   N   =   644
                                                      55.5%,   Stage   3,   N   =   881
 0.2                                                  8.5%,    Stage   4,   N   =   390

         0   10      20       30       40        50      60
                    Months from Surgery

12                                                                                                                   Outcomes 2008
 Rectal Cancer Recurrence Rates
 Optimal surgery combined with proper use of chemotherapy and radiation resulted in low rates of local recurrence for rectal
 cancer patients. In 2008, the local recurrence rate for rectal cancer was less than 1 percent, 3 percent and 4 percent for
 upper, middle, and low rectal cancers respectively.
 Recal Cancer Recurrence Rate




            Upper Third       Middle Third    Lower Third

                              Rectal Cancer

 Laparoscopic Surgery in the Treatment of Colorectal Cancer
 Laparoscopic surgery for colorectal cancer was shown to result in cancer-related outcomes similar to those of traditional open
 surgery. Advantages of the laparoscopic approach include decreased hospital stay, decreased pain and more rapid recovery.
 In 2008, approximately 50 percent of colorectal cancer operations were performed by laparoscopic approach.

 Comparison on Median Length of Stay for Colorectal Cancer – Laparoscopic vs. Open

 Open Surgery                                          N       Median LOS
 Partial Colectomy                                    89            6
 Anterior Resection                                   83            7
 Total                                               172            7
 Laparoscopic Surgery
 Partial Colectomy                                   127            4
 Anterior Resection                                   15            5
 Total                                               142            5
 LOS: Length of stay after surgery

Digestive Disease Institute                                                                                                    13
 Colon and Rectal Cancer

Colorectal Cancer in the Elderly

often have associated medical comorbidities that affect their ability to tolerate surgery

rectal cancer, stage-for-stage.

5-Year Disease-Free Survival for Stage I-III Colon Cancer by Age
 Proportion DFS Survival


                                                >75, N = 861


         0   10       20          30    40       50       60
                      Months from Surgery

14                                                                                          Outcomes 2008
                              Jagelman Registries

                              Center is composed of physicians, researchers and nurses from several institutes including the

                              to provide outstanding clinical care, education to caregivers, patients and families, and to
                              research hereditary colorectal cancer.

                              Jagelman Registry Numbers

                               2% Hyperplastic Polyposis (17)
                                                                   2% MYH-associated Polyposis (13)
                                    3% Peutz-Jehgers (27)
                              4% Juvenile Polyposis (34)

                                                                                  89% Familial Adenoma Polyposis (754)

Digestive Disease Institute                                                                                                    15
 Colon and Rectal Cancer

                  Effect of Chemoprevention on Familial Adenoma Polyposis
                  A 2008 Digestive Disease Institute study evaluated the effect of chemoprevention on
                  the rate of rectal cancer and proctectomy in 290 patients with familial adenomatous

                  receiving chemoprevention were less likely to undergo proctectomy, develop rectal
                  cancer, or die from their disease.

                                           No Chemoprevention (CP)       Chemoprevention (CP)

                  Proportion Without Cancer or Proctectomy
                                                                                 No CP
                  0.8                                                            CP
                                                                             p <0.0001



                        0    6      12      18     24      30     36      42
                                         Years since IRA

16                                                                                          Outcomes 2008
Diverticular Disease

surgery. A further cohort is referred for reconstructive surgery, having had an emergency procedure performed elsewhere.

Diverticular Operations - Volumes and Length of Stay

                                                  N           Median Length of Stay

Complications of Primary Resection and Anastomosis vs. Hartmann Reversal Procedure
                                   Primary Resection / Anastomosis n (%)         Hartmann Reveral n (%)          P-value

associated with a higher prevalence of surgical or medical complications compared with primary resection and anastomosis.

postoperative period. Our results add emphasis to importance of timely and appropriate surgery for sigmoid diverticulitis so a

Digestive Disease Institute                                                                                                  17
Patients Who Underwent Repeat Pouch Surgery to Salvage a Failed Pouch and Avoid Permanent Ileostomy.

Variable                                       Abdominal Repeat Pouch              Primary IPAA Group             P-value
                                                   Surgery Group

IPAA: ileal pouch-anal anastomosis

In 2008, we continued our tradition of providing the highest level of care to patients with Crohn’s disease, ulcerative colitis

18                                                                                                                    Outcomes 2008
Ileoanal Pouch for Crohn’s Disease Patients

Diagnosis of Crohn’s Disease (CD) in Patients with Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis. (N = 204)


Post-Operative Outcomes in Patients with Intentional or Incidental Pouch with Crohn’s Disease Versus
Delayed Diagnosis of Crohn’s Disease.

Outcome                            Overall            Intentional or      Delayed CD           P-value
                                                        Incidental         diagnosis
                                                        CD Pouch

Digestive Disease Institute                                                                                            19
 Inflammatory Bowel Disease

Infliximab (Remicade) Use Increased Frequency of Complications in Patients with Both Crohn’s Disease and
Ulcerative Colitis
A recent study performed by Digestive Disease Institute colorectal surgeons suggests that the surgical approach to ulcerative
colitis may require modifications in ulcerative colitis patients treated with infliximab.
                                                          Infliximab             Non-Infliximab              P-value
Sepsis                                                    10 (22%)                   1 (2%)                   0.016
Leak                                                       8 (17%)                   1 (2%)                   0.023
Overall early postoperative complication                  16 (35%)                   7 (15%)                  0.027
Pouchitis                                                 18 (39%)                   7 (15%)                  0.037
Stricture                                                  5 (11%)                   9 (20%)                   0.39
SBO                                                       3 (6.5%)                 6 (13.0%)                   0.45
Overall late postoperative complication                   24 (52%)                  17 (37%)                   0.23

The increased incidence of septic complications in ulcerative colitis patients treated with infliximab has resulted in increased
use of three stage pouch procedures in this patient population with the aim of decreased post-operative complications.

Inflammatory Bowel Disease Complications and Functional Results After Ileoanal Pouch Formation in
Obese Patients
1983 – 2007

Ileoanal pouch formation (IPAA) can be technically challenging in obese patients, and there is little data evaluating results
after the procedure in these patients. We compared outcomes for patients with a body mass index (BMI) 30 or more
undergoing IPAA when compared with those for patients with BMI less than 30.
                                                            Obese                    Not obese                    P-value
N                                                            345                       1671
Pelvic Sepsis                                                6.7%                      5.3%                       NS
Pouch Failure                                                  6%                      4.5%                       NS
Wound Infection                                              19%                       8.1%                       P<.05
Anastomotic Leak                                             10%                          5%                      p<.05
Long-term outcome including QOL and function after 15 years was comparable between groups. CONCLUSIONS: Although
technically demanding, IPAA can be undertaken in obese patients with acceptable morbidity. Good long-term functional
results and QOL that is comparable to nonobese patients may be anticipated.

20                                                                                                                     Outcomes 2008
Short and Long-Term Morbidity of Ileal Pouch Anal Anastomosis
(IPAA) Surgery
We recently reported outcomes for all patients who underwent primary

patients who underwent the procedure at a different center before being

Surgical Technique for IPAA (N = 3,080)

Early (30-day) Post-Operative Complications of IPAA (N = 3,080)

Digestive Disease Institute                                               21
Ileal Pouch Failure Model

 Pr (pouch failure)

 0.2                                                          score as calculated by the Weibull survival

     0                                                        probabilities are shown (orange circles).
         0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6          6.5
                            CCF-IPF score

Total Morbidity for Crohn’s Disease (N = 2,212)

Year             Volume           30 Day            30 Day          Abdominal           Obstruction          Anast.
                                Mortality (%)   Readmission (%)    Abscess (%)          or Ileus (%)        Leak (%)

22                                                                                                                 Outcomes 2008
Rare or No Incontinence




                BL            1 yr        5 yrs   15 yrs
                              Time Post Surgery

Bowel Movements: Frequency

and about one to two times at night. These results were much better
than prior to surgery.

Digestive Disease Institute                                           23
Cleveland Clinic Quality of Life Score
 Mean QOL Score




           BL         1 yr       5 yrs     15 yrs
                     Time Post Surgery

Continent Ileostomy
Continent ileostomy is an option in patients in whom an ileal pouch surgery is not possible or in whom the initial and
subsequent repeat ileoanal pouch surgery failed and the patient is reluctant to accept a permanent ileostomy. Continent
ileostomy, or Kock pouch, is constructed by three loops of small bowel and a one-way valve, which allows patients to avoid
wearing an outer appliance. One has to cannulate the Kock pouch three or four times a day to empty itself. Cleveland Clinic

Complications                               # of Patients                  %

Koch Pouch Status                           # of Patients                  %

24                                                                                                                Outcomes 2008
Liver Disease

 Liver Transplantation

 the liver transplant program we have maintained graft and patient
 survival above the national average.

 Liver Transplant Volume




               2004           2005   2006   2007    2008


Digestive Disease Institute                                          25
 Liver Disease

                 Liver Transplant Patient Survival
                 (Includes Liver/Heart, Liver/Kidney Liver/Lung and Liver/Pancreas)
                 2004 – 2008
                 Percent Survival

                                                                All Patients



                       0            6           12            18               24

                 Survival Analysis: Patient survival for 587 primary liver, liver/heart,
                 liver/kidney, liver/lung and liver/pancreas transplants 2004-2008

                 Liver Transplant Graft Survival
                 (Includes Liver/Heart, Liver/Kidney Liver/Lung and Liver/Pancreas)
                 2004 – 2008
                 Percent Survival

                                                                All Patients



                       0            6           12            18               24

                 Survival Analysis: Liver graft survival for 587 primary liver, liver/heart,
                 liver/kidney, liver/lung and liver/pancreas transplants 2004-2008

26                                                                                  Outcomes 2008
Intestinal Rehabilitation and Transplant Program

the Country. 2008 was a very productive year for the Intestinal

Intestinal Transplant in Ohio.

reconstructive surgery or transplantation.

A lesser percentage of referred patients were readmitted with

lesser percentage of referred patients were discharged from the

Digestive Disease Institute                                       27
 Esophageal Cancer

Early Esophageal Cancer in High-Risk Patients

measured by histologic response rate and cancer-free survival at Cleveland Clinic’s Digestive Disease Institute between

patients with complete response had recurrence of dysplasia or cancer in the gastric cardia.

year follow-up.

Probability of Cancer Free Survival
        Proportion Cancer Free



       0.4                                                                Upper and Lower
                                                                          Confidence Intervals
       0.2                                                                Cancer-free Survival
 Post-CSA 0       3       6      9    12          18           24
 N at Risk 31     31      27     22   22          14           10
                       September 2005 – September 2008

28                                                                                                                 Outcomes 2008
Nursing Quality

Inpatient Nursing Risk Assessment Improvement


                                                         Assess Skin on Admit
    80                                                   Braden on Admit
                                                         Daily Braden Done
                                                         WOSCN position

                   2005            2006           2007             2008

Results of 2008 WOSCN Survey: All Peers
                                                                                Peer Evaluation Averages

       Support of Bedside Nurse

    Overall Quality of Skin Care

         Nurse: MD Collaboration

 Overall Quality of Patient Care

                                   0      1   2      3       4      5      6     7       8      9      10

Digestive Disease Institute                                                                                 29
 Surgical Quality Improvement

Hospital Compare: Surgical Care Improvement Project (SCIP)

data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also

SCIP - Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision (N = 902)

 Average*                                                                     86

    Clinic                                                                            95

             0              20              40              60               80            100
                                           Percent of Patients
             * Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

30                                                                                                                Outcomes 2008
SCIP - Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time (N = 813)



               0              20              40              60               80             100
                                             Percent of Patients
               * Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

SCIP - Prophylactic Antibiotic Selection for Surgical Patients (N = 937)

Average*                                                                                92

    Clinic                                                                               95

               0              20              40              60               80             100
                                             Percent of Patients
               * Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

Digestive Disease Institute                                                                         31
 Surgical Quality Improvement

SCIP - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (N = 677)



             0              20              40              60               80            100
                                           Percent of Patients
             * Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

SCIP - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis
within 24 Hours Prior to Surgery to 24 Hours After Surgery (N = 677)

 Average*                                                                 81

    Clinic                                                                            95

             0              20              40              60               80            100
                                           Percent of Patients
             * Source: www.hospitalcompare.hhs.gov, discharges July 2007- June 2008

32                                                                                               Outcomes 2008
SCIP - Surgery Patients with Appropriate Hair Removal (N = 1,386)

Average*                                                                               95

    Clinic                                                                             94

               0              20              40               60              80           100
                                             Percent of Patients
               * Source: www.hospitalcompare.hhs.gov, discharges January - June 2008

Digestive Disease Institute                                                                       33
 Surgical Quality Improvement

National Surgical Quality Improvement Project - Colorectal Surgery (N = 261)




              30-Day               30-Day           Length of Stay*   Surgical Site
              Mortality            Morbidity          (N = 186)        Infection

      *Length of stay for patients without complications

morbidity outcomes and length-of-stay data are reported. Cleveland Clinic’s most

34                                                                                    Outcomes 2008
Leapfrog Survey - Pancreatic Resection

    One bar = willing to report data
    Two bars = some progress
    Three bars = substantial progress

mistakes and improve the quality and affordability of

pancreatic resection rating appears above.


Digestive Disease Institute                             35
 Patient Experience

Cleveland Clinic has placed a renewed emphasis on improving the patient

that patients seek more than solely a successful clinical outcome, the mission

the well-being of our patients, families and employees in a way that elevates
Cleveland Clinic’s reputation as one of the world’s best hospitals.

institutes to research and implement innovative patient- and family-based
programs that support this mission.

Outpatient – Digestive Diseases Institute

Overall Rating of Outpatient Care and Services

                                                                             2007 (N = 2,403)
                                                                             2008 (N = 2,591)




                Excellent          Very Good              Good            Fair          Poor

     Source: Quality Data Management, a national hospital survey vendor

36                                                                                              Outcomes 2008
Rating of Outpatient Provider

                                                                                2007 (N = 2,403)
                                                                                2008 (N = 2,591)




              Excellent         Very Good              Good              Fair             Poor

  Source: Quality Data Management, a national hospital survey vendor

Recommend Outpatient Provider

                                                                            2007 (N = 2,403)
                                                                            2008 (N = 2,591)




             Extremely          Very Likely         Somewhat           Somewhat           Very
               Likely                                 Likely            Unlikely         Unlikely
  Source: Quality Data Management, a national hospital survey vendor

Digestive Disease Institute                                                                         37
 Patient Experience

Inpatient – Digestive Diseases Institute

reporting are available at www.hospitalcompare.hhs.gov.

HCAHPS Overall Assessment

 100                                                          2007 total survey respondents = 787
                                                              2008 total survey respondents = 1,081
     80                                                                     73%          73%
                         61%           61%



                           Rate Hospital                                  Would Recommend
                         % respondents                                 % respondents choosing
                        choosing 9 or 10                                    'definitely yes'

     Source: Quality Data Management and Press Ganey, national hospital survey vendors

     For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to
     account for a survey mode administration change as recommended by CMS.

38                                                                                                    Outcomes 2008
HCAHPS Domains of Care

                                                        Respondents choosing 'always' or 'yes'
                                                                                                 2007 total survey respondents = 781
  80                                                                                             2008 total survey respondents = 1,081




             Discharge           Doctor          Nurse             Pain                Room     Communication Responsiveness       Quiet at
            Information       Communication   Communication     Management             Clean    New Medications  to Needs           Night

   Source: Quality Data Management and Press Ganey, national hospital survey vendors

   For comparison purposes, 2007 and Q1 2008 HCAHPS scores have been adjusted to account for a survey mode administration change
   as recommended by CMS.

Digestive Disease Institute                                                                                                                   39

Endoscopic Cryospray Ablation

less than one minute thaw time between applications.

same vicinity treated by endoscopic mucosectomy or argon plasma coagulation.

crycopharyngeal location (one stricture requiring temporary naso-enteric tube feeding and dilations, one stricture treated

palliation gastrostomy or pharyngolaryngectomy. Two patients averted radiation therapy. One patient died of metastatic
disease after a clinical response of the esophageal lesion and improvement in dysphagia. One patient with a crycopharyngeal

40                                                                                                                  Outcomes 2008
                                    Example of patient with invasive squamous cell
                                    cancer at the cricopharyngeus facing laryngectomy
                                    as an alternative to cryotherapy. By treating
                                    this early cancer with cryotherapy, the patient
                                    maintains ability to speak and swallow.


During procedure                    Post-procedure

Minimally Invasive/Robotic Liver and Pancreas Surgery Program
Minimally invasive techniques have been proven to benefit patients by decreasing length of
hospital stay and time required to return to full activities. The surgical robot has allowed
surgeons at DDI to expand minimally invasive surgery to the areas of liver and pancreas.
The surgical robot incorporates 3D visualization with articulating instrumentation to give
surgeons the dexterity of conventional open surgery while maintaining the benefits of the
minimally invasive approach.

Digestive Disease Institute                                                                    41
Selected Publications

200 Publications
Digestive Disease Institute staff authored more than   bowel disease genetics. Curr Opin Gastroenterol. 2008


                                                       associated with adverse postoperative outcomes in Crohn’s
                                                       patients. J Gastrointest Surg

                                                       technology to promote gastrointestinal outcomes research: a
                                                       case for electronic health records. Am J Gastroenterol. 2008

                                                       report of a rare indication for liver transplantation. Liver

                                                       measurements improve the management of portosystemic
                                                       shunts during liver transplantation. Liver Transpl. 2008

                                                       colitis are attenuated in the absence of signal transducer
                                                                                         Am J Pathol. 2008

42                                                                                                           Outcomes 2008
and morbidity in patients with chronic intestinal failure including those
who are referred for small bowel transplantation. Transplantation. 2008

polyposis. Clin Gastroenterol Hepatol

and distal splenorenal shunt. J Hepatol

                                              J Endourol. 2008

of fatty liver and disease progression to steatohepatitis: implications for
treatment. Am J Gastroenterol

ed. Current Surgical Therapy

staging system separates patients with intra-abdominal, familial
adenomatous polyposis-associated desmoid disease by behavior
and prognosis. Dis Colon Rectum

sword has two edges. Dis Colon Rectum

Digestive Disease Institute                                                   43
 Selected Publications

what have we learned? A collection of perspectives and
panel discussion. Cleve Clin J Med                                for serrated colorectal cancer, selectively represses beta-
                                                                  catenin-dependent transcription. Oncogene. 2008 Oct

between donor-recipient serum sodium differences and
orthotopic liver transplant graft function. Liver Transpl. 2008   Colorectal Dis

                                                                  of metabolic syndrome in the setting of recurrent
                                                                  hepatitis C after liver transplantation. Liver Transpl. 2008
cost. Dis Colon Rectum

                                                                  On-treatment prediction of response to peginterferon/
                                                                  ribavirin therapy. Liver Transpl
for screening and surveillance of esophageal varices in
patients with portal hypertension. Hepatology. 2008

                                                                  of metabolic syndrome in the setting of recurrent
colon and rectal surgery. Clin Colon Rectal Surg. 2008            hepatitis C after liver transplantation. Liver Transpl. 2008

                                                                  liver transplantation. J Hepatobiliary Pancreat Surg.
techniques. Endoscopy

                                           Endoscopy. 2008
                                                                  Female Urology

Impact of orthotopic liver transplant for primary sclerosing
cholangitis on chronic antibiotic refractory pouchitis. Clin      lymphoproliferative disorders after liver transplantation in
Gastroenterol Hepatol                                             relation to age and duration of follow-up. Liver Transpl. 2008

44                                                                                                                    Outcomes 2008

manner. Transplantation
                                                             patterns of use and effects on liver function. Am
                                                             J Gastroenterol

Colon Rectal Surg
                                                             Incidental reduction in the size of liver hemangioma following
Kelley DE. Estimates of hepatic glyceroneogenesis in                                                J Hepatol. 2008
type 2 diabetes mellitus in humans. Metabolism. 2008

                                                             pathology. Dis Colon Rectum
Dis Colon Rectum

                                                                                             Med Clin North Am. 2008

results after ileoanal pouch formation in obese patients.
J Gastrointest Surg

case in an unusual location. Tech Coloproctol. 2008          of clinical outcomes in primary biliary cirrhosis by
                                                                                                   Hepatology. 2008

                                         Nat Clin Pract
Gastroenterol Hepatol
                                                             ileal pouch-anal anastomosis and Crohn’s disease: pouch
                                                             retention and implications of delayed diagnosis. Ann Surg.

ulcerative colitis: a randomized placebo-controlled trial.
Gastroenterology                                             with living liver donation. Transplant Rev (Orlando).

Digestive Disease Institute                                                                                               45
 Selected Publications

                                                                Adv Exp Med Biol

Neurogastroenterol Motil

                                                                of meperidine and midazolam during endoscopy. Clin
                                                                Gastroenterol Hepatol
with an increased risk of postoperative complications after
restorative proctocolectomy. Dis Colon Rectum. 2008

                                                                is portal hyperperfusion, not arterial siphon. Liver Transpl.
after ileal pouch surgery for ulcerative colitis. Endoscopy.

                                                                Will it ever yield grafts for two adults? Liver Transpl. 2008

the early postoperative period with noninvasive indocyanine
green elimination following orthotopic liver transplantation.
                                                                laparoscopy in colorectal surgery. Colorectal Dis. 2008
Liver Transpl

methylationalterations in endoscopic retrograde
                                                                disease: progress in basic and clinical science. Curr Opin
cholangiopancreatography brush samples of patients with
suspected pancreaticobiliary disease. Clin Gastroenterol

                                                                all responsible. Dis Colon Rectum

spontaneous bacterial peritonitis. Gastroenterology. 2008

                                                                associated complications after restorative proctocolectomy.
                                                                Clin Gastroenterol Hepatol

cholangiopancreatography and pancreatic function test
in suspected chronic pancreatitis and negative cross-
sectional imaging. Clin Gastroenterol Hepatol. 2008

46                                                                                                                  Outcomes 2008
pouch failure in patients with different phenotypes of             of a steroid-free regimen with thymoglobulin induction in
Crohn’s disease of the pouch.                     . 2008           pancreas-kidney transplantation. Transplant Proc. 2008

                                                                   mucosa in cirrhosis and portal hypertension. World J
pouches. J Clin Gastroenterol                                      Gastroenterol

                                                                   aspiration for suspected pancreatic cystic neoplasms. JOP.
anastomosis. Clin Gastroenterol Hepatol. 2008

laparoscopic versus open ileocolic resection for Crohn’s           of suspected pancreatic cystic neoplasms based on cyst size.
disease: follow-up of a prospective randomized trial.              Surgery
                                                                   Best Pract Res Clin Gastroenterol
transplantation as a rescue operation for recurrent
hepatocellular carcinoma after partial hepatectomy.
World J Gastroenterol

and endoscopic retrograde pancreatography for the prediction
                                  Dig Dis Sci. 2008

secretin-stimulated endoscopic and Dreiling tube pancreatic
function testing in patients evaluated for chronic pancreatitis.
Gastrointest Endosc

Digestive Disease Institute                                                                                                     47
 Staff Listing

Institute Chairman

Department of Colorectal Surgery


                                                Section Head

                                                Swallowing Center

                                                Section Head


                                                Outcomes Section
Department of Gastroenterology and Hepatology
                                                Clinical Hepatology Section
Colon Cancer                                    Section Head

Endoscopy Section

Section Head

48                                                                            Outcomes 2008
Gastroenterology Regional Practice

                                                        General and Liver Transplantation Anesthesiology Section

                                                        Section Head

Department of Hepato-pancreato-biliary
and Transplant Surgery
                                                        Allen Keebler, DO

Program and Surgical Director, Liver Transplantation

Surgical Director, Intestinal Transplantation

Vice Chairman, Department of Hepato-pancreato-biliary
and Transplant Surgery

Digestive Disease Institute Anesthesiology

Section Head

Digestive Disease Institute                                                                                        49
 Contact Information

General Patient Referral                               Additional Contact Information

                                                       General Information

Colorectal Surgery Appointments/Referrals
                                                       Hospital Patient Information

Gastroenterology & Hepatology Appointments/Referrals
                                                       Patient Appointments

                                                       Medical Concierge for Out-of-State Patients
                                                       Complimentary assistance for out-of-state patients
                                                       and families


                                                       Global Patient Services / International Center
                                                       Complimentary assistance for international patients
                                                       and families

                                                       Cleveland Clinic in Florida

                                                       For address corrections or changes, please call

50                                                                                                         Outcomes 2008
Institute Locations

Main Campus/A30                                Solon Family Health Center
9500 Euclid Ave.

Beachwood Family Health and Surgery Center     Strongsville Family Health and Surgery Center

                                               Westlake Family Health Center
Hillcrest Hospital Atrium

                                               Willoughby Hills Family Health Center
Elyria Chestnut Commons Family Health Center

Independence Family Health Center

Crown Center II

Digestive Disease Institute                                                                    51
 Cleveland Clinic Overview

bundling all clinical specialties into integrated practice
units called institutes. An institute combines all the         offers all students full tuition scholarships. The program will

under a single roof. Each institute has a single leadership
and focuses the energies of multiple professionals onto the
                                                               Cleveland Clinic is consistently ranked among the top
point-of-care service, institutes will improve the patient     hospitals in America by U.S.News & World Report, and our

outpatient clinic, specialty institutes and supporting labs    clevelandclinic.org.

Cleveland Clinic Abu Dhabi (United Arab Emirates), a
multispecialty care hospital and clinic, is scheduled to

associates and postdoctoral fellows are involved in
laboratory-based, translational and clinical research. Total

federal agencies, non-federal societies and associations,
endowment funds and other sources. In an effort to
bring research from bench to bedside, Cleveland Clinic

at any given time.

52                                                                                                                 Outcomes 2008
Resources for Physicians

Cleveland Clinic Secure Online Services                           Critical Care Transport: Anywhere in the world
Cleveland Clinic uses state-of-the-art digital information        Cleveland Clinic’s critical care transport team serves
systems to offer secure online services such as online medical    critically ill and highly complex patients across the
second opinions, medical record access, patient treatment         globe. The transport fleet comprises mobile ICU
progress for referring physicians (see below), and imaging        vehicles, helicopters and fixed-wing aircraft. The
interpretations by our subspecialty trained radiologists. For     transport teams are staffed by physicians, critical care
more information, please visit eclevelandclinic.org.              nurse practitioners, critical care nurses, paramedics and
                                                                  ancillary staff, and are customized to meet the needs
MyChart This secure online tool connects patients to their        of the patient. Critical care transport is available for
own health information from the privacy of their home             children and adults.
any time, day or night. Some features include renewing
prescriptions, reviewing test results and viewing medications,    To arrange a transfer for STEMI (ST elevated myocardial
all online. For the convenience of physicians and patients        infarction), acute stroke, ICH (intracerebral hemorrhage),
across the country, MyChart now offers a secure connection        SAH (subarachnoid hemorrhage) or aortic syndromes,
to GoogleTM Health. Google Health users can securely share        call 877.279.CODE (2633).
personal health information with Cleveland Clinic, and record
and share the details of their Cleveland Clinic treatment with    For all other transfers, call 216.444.8302 or
the physicians and healthcare providers of their choice. To       800.553.5056.
establish a MyChart account, visit clevelandclinic.org/mychart.
                                                                  CME Opportunities: Live and Online
DrConnect Whether you are referring from near or far,
DrConnect streamlines communication from Cleveland Clinic         Cleveland Clinic’s Center for Continuing Education’s
physicians to your office. This complimentary online tool         website, clevelandclinicmeded.com, offers hundreds
offers secure access to your patient’s treatment progress at      of convenient, complimentary learning opportunities,
Cleveland Clinic. With one-click convenience, you can track       from webcasts and podcasts to a host of medical
your patient’s care using the secure DrConnect website. To        publications including the Disease Management Project
establish a DrConnect account, visit clevelandclinic.org/         Online Medical Textbook, with more than 150 chapters.
drconnect or email drconnect@ccf.org.                             The site also offers a schedule of live CME courses,
                                                                  including international summits that focus on key areas
MyConsult Online Medical Second Opinion This secure               of translational research. Many live CME courses are
online service provides specialist consultations from our         hosted in Cleveland, an economical option for business
Cleveland Clinic experts and remote medical second                travel. Physicians can manage their CME credits by
opinions for more than 1,000 life-threatening and life-           using the myCME Web Portal. Available 24/7, the site
altering diagnoses. MyConsult is particularly valuable for        offers CME opportunities to medical professionals across
people who wish to avoid the time and expense of travel. For      the globe.
more information, visit clevelandclinic.org/myconsult, email
eclevelandclinic@ccf.org or call 800.223.2273, ext 43223.

Digestive Disease Institute                                                                                               53
staffed beds, an education institute and a research institute.


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