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9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org

15-OUT-351

Orthopaedic & Rheumatologic Institute

2014 Outcomes

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This project would not have been possible without the commitment and expertise of a team led by Carlos Higuera-Rueda, MD; Chad Deal, MD; Robert Overman, MPH; Charvelle Metcalf, MEd, MS; June Cassano, BSN, MBA; and Greg Strnad, MS. Graphic design and photography were provided by Cleveland Clinic's Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015

Measuring Outcomes Promotes Quality Improvement


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.

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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

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Prefer an e-version?

Visit clevelandclinic.org/OutcomesOnline, and

we’ll remove you from the hard copy mailing list

and email you when next year’s books are online.

what’s inside

Chairman’s Letter 04

Institute Overview 05

Quality and Outcomes Measures

Orthopaedics Overview 06

Adult Total Shoulder Arthroplasty for Osteoarthritis 20

Adult Total Hip Arthroplasty for Osteoarthritis 22

Adult Unilateral Total Knee Arthroplasty for Osteoarthritis 24

Orthopaedic Surgical Quality Improvement 26

Spinal Disease 28

Sports Medicine 36

Rheumatology Overview 42

Transplant 45

Osteoporosis 46

Gout 51

Rheumatoid Arthritis 54

Immunodeficiency 56

Psoriatic Arthritis 58

Vasculitis 62

Fibromyalgia 64

Progressive Systemic Sclerosis 66

Reversible Cerebral Vasoconstriction Syndrome 69

Osteoarthritis 72

Autoinflammatory Disease 73

Infusion Center 74

Institute Patient Experience 76

Cleveland Clinic – Implementing Value-Based Care 78

Innovations 84

Contact Information 88

About Cleveland Clinic 90

Resources 92

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Chairman LetterChairman’s Letter

Dear Colleagues,

Thank you for your interest in the 2014 Outcomes for Cleveland Clinic’s Orthopaedic & Rheumatologic Institute. Here we provide an overview of our ongoing efforts to measure our patients’ health and functional outcomes following the full range of surgical procedures and nonsurgical treatments.

Our institute is committed to the best outcomes for patients, and we continually strive to make advancements. 2014 was a productive year for us, and some of our standout advancements included:

• Care path implementation for total hip and knee arthroscopy, which standardized care processes to reduce variability and improve outcomes

• Successful execution of the Bundled Payments for Care Improvement initiative, an innovative payment model from the Centers for Medicare & Medicaid Services that includes financial and performance accountability for patient episodes of care

• Clinical integration of five orthopaedic programs within the National Orthopaedic and Spine Network as well as a Multidisciplinary Musculoskeletal Ultrasound Program across the Cleveland Clinic health system

• Development and implementation of the point of care OrthoMiDaS clinical data collection software and the Rheumatology Patient Reported Outcomes software, both of which allow us to keep our commitment to measuring patients’ health and functional outcomes

We welcome your feedback, questions, and ideas for collaboration. Please contact me via email at [email protected] and reference the Orthopaedic & Rheumatologic Institute Outcomes book in your message.

Sincerely,

Joseph Iannotti, MD, PhD Chairman, Orthopaedic & Rheumatologic Institute

Outcomes 20144

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Institute OverviewInstitute Overview

Orthopaedic & Rheumatologic Institute 5

Total clinic visits

493,323

Total surgeries

21,600

Total 2014 musculoskeletal and rheumatology funding — basic, translational, and clinical research

$4,946,165

This year’s Outcomes book profiles the clinical outcomes of patients treated by the institute’s caregivers in 2014. Patients with the most complex clinical problems from around the nation and the world come to the Orthopaedic & Rheumatologic Institute for care and expert opinions. These outcomes contributed to Cleveland Clinic’s ranking among the nation’s top 2 rheumatology programs and top 3 orthopaedics programs in U.S. News & World Report’s “America’s Best Hospitals” survey for 2014-2015.

The institute comprises Orthopaedic Surgery, Rheumatic and Immunologic Diseases, Musculoskeletal Physical Medicine and Rehabilitation, and Orthotics and Prosthetics. Current full-time faculty include 58 orthopaedic surgeons (53 orthopaedic, 5 spine), 31 rheumatologists, 12 musculoskeletal radiologists, 7 podiatrists, 9 sports and exercise medicine primary physicians, 5 nonoperative orthopaedists, and 4 physiatrists (PM&R physicians).

The institute also is dedicated to the cultivation of new knowledge and innovation through basic, translational, and clinical research. One of its missions is to educate and train residents and fellows as well as colleagues at Cleveland Clinic and beyond contributing to the fields of orthopaedics and rheumatology.

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6

Procedure Yearly Volume Average Age, Years

Males/ Females, %

Length of Stay, Days

Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery 1082 1093

Total shoulder arthroplasty 190 185 66.4 65.9 52/48 51/49 2.4 2.3 93 93

Osteoarthritis 166 164 66.6 65.6 55/45 52/48 2.3 2.1 94 95

Other reasons 24 21 65.1 69.0 29/71 43/57 2.8 4.0 87 75

Reverse total shoulder arthroplasty 98 171 71.0 71.1 34/66 43/57 2.6 2.7 84 81

Hemiarthroplasty 80 42 58.3 53.0 56/44 45/55 2.5 2.1 91 88

Revision of total shoulder arthroplasty 56 58 62.9 66.4 52/48 57/43 3.1 3.0 90 90

Rotator cuff repair 334 258 57.4 56.5 58/42 53/47 - - 100 100

Capsulorrhaphy 51 53 28.2 29.5 72/28 68/32 - - 100 100

Biceps tenodesis 52 75 51.3 52.6 78/22 75/25 - - 100 99

Fracture treatment 69 80 50.4 47.4 50/50 56/44 3.3 2.9 94 95

Proximal humerus 39 37 59.5 61.7 31/69 32/68 3.3 3.0 90 89

Clavicle 30 43 38.6 35.1 75/25 77/23 - - 99 100

Other treatment 152 171 51.7 51.1 57/43 57/43 6.3 4.5 94 97

Arthroscopic Surgery 1233 1295

Rotator cuff repair 577 668 56.3 56.9 62/38 61/39 - - 100 100

Capsulorrhaphy 97 76 29.1 29.1 74/26 75/25 - - 100 100

Biceps tenodesis 37 61 51.5 51.6 63/37 64/36 - - 99 100

SLAP repair 129 119 32.0 31.8 81/19 80/20 - - 100 100

Subacromial decompression 254 184 51.4 50.9 58/42 60/40 - - 100 100

Debridement 93 132 50.3 51.1 64/36 55/45 - - 98 98

Other treatment 46 55 44.1 47.4 62/38 64/36 - - 99 98

Adult Shoulder Surgery, 2009 – 2014

Data reflect outcomes of care provided by Cleveland Clinic physicians irrespective of practice location, including Cleveland Clinic main campus, Cleveland Clinic Northeast Ohio regional hospitals, and Cleveland Clinic Florida.

Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior

Column descriptions: • Procedure: type of surgical procedure performed • Yearly Volume: number of surgeries performed per year • Average Age, Years: average patient age

• Males/Females, %: males-to-females ratio • Length of Stay, Days: average length of stay in days for inpatient surgeries • Discharged Home, %: percentage of patients who were discharged home or to home care

Outcomes 20146

Orthopaedics Overview

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Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy.SLAP = superior labrum from anterior to posterior

Column descriptions: • Procedure: type of surgical procedure performed • In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred • 30-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 30 days of discharge • 30-Day Reoperation Rate, %: rate of reoperation on the same joint within 30 days of discharge • 90-Day Infection Rate, %: rate of infection within 90 days of surgery

• Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems prior to surgery; scores range from 0 (extreme limitations, low function) to 10 (no limitations, high function) • 90-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to arm problems 90 days after surgery; scores range from 0 (extreme limitations, low function) to 10 (no limitations, high function)

Procedure In-Hospital Mortality, %

30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %

90-Day Infection Rate, %

Preop Function

90-Day Postop Function

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery

Total shoulder arthroplasty 0.0 0.0 1.8 1.7 0.7 0.5 0.0 0.0 2.4 2.6 6.4 6.0

Osteoarthritis 0.0 0.0 1.2 1.3 0.6 0.6 0.0 0.0 2.4 2.6 6.5 6.1

Other reasons 0.0 0.0 5.9 5.0 1.6 0.0 - - - - - -

Reverse total shoulder arthroplasty 0.0 0.0 2.4 1.8 0.4 0.6 0.2 0.0 2.0 2.4 5.4 5.3

Hemiarthroplasty 0.0 0.0 2.7 0.0 0.5 0.0 0.3 0.0 2.3 1.6 5.1 3.6

Revision of total shoulder arthroplasty 0.7 0.0 7.9 6.9 5.3 5.2 1.8 0.0 2.1 2.9 4.1 5.0

Rotator cuff repair 0.0 0.0 1.1 0.5 0.4 0.8 0.3 0.0 3.2 3.1 5.6 5.2

Capsulorrhaphy 0.0 0.0 0.0 2.0 0.0 0.0 - - - - - -

Biceps tenodesis 0.0 0.0 1.6 2.9 0.4 0.0 - - 3.2 2.7 5.9 5.0

Fracture treatment 0.0 0.0 4.7 5.4 1.2 1.3 - - 2.0 1.8 5.9 6.0

Proximal humerus 0.0 0.0 7.5 11.4 2.1 2.7 - - - - - -

Clavicle 0.0 0.0 0.8 0.0 0.0 0.0 - - - - - -

Other treatment 0.3 0.0 4.9 6.8 1.5 4.1 - - - - - -

Arthroscopic Surgery

Rotator cuff repair 0.0 0.0 1.0 0.5 0.2 0.1 0.2 0.0 3.3 3.2 5.9 5.6

Capsulorrhaphy 0.0 0.0 0.0 1.4 0.2 0.0 0.0 0.0 3.7 4.8 6.2 6.1

Biceps tenodesis 0.0 0.0 0.0 0.0 0.0 0.0 - - 2.6 3.6 4.8 6.1

SLAP repair 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.0 4.2 3.9 6.3 5.9

Subacromial decompression 0.0 0.0 0.5 1.2 0.1 0.0 0.0 0.0 3.2 3.1 5.5 5.3

Debridement 0.0 0.0 1.5 1.6 0.4 0.8 0.0 0.0 3.4 2.8 6.0 5.4

Other treatment 0.0 0.0 2.2 1.9 0.9 0.0 - - - - - -


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Adult Hand and Upper Extremity Surgery, 2009 – 2014Procedure Yearly Volume Average Age,

YearsMales/

Females, %Length of Stay, Days

Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery 3606 4160 Total elbow arthroplasty 20 14 62.4 67.9 22/78 29/71 - - 86 77 Ulnar nerve neuroplasty at elbow 96 101 51.9 55.3 57/43 52/48 - - 100 100 Elbow tenotomy 80 78 47.8 48.7 48/52 45/55 - - 100 100 Distal bicep repair 52 76 47.6 49.3 96/4 97/3 - - 99 100 Carpal tunnel release 1141 1439 59.2 59.6 37/63 37/63 - - 100 100 Without distal radial fracture 1120 1405 59.2 59.8 37/63 37/63 - - 100 100 With distal radial fracture 21 34 55.5 51.8 27/73 26/74 - - 98 100 Wrist arthrodesis 41 47 53.1 56.5 63/37 62/38 - - 98 100 Hand arthroplasty 157 183 60.7 61.5 20/80 25/75 - - 100 100 Palmar fasciectomy 31 26 63.0 65.7 75/25 81/19 - - 100 100 De Quervain's release 73 74 51.9 52.8 19/81 16/84 - - 100 100 Trigger finger release 349 464 60.9 61.0 36/64 40/60 - - 100 100 Finger arthrodesis 60 65 56.7 56.9 34/66 29/71 - - 100 100 Finger amputation 34 54 55.4 56.4 69/31 67/33 - - 94 94

Fracture treatment 491 555 49.2 49.9 46/54 45/55 4.1 4.4 97 96 Humeral shaft 37 36 59.1 60.6 36/64 28/72 5.2 4.7 79 77 Distal humerus 21 21 57.7 60.1 36/64 48/52 - - 89 89 Radial head 8 6 - - - - - - - - Proximal ulna 23 26 56.8 60.6 42/58 42/58 - - 95 95 Radial or ulnar shaft 31 24 48.3 50.7 50/50 42/58 - - 94 90 Distal radius 169 216 57.4 57.8 26/74 20/80 - - 98 98 Scaphoid 55 67 40.4 39.4 61/39 63/37 - - 99 98 Hand or finger 147 159 38.5 38.5 68/32 74/26 - - 100 99 Mass excision 351 343 52.0 52.9 38/62 34/66 - - 100 100 Other treatment 630 641 49.7 51.4 58/42 56/44 - - 97 97Arthroscopic Surgery 47 29 Elbow treatment 25 18 42.0 38.9 84/16 72/28 - - 100 100 Wrist treatment 20 9 - - - - - - - - Other treatment 2 2 - - - - - - - -


Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy.



Outcomes 20148


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30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %


Preop Function


2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery Total elbow arthroplasty 0.0 0.0 6.2 0.0 3.0 0.0 - - - - - - Ulnar nerve neuroplasty at elbow 0.0 0.0 0.6 0.0 0.2 0.0 - - - - - - Elbow tenotomy 0.0 0.0 0.3 0.0 0.3 0.0 - - 3.4 5.5 5.4 6.5 Distal bicep repair 0.0 0.0 0.0 0.0 1.2 1.3 - - 2.8 2.9 5.8 4.8 Carpal tunnel release 0.0 0.0 0.7 0.5 0.4 0.1 - - 3.4 2.2 6.8 7.4 Without distal radial fracture 0.0 0.0 0.7 0.5 0.4 0.1 - - 4.3 4.8 6.8 6.9 With distal radial fracture 0.0 0.0 1.0 0.0 0.0 0.0 - - - - - - Wrist arthrodesis 0.0 0.0 0.5 0.0 1.0 6.4 - - - - - - Hand arthroplasty 0.0 0.0 0.9 0.0 0.1 0.0 - - 3.4 4.6 5.6 5.8 Palmar fasciectomy 0.0 0.0 0.0 3.8 0.0 0.0 - - 4.3 4.2 6.4 6.6 De Quervain's release 0.0 0.0 0.9 1.5 0.0 0.0 - - - - - - Trigger finger release 0.0 0.0 0.5 1.2 0.3 0.0 - - - - - - Finger arthrodesis 0.0 0.0 1.3 1.7 0.0 1.5 - - 5.9 6.8 7.3 8.2 Finger amputation 0.0 0.0 6.9 2.0 1.2 3.7 - - - - - -

Fracture treatment 0.0 0.2 1.7 2.0 1.6 0.5 - - - - - - Humeral shaft 0.0 3.2 6.9 6.5 1.1 2.8 - - 3.5 2.7 6.8 7.2 Distal humerus 0.0 0.0 2.0 5.3 3.8 0.0 - - - - - - Radial head - - - - - - - - - - - - Proximal ulna 0.0 0.0 4.4 9.5 2.7 3.8 - - - - - - Radial or ulnar shaft 0.0 0.0 0.7 0.0 2.6 0.0 - - - - - - Distal radius 0.0 0.0 1.6 2.6 1.9 0.0 - - - - - - Scaphoid 0.0 0.0 0.7 0.0 0.7 0.0 - - - - - - Hand or finger 0.0 0.0 0.9 0.0 1.1 0.6 - - - - - - Mass excision 0.0 0.0 0.5 0.6 0.5 1.5 - - - - - - Other treatment 0.2 0.2 2.4 1.5 1.9 0.9 - - 6.0 6.1 7.5 6.4Arthroscopic Surgery Elbow treatment 0.0 0.0 1.6 0.0 0.8 0.0 - - - - 6.1 7.0 Wrist treatment - - - - - - - - - - - - Other treatment - - - - - - - - - - - -






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Adult Hip Surgery, 2009 – 2014Procedure Yearly Volume Average Age,

YearsMales/


Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery 2687 3265 Hip resurfacing 351 380 53.8 53.4 71/29 78/22 3.1 2.6 93 98 Total hip arthroplasty 1363 1786 62.9 63.9 45/55 47/53 3.5 2.7 59 76 Osteoarthritis 1125 1505 64.1 64.6 44/56 48/52 3.4 2.6 60 76 Rheumatoid arthritis 35 45 62.7 66.8 21/79 16/84 3.8 3.0 48 62 Avascular necrosis 155 169 53.7 56.2 58/42 49/51 3.7 2.9 63 76 Other reasons (eg, fracture) 48 67 64.2 66.0 39/61 40/60 6.8 5.9 32 54 Conversion to total hip arthroplasty 79 89 62.5 63.3 51/49 40/60 4.3 4.5 65 55 Hemiarthroplasty 78 63 77.9 80.5 36/64 33/67 8.3 6.9 12 9 Revision of total hip arthroplasty 295 307 65.0 64.1 47/53 52/48 5.2 4.6 50 60 Infection 56 58 64.3 63.3 57/43 55/45 7.3 8.0 40 50 Other reasons 239 249 65.2 64.3 44/56 51/49 4.7 3.8 52 63 Treatment of hip or pelvis fracture 262 374 75.5 73.2 31/69 41/59 6.5 7.0 21 25 Other treatment 259 266 58.7 58.3 45/55 48/52 9.1 10.1 62 66Arthroscopic Surgery 154 216

Treatment of labral tear 136 203 34.6 35.6 33/67 31/69 - - 100 100 Without osteoarthritis 124 178 33.6 34.2 32/68 31/69 - - 100 100 With osteoarthritis 12 25 44.4 46.0 41/59 28/72 - - 100 100 Other treatment 18 13 38.1 37.5 39/61 54/46 - - 99 100





Outcomes 201410


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At Cleveland Clinic main campus, 24% of all total hip arthroplasty surgeries performed are revisions, which is approximately double the rate performed at all other Cleveland Clinic hospitals. Approximately 44% of all total hip arthroplasty revision surgeries across the Cleveland Clinic health system are performed at Cleveland Clinic main campus.


30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %


Preop Function


2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery Hip resurfacing 0.0 0.0 1.5 2.4 0.2 0.0 0.6 0.0 2.7 2.5 7.0 6.6 Total hip arthroplasty 0.0 0.0 3.9 3.0 1.0 1.0 1.0 1.1 2.8 2.6 7.2 6.8 Osteoarthritis 0.0 0.0 3.4 2.8 0.9 0.9 0.8 1.1 2.8 2.8 7.3 7.0 Rheumatoid arthritis 0.6 0.0 4.0 0.0 1.1 0.0 0.8 0.0 - - - - Avascular necrosis 0.0 0.0 5.0 4.8 1.3 1.2 1.8 1.0 2.4 1.8 6.3 6.0 Other reasons (eg, fracture) 1.3 0.0 14.3 10.3 3.4 1.5 - - - - - - Conversion to total hip arthroplasty 0.3 0.0 7.7 14.3 1.8 5.6 1.1 8.3 2.2 2.7 6.1 4.8 Hemiarthroplasty 3.2 2.1 20.8 19.1 1.3 0.0 - - - - - - Revision of total hip arthroplasty 0.2 0.4 9.5 8.6 3.9 3.3 1.4 2.5 3.0 2.6 5.2 4.8 Infection 0.4 0.0 15.2 12.5 5.0 3.4 0.0 0.0 2.4 2.9 4.2 4.1 Other reasons 0.2 0.4 8.2 7.6 3.7 3.2 1.8 3.1 3.2 2.6 5.5 5.0 Treatment of hip or pelvis fracture 1.7 1.0 13.4 11.8 1.4 1.3 - - - - - - Other treatment 1.4 1.3 11.5 8.7 4.9 3.8 - - 3.4 3.7 4.7 3.5Arthroscopic Surgery

Treatment of labral tear 0.0 0.0 0.4 0.0 0.0 0.0 - - 3.6 3.0 6.6 5.3 Without osteoarthritis 0.0 0.0 0.5 0.0 0.0 0.0 - - 3.6 3.0 6.7 5.3 With osteoarthritis 0.0 0.0 0.0 0.0 0.0 0.0 - - - - - - Other treatment 0.0 0.0 2.4 0.0 0.0 0.0 - - - - - -





• Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems prior to surgery; scores range from 0 (extreme limitations, low function) to 10 (no limitations, high function) • 90-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems 90 days after surgery; scores range from 0 (extreme limitations, low function) to 10 (no limitations, high function)

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Adult Knee Surgery, 2009 – 2014Procedure Yearly Volume Average Age,

YearsMales/


Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery 3715 4081 Unilateral total knee arthroplasty 2002 2427 65.2 65.2 38/62 38/62 3.6 2.9 50 72 Osteoarthritis 1885 2282 65.4 65.3 38/62 39/61 3.6 2.8 50 72 Rheumatoid arthritis 76 78 63.8 64.6 22/78 21/79 3.7 3.0 44 64 Avascular necrosis 17 14 57.4 57.7 - - - - - - Other reasons 24 53 60.6 64.1 47/53 43/57 6.9 6.1 61 65 Bilateral total knee arthroplasty 163 124 61.8 61.3 41/59 42/58 4.0 3.7 7 22 Partial knee arthroplasty 359 408 62.9 64.5 46/54 46/54 2.4 2.1 87 93 Revision of total knee arthroplasty 355 378 63.8 64.2 43/57 46/54 4.4 4.1 56 65 Infection 77 96 63.9 64.4 52/48 58/42 6.1 6.4 47 56 Other reasons 278 282 63.7 64.1 40/60 42/58 3.9 3.3 58 67 Treatment of periarticular knee fracture 111 121 61.4 58.7 36/64 40/60 6.7 7.2 49 61 Other treatment 725 623 53.8 52.5 52/48 54/46 7.6 8.1 77 81Arthroscopic Surgery 3086 2774 ACL reconstruction 435 445 32.1 31.0 63/37 59/41 - - 100 100 Meniscectomy 1899 1724 51.7 52.2 54/46 53/47 - - 100 100 Meniscus injury without osteoarthritis 851 712 48.4 47.9 58/42 55/45 - - 100 100 Meniscus injury with osteoarthritis 1021 1004 54.6 55.2 51/49 52/48 - - 100 100 Other reasons 27 8 - - - - - - - - Meniscus repair 31 22 33.8 28.8 64/36 64/36 - - 100 100 Chondroplasty 256 234 43.6 44.6 45/55 41/59 - - 99 100 Other treatment 465 349 50.9 47.9 46/54 47/53 - - 99 97


Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament



Outcomes 201412


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At Cleveland Clinic main campus, Cleveland Clinic Florida, and Lakewood Hospital, approximately 20% of all total knee arthroplasty surgeries performed are revisions, while all other Cleveland Clinic hospitals perform < 10%. Approximately 40% of all total knee arthroplasty revision surgeries across the Cleveland Clinic health system are performed at Cleveland Clinic main campus.


30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %


Preop Function


2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery Unilateral total knee arthroplasty 0.0 0.0 4.6 3.4 0.9 0.6 1.5 1.0 3.1 3.0 6.5 6.4 Osteoarthritis 0.0 0.0 4.5 3.3 0.9 0.5 1.4 1.0 3.1 3.1 6.5 6.5 Rheumatoid arthritis 0.0 0.0 4.5 3.8 1.3 1.3 3.4 0.0 3.1 3.8 6.0 5.6 Avascular necrosis - - - - - - - - - - - - Other reasons 1.3 0.0 15.2 8.8 0.0 3.8 1.5 3.4 3.3 1.2 6.0 4.3 Bilateral total knee arthroplasty 0.0 0.0 4.5 3.3 1.5 0.0 0.4 0.0 3.2 2.6 6.9 6.3 Partial knee arthroplasty 0.0 0.0 2.5 2.8 0.5 0.5 0.5 0.0 3.5 3.1 6.6 5.9 Revision of total knee arthroplasty 0.1 0.0 7.9 8.0 3.0 3.7 2.0 4.3 2.7 3.0 5.0 4.6 Infection 0.0 0.0 14.0 11.5 6.0 7.3 1.3 2.0 2.7 3.3 4.2 2.9 Other reasons 0.1 0.0 6.2 6.8 2.2 2.5 2.2 5.1 2.7 2.9 5.3 5.1 Treatment of periarticular knee fracture 0.4 0.0 9.2 8.2 2.3 0.8 - - - - - - Other treatment 0.5 0.2 7.3 5.8 2.3 1.1 0.8 0.0 3.6 3.2 4.8 4.5Arthroscopic Surgery ACL reconstruction 0.0 0.0 1.1 0.9 0.6 0.9 0.4 0.4 4.6 4.5 7.0 7.1 Meniscectomy 0.0 0.0 0.9 0.8 0.2 0.2 0.2 0.0 4.0 4.0 6.0 5.9 Meniscus injury without osteoarthritis 0.0 0.0 0.9 0.8 0.2 0.1 0.1 0.0 4.2 4.4 6.2 6.1 Meniscus injury with osteoarthritis 0.0 0.0 0.8 0.8 0.2 0.2 0.3 0.0 3.9 3.8 5.8 5.7 Other reasons - - - - - - - - - - - - Meniscus repair 0.0 0.0 0.6 0.0 0.6 0.0 - - - - - - Chondroplasty 0.1 0.0 1.1 0.9 0.6 1.3 0.2 0.0 4.0 3.9 5.8 5.6 Other treatment 0.0 0.3 8.0 3.0 17.2 6.6 0.2 0.0 3.8 4.0 5.6 5.9



Adult patients are aged 18 or older. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy.ACL = anterior cruciate ligament



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14

Procedure Yearly Volume Average Age, Years

Males/ Females, %

Length of Stay, Days

Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery 2059 2246 Total ankle arthroplasty 12 14 65.4 72.3 57/43 43/57 - - 85 79 Ankle arthrodesis 53 62 57.1 56.7 54/46 44/56 - - 86 84 Osteoarthritis 23 23 59.7 62.4 52/48 39/61 - - 92 80 Rheumatoid arthritis 4 2 - - - - - - - - Traumatic injury 13 11 54.5 54.8 55/45 55/45 - - 87 100 Other reasons 13 26 55.2 52.8 64/36 42/58 - - 78 78 Achilles tendon treatment 105 114 45.6 44.1 69/31 72/28 - - 99 99 Acute rupture repair 82 85 43.6 41.4 77/23 82/18 - - 100 100 Chronic reconstruction 23 29 52.9 51.7 42/58 41/59 - - 97 96 Foot arthrodesis 113 124 54.7 52.4 36/64 43/57 - - 92 93 Osteoarthritis 62 38 57.0 58.8 35/65 47/53 - - 92 96 Rheumatoid arthritis 7 4 - - - - - - - - Deformity 17 30 51.7 55.1 35/65 33/67 - - 88 81 Other reasons 27 52 50.4 46.8 39/61 48/52 - - 97 100 Flat foot or cavus foot correction 159 161 52.7 57.1 18/82 16/84 - - 99 99 Big toe arthrodesis 172 174 59.0 60.8 21/79 22/78 - - 99 99 Osteoarthritis 58 36 60.4 60.7 22/78 17/83 - - 99 94 Rheumatoid arthritis 16 15 60.4 59.0 6/94 20/80 - - 97 100 Deformity 94 116 58.2 61.3 21/79 23/77 - - 99 100 Other reasons 4 7 - - - - - - - - Cheilectomy 69 50 53.3 51.5 32/68 42/58 - - 100 100 Bunion correction 161 138 49.7 52.4 11/89 7/93 - - 100 100 Hammertoe correction 78 74 60.0 59.9 21/79 19/81 - - 100 100 Bunion and hammertoe correction 43 30 59.2 56.4 8/92 13/87 - - 100 100 Fracture treatment 363 437 47.3 47.6 46/54 45/55 4.6 4.5 86 87 Tibia or fibula 140 177 45.7 46.3 55/45 58/42 4.6 4.6 86 87 Ankle 159 181 50.6 51.3 36/64 36/64 4.7 4.7 82 81 Foot or toes 64 79 42.7 41.7 51/49 39/61 - - 97 98 Amputation 141 223 61.0 61.4 62/38 65/35 9.2 8.5 75 77 Below knee 31 45 55.5 52.9 65/35 58/42 11.8 8.9 26 55 Foot 42 97 61.6 61.1 64/36 74/26 8.2 8.3 76 77 Toes 68 81 63.2 66.4 60/40 59/41 6.8 8.2 93 89 Excision of leg or ankle tumor 63 57 48.4 49.2 44/56 33/67 - - - - Excision of foot or toe tumor 105 105 50.4 54.1 31/69 43/57 - - - - Other treatment 422 483 48.6 48.1 40/60 44/56 7.7 9.0 94 93Arthroscopic Surgery 51 48 Osteochondritis dissecans lesion repair 16 11 38.3 41.4 52/48 55/45 - - - - Other treatment 35 37 40.3 42.8 44/56 46/54 - - 99 100





Outcomes 201414

Adult Foot and Ankle Surgery, 2009 – 2014


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15


30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %


Preop Function


2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Surgery Total ankle arthroplasty - - - - - - - - 4.0 3.1 6.0 6.6 Ankle arthrodesis 0.0 0.0 2.3 2.0 0.8 0.0 - - 2.9 3.2 5.1 3.4 Osteoarthritis 0.0 0.0 4.6 5.0 0.9 0.0 - - - - - - Rheumatoid arthritis - - - - - - - - - - - - Traumatic injury - - - - - - - - - - - - Other reasons - - - - 1.5 0.0 - - - - - - Achilles tendon treatment 0.0 0.0 1.6 1.0 0.6 0.0 - - 4.1 4.3 5.8 5.7 Acute rupture repair 0.0 0.0 1.5 1.2 0.7 0.0 - - 4.0 4.1 6.0 6.0 Chronic reconstruction 0.0 0.0 1.9 0.0 0.0 0.0 - - - - - - Foot arthrodesis 0.0 0.0 1.0 2.2 1.2 0.8 - - 3.8 4.2 5.2 4.3 Osteoarthritis 0.0 0.0 1.1 0.0 1.9 2.6 - - - - - - Rheumatoid arthritis - - - - - - - - - - - - Deformity 0.0 0.0 1.3 3.7 0.0 0.0 - - - - - - Other reasons 0.0 0.0 0.0 2.9 0.0 0.0 - - - - - - Flat foot or cavus foot correction 0.0 0.0 0.4 0.0 0.5 0.0 - - 5.6 5.1 6.4 5.1 Big toe arthrodesis 0.0 0.0 1.0 1.2 0.2 0.0 - - 5.8 5.5 6.9 6.6 Osteoarthritis 0.0 0.0 0.4 0.0 0.0 0.0 - - - - - - Rheumatoid arthritis - - - - - - - - - - - - Deformity 0.0 0.0 1.3 0.9 0.4 0.0 - - 6.1 5.7 7.0 6.4 Other reasons - - - - - - - - - - - - Cheilectomy 0.0 0.0 0.3 0.0 0.0 0.0 - - - - - - Bunion correction 0.0 0.0 0.9 0.7 0.5 0.7 - - - - - - Hammertoe correction 0.0 0.0 1.8 0.0 0.8 0.0 - - - - - - Bunion and hammertoe correction 0.0 0.0 1.0 0.0 1.4 0.0 - - - - - - Fracture treatment 0.0 0.0 6.0 5.7 3.4 3.7 - - 3.5 3.1 6.0 4.5 Tibia or fibula 0.0 0.0 6.7 8.8 3.4 6.2 - - 3.0 3.6 5.9 4.9 Ankle 0.0 0.0 6.5 4.5 4.4 2.8 - - 3.5 2.9 6.1 3.6 Foot or toes 0.0 0.0 3.5 1.5 0.9 0.0 - - - - - - Amputation 0.2 0.0 8.8 9.0 2.7 0.9 - - 5.2 4.8 6.0 5.8 Below knee 0.9 0.0 17.1 10.3 3.2 0.0 - - - - - - Foot 0.0 0.0 11.0 13.3 4.3 1.0 - - - - - - Toes 0.0 0.0 4.3 3.0 1.5 1.2 - - - - - - Excision of leg or ankle tumor 0.0 0.0 3.0 5.8 0.6 0.0 - - 4.7 3.6 5.9 4.4 Excision of foot or toe tumor 0.0 0.0 1.8 0.0 0.6 0.0 - - - - - - Other treatment 0.1 0.0 3.1 2.1 2.2 2.7 - - 4.7 4.1 5.9 5.2Arthroscopic Surgery Osteochondritis dissecans lesion repair - - - - - - - - - - - - Other treatment 0.0 0.0 0.6 0.0 0.0 2.7 - - - - - -

15Orthopaedic & Rheumatologic Institute



Column descriptions: • Procedure: type of surgical procedure performed • In-Hospital Mortality, %: rate of patient mortality prior to discharge from the hospital encounter during which surgery occurred • 30-Day Readmission Rate, %: rate of readmission as an inpatient for any reason to a Cleveland Clinic hospital within 30 days of discharge • 30-Day Reoperation Rate, %: rate of reoperation on the same joint within 30 days of discharge

• 90-Day Infection Rate, %: rate of infection within 90 days of surgery • Preop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems prior to surgery; scores range from 0 (extreme limitations, low function) to 10 (no limitations, high function) • 90-Day Postop Function: how much physical activities (eg, daily activities, housework, work outside the home, and exercising) are free of limitations due to leg problems 90 days after surgery; scores range from 0 (extreme limitations, low function) to 10 (no limitations, high function)

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16


Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior, UE = upper extremity



Outcomes 201416

Pediatric Shoulder and Hand/Upper Extremity Surgery, 2009 – 2014Procedure Yearly Volume Average Age,

YearsMales/


Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Shoulder Surgery 36 34 Capsulorrhaphy 13 10 16.0 16.4 72/28 100/0 - - - - Treatment of shoulder fracture 14 16 14.7 15.3 84/16 88/12 - - - - Other treatment 9 8 - - - - - - - -Arthroscopic Shoulder Surgery 63 56

Capsulorrhaphy 31 25 16.0 16.3 77/23 68/32 - - 100 100 SLAP repair 27 29 16.0 15.7 81/19 79/21 - - 100 100 Other treatment 5 2 - - - - - - - -

Open Hand/UE Surgery 379 366

Trigger finger release 12 15 3.9 2.3 47/53 47/53 - - - - Fracture treatment 230 237 10.1 10.4 66/34 66/34 1.0 0.9 100 100 Humeral shaft 62 70 6.6 7.3 52/48 50/50 0.9 0.6 100 100 Distal humerus 3 1 - - - - - - - - Radial head 6 2 - - - - - - - - Proximal ulna 5 8 - - - - - - - -

Radial or ulnar shaft 42 41 8.8 9.4 67/33 63/37 - - 100 100 Distal radius 48 46 11.0 10.7 72/28 67/33 - - 100 100 Scaphoid 11 11 15.8 16.5 89/11 91/9 - - - - Hand or finger 53 58 13.3 13.0 73/27 79/21 - - 100 100 Mass excision 23 23 12.5 12.3 43/57 30/70 - - - - Other treatment 114 91 8.0 9.3 61/39 68/32 - - 100 100Arthroscopic Hand/UE Surgery 5 1


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17Orthopaedic & Rheumatologic Institute 17


Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. SLAP = superior labrum from anterior to posterior, UE = upper extremity




30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %


Preop Function


2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Shoulder Surgery Capsulorrhaphy - - - - - - - - - - - - Treatment of shoulder fracture - - - - - - - - - - - - Other treatment - - - - - - - - - - - -Arthroscopic Shoulder Surgery

Capsulorrhaphy 0.0 0.0 0.7 0.0 0.0 0.0 - - - - - - SLAP repair 0.0 0.0 0.0 0.0 0.0 0.0 - - - - - - Other treatment - - - - - - - - - - - -

Open Hand/UE Surgery

Trigger finger release - - - - - - - - - - - - Fracture treatment 0.0 0.0 0.5 0.5 1.5 0.8 - - 3.0 2.6 7.8 7.2 Humeral shaft 0.0 0.0 0.7 1.7 1.0 1.4 - - - - - - Distal humerus - - - - - - - - - - - - Radial head - - - - - - - - - - - - Proximal ulna - - - - - - - - - - - -

Radial or ulnar shaft 0.0 0.0 0.0 0.0 3.8 0.0 - - - - - - Distal radius 0.0 0.0 0.4 0.0 1.2 2.2 - - - - - - Scaphoid - - - - - - - - - - - - Hand or finger 0.0 0.0 0.4 0.0 0.7 0.0 - - - - - - Mass excision 0.0 0.0 0.0 0.0 - - - - - - - - Other treatment 0.0 0.0 1.1 0.0 0.5 0.0 - - - - - -Arthroscopic Hand/UE Surgery

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18


Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament



Outcomes 201418

Pediatric Hip, Knee, and Foot/Ankle Surgery, 2009 – 2014 Procedure Yearly Volume Average Age,

YearsMales/


Discharged Home, %

2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Hip Surgery 69 60 Treatment of hip or pelvis fracture 6 4 - - - - - - - - Other treatment 63 56 8.5 9.1 47/53 41/59 3.3 3.0 99 100Arthroscopic Hip Surgery 36 31Open Knee Surgery 131 130 Treatment of periarticular knee fracture 22 17 9.6 9.0 80/20 82/18 - - - - Other treatment 109 113 13.3 13.8 50/50 44/56 3.4 3.5 99 100Arthroscopic Knee Surgery 311 294

ACL reconstruction 151 172 15.5 15.7 49/51 44/56 - - 100 100 Meniscectomy 70 57 15.5 15.6 64/36 67/33 - - 100 100 Meniscus repair 17 5 - - - - - - - - Chondroplasty 23 26 14.7 14.4 58/42 42/58 - - 100 100 Other treatment 50 34 15.1 14.9 48/52 41/59 - - 100 100Open Foot/Ankle Surgery 268 202 Flat foot or cavus foot correction 22 22 12.7 13.5 51/49 45/55 - - 98 100

Fracture treatment 67 49 13.4 13.9 70/30 71/29 - - 100 100 Tibia or fibula 41 27 13.2 14.0 71/29 81/19 - - 99 100 Ankle 10 9 - - - - - - - - Foot or toes 16 13 13.6 14.1 68/32 77/23 - - - - Excision of leg or ankle tumor 12 12 12.8 13.3 52/48 58/42 - - - - Excision of foot or toe tumor 9 10 - - - - - - - - Other treatment 158 109 10.8 11.0 49/51 55/45 - - 100 100Arthroscopic Foot/Ankle Surgery 5 3


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Pediatric patients are younger than 18 years. A dash indicates that insufficient data were available to calculate the measure with reasonable accuracy. ACL = anterior cruciate ligament




30-Day Readmission

Rate, %

30-Day Reoperation

Rate, %


Preop Function


2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014 2009-13 2014

Open Hip Surgery Treatment of hip or pelvis fracture - - - - - - - - - - - - Other treatment 0.0 0.0 3.3 3.6 4.4 0.0 - - - - - -Arthroscopic Hip SurgeryOpen Knee Surgery Treatment of periarticular knee fracture - - - - - - - - - - - - Other treatment 0.0 0.0 2.8 0.0 0.9 1.8 0.6 0.0 3.9 3.2 5.6 5.5Arthroscopic Knee Surgery

ACL reconstruction 0.0 0.0 0.9 0.0 0.7 0.0 0.3 0.0 3.5 2.8 5.8 5.0 Meniscectomy 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 - - - - Meniscus repair - - - - - - - - - - - - Chondroplasty 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - - Other treatment 0.0 0.0 1.3 0.0 0.8 0.0 0.0 0.0 - - - -Open Foot/Ankle Surgery Flat foot or cavus foot correction 0.0 0.0 1.8 0.0 0.0 0.0 - - - - - -

Fracture treatment 0.0 0.0 0.3 2.0 0.3 2.0 - - - - - - Tibia or fibula 0.0 0.0 0.5 3.7 0.5 3.7 - - - - - - Ankle - - - - - - - - - - - - Foot or toes - - - - - - - - - - - - Excision of leg or ankle tumor - - - - - - - - - - - - Excision of foot or toe tumor - - - - - - - - - - - - Other treatment 0.0 0.0 1.0 3.9 0.6 1.8 - - - - - -Arthroscopic Foot/Ankle Surgery

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20 Outcomes 201420

Adult Total Shoulder Arthroplasty for Osteoarthritis

Shoulder-Related Pain 1 Year After Surgery

2009 − 2013

Shoulder-Related Function 1 Year After Surgery

2009 − 2013

On average, 91% of patients reported a clinically important improvement in shoulder-related pain after 1 year, while 1% reported worsening (8% showed no detectable change in shoulder-related pain).

On average, 92% of patients reported a clinically important improvement in shoulder-related function after 1 year, while 1% reported worsening (7% showed no detectable change in shoulder-related function).

ªMCID refers to the “minimal clinically important difference” and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For shoulder-related pain, the MCID is 12.3 (N = 336) on a scale from 0 (extreme pain) to 100 (no pain). For shoulder-related function, the MCID is 13.5 (N = 316) on a scale from 0 (extreme limitations) to 100 (no limitations).

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 2013136N = 40

Worsening

2009 − 2012 2013136 40

> 3 MCIDa

1 – 3 MCID

0

100

80

00

60

40

20

Patients (%)

Improving

2009 − 2012 2013124N = 31

Worsening

2009 − 2012 2013124 31

> 3 MCIDa

1 – 3 MCID

Shoulder-related pain and function are measured using a modified Penn Shoulder Score (PSS) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years.

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Arm-Related Physical Function 1 Year After Surgery

2009 − 2013

Whole-Body Physical Function 1 Year After Surgery

2009 − 2013

On average, 87% of patients reported a clinically important improvement in arm-related physical function after 1 year, while 4% reported worsening (9% showed no detectable change in arm-related physical function).

On average, 53% of patients reported a clinically important improvement in whole-body physical function after 1 year, while 9% reported worsening (38% showed no detectable change in whole-body physical function).

ªMCID refers to the “minimal clinically important difference” and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For arm-related physical function, the MCID is 1.6 (N = 465) on a scale from 0 (extreme limitations) to 10 (no limitations). For whole-body physical function, the MCID is 5.1 (N = 391) on a norm-based scale where 50 represents the mean score of a nonpatient control group and every 10 units represents 1 SD from the mean.

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 2013278N = 75

Worsening

2009 − 2012 2013278 75

> 3 MCIDa

1 – 3 MCID

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 2013149N = 52

Worsening

2009 − 2012 2013149 52

> 3 MCIDa

1 – 3 MCID

Arm-related physical function is measured using the Review of Musculoskeletal System (ROMS) questionnaire. Whole-body physical function is measured using the Veterans RAND 12 (VR-12) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years.

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22

Adult Total Hip Arthroplasty for Osteoarthritis

Hip-Related Pain 1 Year After Surgery

2009 − 2013

Hip-Related Function 1 Year After Surgery

2009 − 2013

On average, 93% of patients reported a clinically important improvement in hip-related pain after 1 year, while 1% reported worsening (6% showed no detectable change in hip-related pain).

On average, 91% of patients reported a clinically important improvement in hip-related function after 1 year, while 2% reported worsening (7% showed no detectable change in hip-related function).

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 2013655N = 160

Worsening

2009 − 2012 2013655 160

> 3 MCIDa

1 – 3 MCID

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 2013667N = 154

Worsening

2009 − 2012 2013667 154

> 3 MCIDa

1 – 3 MCID

ªMCID refers to the “minimal clinically important difference” and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For hip-related pain, the MCID is 11.6 (N = 951) on a scale from 0 (extreme pain) to 100 (no pain). For hip-related function, the MCID is 12.8 (N = 935) on a scale from 0 (extreme limitations) to 100 (no limitations).

Hip-related pain and function are measured using a modified Hip dysfunction and Osteoarthritis Outcome Score (HOOS) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years.

Outcomes 201422

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23

Leg-Related Physical Function 1 Year After Surgery

2009 − 2013


2009 − 2013

On average, 78% of patients reported a clinically important improvement in leg-related physical function after 1 year, while 7% reported worsening (15% showed no detectable change in leg-related physical function).


ªMCID refers to the “minimal clinically important difference” and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For leg-related physical function, the MCID is 2.0 (N = 1859) on a scale from 0 (extreme limitations) to 10 (no limitations). For whole-body physical function, the MCID is 5.8 (N = 1784) on a norm-based scale where 50 represents the mean score of a nonpatient control group and every 10 units represents 1 SD from the mean.

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 20131116N = 327

Worsening

2009 − 2012 20131116 327

> 3 MCIDa

1 – 3 MCID

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 2013666N = 217

Worsening

2009 − 2012 2013666 217

> 3 MCIDa

1 – 3 MCID

Leg-related physical function is measured using the Review of Musculoskeletal System (ROMS) questionnaire. Whole-body physical function is measured using the Veterans RAND 12 (VR-12) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years.


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24

Adult Unilateral Total Knee Arthroplasty for Osteoarthritis

Knee-Related Pain 1 Year After Surgery

2009 − 2013

Knee-Related Function 1 Year After Surgery

2009 − 2013

On average, 88% of patients reported a clinically important improvement in knee-related pain after 1 year, while 2% reported worsening (10% showed no detectable change in knee-related pain).

On average, 82% of patients reported a clinically important improvement in knee-related function after 1 year, while 2% reported worsening (16% showed no detectable change in knee-related function).

ªMCID refers to the “minimal clinically important difference” and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For knee-related pain, the MCID is 12.0 (N = 1614) on a scale from 0 (extreme pain) to 100 (no pain). For knee-related function, the MCID is 12.9 (N = 1505) on a scale from 0 (extreme limitations) to 100 (no limitations).

Outcomes 201424

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 20131097N = 289

Worsening

2009 − 2012 20131097 289

> 3 MCIDa

1 – 3 MCID

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 20131078N = 268

Worsening

2009 − 2012 20131078 268

> 3 MCIDa

1 – 3 MCID

0

Knee-related pain and function are measured using a modified Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years.

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25

Leg-Related Physical Function 1 Year After Surgery

2009 − 2013


2009 − 2013

On average, 74% of patients reported a clinically important improvement in leg-related physical function after 1 year, while 7% reported worsening (19% showed no detectable change in leg-related physical function).


ªMCID refers to the “minimal clinically important difference” and is estimated here as one-half of the SD of patient-reported data 1 year after surgery. For leg-related physical function, the MCID is 1.8 (N = 3340) on a scale from 0 (extreme limitations) to 10 (no limitations). For whole-body physical function, the MCID is 5.5 (N = 2443) on a norm-based scale where 50 represents the mean score of a nonpatient control group and every 10 units represents 1 SD from the mean.

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 20132032N = 602

Worsening

2009 − 2012 20132032 602

> 3 MCIDa

1 – 3 MCID

100

80

0

60

40

20

Patients (%)

Improving

2009 − 2012 20131071N = 372

Worsening

2009 − 2012 20131071 372

> 3 MCIDa

1 – 3 MCID

Leg-related physical function is measured using the Review of Musculoskeletal System (ROMS) questionnaire. Whole-body physical function is measured using the Veterans RAND 12 (VR-12) questionnaire. Data are derived from patient self-reported scores collected during office visits up to 6 months before and 1 year after surgeries performed during the indicated years.


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26 Outcomes 201426

Orthopaedic Surgical Quality Improvement

Orthopaedic Surgery Outcomes July 2013 – June 2014

Total Knee Arthroplasty Outcomes July 2013 – June 2014

Total Hip Arthroplasty Outcomes July 2013 – June 2014

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 orthopaedic surgery ACS NSQIP performance benchmarked against 362 participating sites.

In addition to overall orthopaedic surgery ACS NSQIP outcomes data, data specific to total knee arthroplasty (TKA) and total hip arthroplasty (THA) are provided. TKA performance is benchmarked against 74 participating sites; THA surgery performance is benchmarked against 76 sites.

aIdentified as a high statistical outlier (higher than expected) by the ACS NSQIP hierarchical model

Outcome N Observed Rate (%) Expected Rate (%)

30-day mortality 1052 0.19 0.37

30-day morbidity 1052 4.56 3.59

Pneumonia 1052 0.57a 0.49

Deep vein thrombosis/pulmonary embolism 1052 1.71a 1.00

Urinary tract infection 1050 0.86 0.75

Surgical site infection 1050 1.24 1.06

Return to operating room 1052 2.38 1.89


30-day morbidity 558 2.69 2.68



30-day mortality 419 0.00 0.50

30-day morbidity 419 6.21 4.36


97972_CCFBCH_Rev0_1-96.pdf 26 7/22/15 10:43 AM


Complications April 2011 – March 2014

All-Cause 30-Day Readmissions July 2011 – June 2014

Elective Primary Total Hip Arthroplasy and/or Total Knee Arthroplasty

The Centers for Medicare and Medicaid Services (CMS) calculates 2 elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) outcomes measures based on Medicare claims and enrollment information. The most recent risk-adjusted data available from CMS are shown. Although Cleveland Clinic’s THA/TKA complications and readmissions rates are both slightly lower than the US national rates, CMS ranks Cleveland Clinic’s performance on each as “no different than” the respective US national rates. To further reduce avoidable readmissions, Cleveland Clinic is focused on optimizing transitions from hospital to home or postacute facility. Specific initiatives have been implemented to ensure effective communication, education, and follow-up.

aSource: medicare.gov/hospitalcompare

0

4

6

5

3

2

1

Percent

Complications Readmissions

N = 794 844

Cleveland ClinicNational ratea

97972_CCFBCH_Rev0_1-96.pdf 27 7/22/15 10:43 AM

28 Outcomes 201428

Spinal Disease

100

80

60

40

20

0

Patients (%)

PDQ Score127N =

EQ-5D Score159

PHQ-9 Score90

ImprovedStableWorsened

Cervical Myelopathy

Change in Functional Status Following Cervical Decompression With Fusion for Myelopathy

Surgical Dates: Jan. 6, 2012 – July 1, 2014

In patients undergoing cervical decompression for myelopathy, among those with EuroQol (EQ-5D™) scores < 1 (N = 159), 36% noted improvement and 10% worsened in health-related quality of life. In those with baseline impairment of physical function, defined as Pain Disability Questionnaire (PDQ) score > 16, 39% noted improvement after surgery and 15% worsened. In those with at least moderate depressive symptoms, defined as a score ≥ 10 on the Patient Health Questionnaire (PHQ-9) prior to treatment, 14% noted improvement in depressive symptoms. Median duration of follow-up after surgery was 125 days (range, 48–719). In this and subsequent graphs, clinically meaningful change was defined as a change of half a standard deviation,1 or a total point change of 0.11, based on 2012 Neurological Institute data, for the EQ-5D, a total point change of > 16 for the PDQ, and a change of ≥ 5 points for the PHQ-9.2

References1. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003 May;41(5):582-592.

2. Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004 Dec;42(12):1194-1201.

The Center for Spine Health provides comprehensive care for a continuum of spinal disorders. Comprehensive care includes medical management, physical therapy, surgical interventions, minimally invasive injection procedures, specialized exercise programs, acupuncture, osteopathic manipulation, and referral to an in-house functional restoration program, all intended to maximize return to participation in vocational, family, and recreational activities.

The Center for Spine Health consists of surgeons, all board-certified in either neurosurgery or orthopedic surgery, and medical specialists board-certified in various fields that include rheumatology, physical medicine and rehabilitation, neurology, internal medicine, sports medicine, pain medicine, psychiatry, and psychology.

97972_CCFBCH_Rev0_1-96.pdf 28 7/22/15 10:43 AM


100

80

60

40

20

0

Patients (%)

PDQ Score38N =

EQ-5D Score45

PHQ-9 Score31


100

80

60

40

20

0

Patients (%)

PDQ Score10N =

EQ-5D Score17

PHQ-9 Score13


Change in Functional Status Following Single-Level Cervical Decompression Without Fusion for Myelopathy

Surgical Dates: Feb. 16, 2012 – June 5, 2014

Among patients undergoing single-level decompression without fusion for cervical myelopathy, 96% (N = 45) had EQ-5D < 1; 44% noted improvement and 9% worsened in health-related quality of life. In those with baseline impairment of physical function (N = 38), defined as PDQ > 16, 42% noted improvement after surgery and 15% worsened. Among patients undergoing single-level decompression without fusion for cervical myelopathy, 75% (N = 31) had at least moderate depressive symptoms (PHQ-9 ≥ 10) prior to treatment; 6.5% noted improvement and 10% worsened in depressive symptoms. Median duration of follow-up after surgery was 161 days (range, 48–668).

Change in Functional Status Following Multilevel Cervical Decompression Without Fusion for Myelopathy

Surgical Dates: Jan. 4, 2012 – Aug. 1, 2014

Among patients undergoing multilevel decompression without fusion for cervical myelopathy, 95% (N = 17) had EQ-5D < 1; 18% noted improvement, 71% remained stable, and 12% worsened in health-related quality of life. Among patients with baseline impairment of physical function (PDQ > 16), 70% noted improvement after surgery and 10% worsened. Among patients who had at least moderate depressive symptoms (PHQ-9 ≥ 10) prior to surgery, 77% remained stable and 23% worsened in depressive symptoms. Median duration of follow-up after surgery was 161 days (range, 83–238).

97972_CCFBCH_Rev0_1-96.pdf 29 7/22/15 10:43 AM

30 Outcomes 201430

Spinal Disease

100

80

60

40

20

0

Patients (%)

PDQ Score74N =

EQ-5D Score95

PHQ-9 Score38


Cervical Disc Herniation

Change in Functional Status Following Cervical Decompression With Fusion for Cervical Disc Herniation

Surgical Dates: Nov. 22, 2011 – July 1, 2014

In patients who underwent surgery for symptoms of cervical disc herniation, 39% of those with EQ-5D < 1 (N = 95) noted improvement and 9.5% noted worsening in health-related quality of life. In those with baseline impairment of physical function, as measured by the PDQ, 51% noted improvement after surgery and 9.5% worsened. In those with at least moderate depressive symptoms (PHQ-9 ≥ 10) prior to treatment, 21% noted improvement in depressive symptoms and the rest remained stable. Median duration of follow-up after surgery was 127 days (range, 55–497).

97972_CCFBCH_Rev0_1-96.pdf 30 7/22/15 10:43 AM


Reference1. Alvin MD, Lubelski D, Abdullah KG, Whitmore RG, Benzel EC, Mroz TE. Cost-utility analysis of anterior cervical discectomy and fusion with plating (ACDFP) versus posterior cervical foraminotomy (PCF) for patients with single-level cervical radiculopathy at 1-year follow-up. J Spinal Disord Tech. 2014 Mar 27. [Epub ahead of print]

Mean PDQ Score100

80

60

40

20

0Anterior Cervical Discectomy and Fusion

71Posterior Cervical Foraminotomy

19

Before surgeryOne year after surgery

N =

Mean EQ-5D Score1.0

0.8

0.6

0.4

0.2

0Anterior Cervical Discectomy and Fusion

71Posterior Cervical Foraminotomy

19N =

Before surgeryOne year after surgery

Cost-Effectiveness in Cervical Spine Surgery

Cleveland Clinic’s Center for Spine Health recognizes the drive to document value and has engaged in a program to measure, compare, and intervene to improve value. The center recently published a comparison of 2 surgeries commonly performed in the cervical spine: anterior cervical discectomy and fusion with plating (ACDFP) and posterior cervical foraminotomy (PCF).1 Both surgeries produced meaningful postoperative improvement in physical function and health-related quality of life, but PCF costs about 23% less than ACDFP. Further work is needed to determine appropriate indications for each surgery and predictors of cost variance.

Change in Physical Function and Quality of Life Following Cervical Spine Surgeries

Surgical Dates: 2009 – 2011

97972_CCFBCH_Rev0_1-96.pdf 31 7/22/15 10:43 AM

32 Outcomes 201432

Spinal Disease

100

80

60

40

20

0

Patients (%)

PDQ Score82N =

EQ-5D Score91

PHQ-9 Score54


Lumbar Spinal Stenosis

Surgical Treatment

Spinal stenosis results in narrowing of the spinal canal, which often causes leg pain that can impair walking, standing, and many aspects of daily function. For symptomatic patients, the goal of surgery is to decompress the spinal canal to eliminate neural compression and relieve leg pain; this may or may not require instrumented fusion of the operated levels.

Change in Functional Status Following Lumbar Decompression With Fusion for Spinal Stenosis

Surgical Dates: Dec. 30, 2011 – Jan. 2, 2014

Among 91 patients undergoing lumbar decompression with fusion, all had EQ-5D < 1; 59% noted improvement and 8% worsened in health-related quality of life after surgery. Clinically meaningful change was defined as half a standard deviation,1 or a total point change of 0.11. Of the patients who had baseline impairment of physical function (PDQ > 16), 57% noted improvement after surgery and 10% worsened. Clinically meaningful change was defined as a total point change of > 16. Among patients reporting at least moderate depressive symptoms (PHQ-9 ≥ 10) prior to surgery, 20% noted improvement and 6% worsened in depressive symptoms. Clinically meaningful change was defined as a total point change of 5.2 Median duration of follow-up was 150 days after surgery (range, 45–524).

References1. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003 May;41(5):582-592.

2. Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004 Dec;42(12):1194-1201.

97972_CCFBCH_Rev0_1-96.pdf 32 7/22/15 10:43 AM

3333Orthopaedic & Rheumatologic InstituteOrthopaedic & Rheumatologic Institute

100

80

60

40

20

0

Patients (%)

Glioma13

Schwannoma4N =

Angioma23

Lipoma5

Ependymoma53


12

10

8

6

4

2

0

Readmission Rate (%)

Q1

272

Q2

309

Q3

294

Q4

309

Q1

290

Q2

284

Q3

296

Q4

27820132012

N =

Q1

254

Q2

437

Q3

408

Q4

2742014

Intramedullary Spinal Cord Tumors

Change in Functional Status Following Surgery for Intramedullary Spinal Cord Tumors (N = 98)

1999 – 2014

Intramedullary spinal cord tumors are uncommon, but potentially catastrophic. Among 98 consecutive patients operated on over 15 years, 54% to 75% achieved functional improvement after surgery and 13% to 40% of patients had worsening of functional status after surgery, as measured with the Modified McCormick Scale, which grades neurological function in spinal cord disorders. Mean duration of follow-up was 65 months.

Readmissions and Mortality

30-Day Unplanned Readmission Rate Among Spine Center Patients (N = 3705)

2012 – 2014

New protocols were initiated in 2012 in an effort to reduce unplanned 30-day readmissions. These new protocols included a Discharge Call Program to contact patients 48 hours after discharge to review disease symptoms, medications, and follow-up plans and to address any questions the patient may have about the plan of care. Patients readmitted for planned surgery or other planned procedures were excluded. N = total number of patients discharged per quarter.

97972_CCFBCH_Rev0_1-96.pdf 33 7/22/15 10:43 AM

34 Outcomes 201434

Spinal Disease

30-Day Postoperative Mortality Rate Following Spinal Surgery (N = 3468)

2014

The 30-day postoperative mortality rate following spinal surgery in 2014 was 0.14%, compared with a rate of 0.30% for the National Surgical Quality Improvement Program (NSQIP)1 database and a rate of 0.40% for the Medicare database.2

References1. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ. Risk

factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program (NSQIP). J Bone Joint Surg Am. 2011 Sep 7; 93(17):1577-1582.

2. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010 Apr 7; 303(13):1259-1265.

New protocols introduced in 2012 to reduce surgical site infections include nasal staphylococcus surveillance and decolonization protocols, an updated perioperative scrub protocol, new rules restricting operating room traffic and updating operating room table preparation, and new wound closure recommendations. The most recent overall postoperative infection rates in the Spine Center of 1.5% for 2013 and 1.9% for 2014 compare favorably with available published data ranging from 1.4% to 11%.1, 2 N = spinal surgeries with available infection surveillance data.

10

8

6

4

2

0

Infections per 100 Clean Cases

N =

Q1

377

Q2

354

Q3

384

Q4

3632013

Q1

366

Q2

366

Q3

366

Q4

3802012

Q1

344

Q2

351

Q3

343

Q4

3452014

Surgical Site Infections

Surgical Site Infection Rates for Spinal Surgery (N = 2861)

2012 – 2014

References1. Smith JS, Shaffrey CI, Sansur CA, Berven SH, Fu KM, Broadstone PA, Choma TJ, Goytan

MJ, Noordeen HH, Knapp DR Jr, Hart RA, Donaldson WF 3rd, Polly DW Jr, Perra JH, Boachie-Adjei O; Scoliosis Research Society Morbidity and Mortality Committee. Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine. 2011 Apr 1; 36(7):556-563.

2. Schimmel JJ, Horsting PP, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J. 2010 Oct; 19(10):1711–1719.

1.0

0.8

0.6

0.4

0.2

0

Mortality Rate (%)

Cleveland ClinicNSQIP1

Medicare2

97972_CCFBCH_Rev0_1-96.pdf 34 7/22/15 10:43 AM


100

80

60

40

20

0

Percent of Total Cost

30 Days Presurgery 90 Days PostsurgeryDay of Surgery

Before initiative (N = 993)After initiative (N = 846)

Cost Reduction With Implementation of Surgical Site Infection Prevention Initiative (N = 1839)

Surgical Dates: April 2012 – December 2013

Average direct internal cost per patient (as a percentage of total direct internal cost before the initiative) was compared for similar cohorts of patients before (April–December 2012) and after (April–December 2013) implementation of the surgical site infection reduction initiative. Overall, comparing nearly 1000 matched patients in each cohort, there was a 14% reduction in average total cost per patient postinitiative. Use of nasal swabs and preoperative antiseptic wash solutions added minimally to the preoperative cost, defined as health system related cost 30 days prior to surgery. Average intraoperative costs decreased minimally by 3%. The main cost savings occurred in the 90 days after surgery, presumably related to a reduction in emergency department visits and readmissions related to surgical site infections.

97972_CCFBCH_Rev0_1-96.pdf 35 7/22/15 10:43 AM

36 Outcomes 201436

Sports Medicine

Concussion is a type of mild traumatic brain injury caused by a bump, blow, or jolt to the head that can present with a variety of symptoms. Cleveland Clinic’s Concussion Center is a leader in the evaluation and management of patients with concussion. In an effort to optimize community-based sports concussion care, the Concussion Center developed and implemented standardized methods of reporting, evaluating, and managing concussion injury in youth and high school athletes. The following outcomes highlight sports concussion care using the Concussion Center’s highly integrated, multidisciplinary approach.

Incident Reporting

The collection and reporting of head injury details (eg, symptoms, date, time, location of injury, and action taken) facilitates the collaboration of care between athletic trainers on the sideline and physicians in the hospital or office. The development and deployment of the Concussion Incident Report module to a mobile device, iPad®, or iPhone® allows athletic trainers, who are typically the first medical personnel to evaluate an injured athlete, to track head injury details. Additional assessment modules are utilized to objectively characterize aspects of cognitive and motor status.

97972_CCFBCH_Rev0_1-96.pdf 36 7/22/15 10:43 AM


30,000

20,000

10,000

0

3000

2000

1000

0

Assessments Incident Reports

Q3 Q42013

Q1 Q2 Q3 Q42014

Follow-upIncident reports

Baseline

The graph illustrates the historical use of the Cleveland Clinic Concussion (C3) Application and the Incident Report (IR) after the pilot phase. Collectively, both the preseason baseline and in-season follow-up assessments increased dramatically from 2013 to the beginning of the fall 2014 sports season. The Concussion Center is currently analyzing both baseline and postinjury data for this data set. As shown by the red line, the number of IRs dramatically increased starting in July 2014, after all Cleveland Clinic athletic trainers received education on its use. The remainder of the reported outcomes will focus on the IR as it provides data that will guide process improvement, facilitate patient hand-offs, and allow calculation of injury rates for communication to community partners.

Incident Reporting Over Time

June 2013 – December 2014

97972_CCFBCH_Rev0_1-96.pdf 37 7/22/15 10:43 AM

38 Outcomes 201438

Sports Medicine

Concussion Incidence Across Various Sports (N = 507)

July 2014 – January 2015

Between July 2014 and January 2015, football, girls’ and boys’ soccer, girls’ basketball, and boys’ wrestling had the highest reported incidence of sports-related concussion. The frequency of these data is similar to those reported throughout the US.1

Reference1. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012 Apr;40(4):747-755.

300

200

100

0

Number of Concussions

Footb

all

Girls’ S

occe

r

Boys’

Socc

er

Girls’ B

aske

tball

Boys’

Wres

tling

Girls’ V

olley

ball

Boys’

Baske

tball

Boys’

Ice H

ocke

y

Chee

rlead

ing

Girls’ S

wim/D

ive

Boys’

Swim

/Dive

Girls’ G

ymna

stics

97972_CCFBCH_Rev0_1-96.pdf 38 7/22/15 10:43 AM


The rates of concussion IR were higher in competition than in practice for all sports, except wrestling, cheerleading, and swimming/diving, in the Cleveland Clinic patient population, and the overall rates of observed concussions among girls’ volleyball and both boys’ and girls’ soccer were higher compared with a national sample.1 The presence of Cleveland Clinic high school athletic trainers at soccer and volleyball practices and competitions likely improved detection. Increased popularity of soccer, as well as community education and awareness of concussion signs and symptoms, may contribute to greater incidence among these athletes.

Concussion Rates by Sport and Venue for High School Athletes (N = 507)


Reference1. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012 Apr;40(4):747-755.

Football

Boys’ ice hockey

Boys’ soccer

Boys’ wrestling

Boys’ basketball

Boys’ swimming/diving

Girls’ soccer

Girls’ basketball

Girls’ gymnastics

Cheerleading

Girls’ volleyball

Girls’ swimming/diving

27.36

2.56

6.89

1.97

2.17

0.00

11.61

4.13

0.20

0.20

2.36

0.00

Sport Game/Event(%)

Practice(%)

Cleveland Clinic

Total(%)

23.82

0.79

1.38

3.35

1.97

0.39

2.17

2.56

0.00

1.18

2.17

0.59

51.18

3.35

8.27

5.31

4.13

0.39

13.78

6.69

0.20

1.38

4.53

0.59

33.58

4.23

5.39

3.86

4.35

0.00

8.15

5.21

0.12

0.12

0.98

0.12

Game/Event(%)

Practice(%)

National1

Total(%)

22.30

0.67

0.92

3.00

1.53

0.12

1.59

1.35

0.06

1.29

0.92

0.12

55.88

4.90

6.31

6.86

5.88

0.12

9.74

6.56

0.18

1.41

1.90

0.24

97972_CCFBCH_Rev0_1-96.pdf 39 7/22/15 10:43 AM

40 Outcomes 201440

Sports Medicine

To better understand how age and position played in football may affect concussion rates, patients with concussion were evaluated in 3 age groups. High school athletes reported 183 concussions while playing football, which is consistent with prior reports of the associated increased incidence of concussion in football players.1 Within the 14- to 17-year-old age group, 47% of football-related concussions occurred on offense, while 37% occurred while playing defense. Offensive and defensive linemen accounted for 32%, 31.1%, and 30.7% of concussions across the < 14, 14–17, and ≥ 18 age groups, respectively. Linemen account for nearly half of football positions on the field. Wide receivers accounted for 12% of all concussions, despite making up approximately 9.1% of the positions on the field.

Reference1. Marar M, McIlvain NM, Fields SK, Comstock

RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012 Apr;40(4):747-755.

Distribution of Football-Associated Concussions by Age and Position (N = 260)


5

4

3

2

1

0

Quarte

rbac

k

Offens

ive Li

ne

Defens

ive Li

ne

Lineb

acke

r

Runnin

g Bac

k

Corn

erbac

k

Fullb

ack

Safet

y

Tight

End

Other

Frequency

10

8

6

4

2

0

Offens

ive Li

ne

Wide

Rec

eiver

Defens

ive Li

ne

Lineb

acke

r

Spec

ial Tea

ms

Corn

erbac

kSa

fety

Runnin

g Bac

k

Quarte

rbac

k

Tight

End

Fullb

ack

Punt

Return

er

Frequency

40

30

20

10

0

Offens

ive Li

ne

Wide

Rec

eiver

Defens

ive Li

ne

Lineb

acke

r

Spec

ial Tea

ms

Corn

erbac

kSa

fety

Runnin

g Bac

kOth

er

Quarte

rbac

k

Tight

End

Fullb

ack

Kick

Retu

rner

Frequency

Age < 14

Age 14 – 17

Age ≥ 18

97972_CCFBCH_Rev0_1-96.pdf 40 7/22/15 10:43 AM


The immediate action following the identification of or evaluation for a concussion is critical in terms of preventing a more serious injury as a result of an immediate subsequent blow to the head. As shown in the graph, most athletes were sent to the locker room or remained on the sideline. Unfortunately, 6.1% exhibited more concerning signs and symptoms and were sent to a local emergency department for a more thorough evaluation. Among athletes who were removed from play and evaluated at the time of injury, 4.3% (N = 7) were returned to play after it was determined that they did not suffer a concussion. The incident reports show a disturbing 6.1% of athletes (N = 10) who did not report their injury during the athletic event and continued to play, putting them at higher risk for further injury and a more prolonged recovery. N = number of same day incident reports.

70

60

50

40

30

20

10

0

Frequency

Sent toLocker Room

Remainedon Sideline

Sent Home Sent to ED Returned to Play;No Concussion

No ActionTaken; InjuryNot Reported

Same-Day Incident Reports: Action Taken After Concussion (N = 163)


ED = emergency department

97972_CCFBCH_Rev0_1-96.pdf 41 7/22/15 10:43 AM

42

Patient Visit Volumes

2010 − 2014

Volume of New Rheumatoid Arthritis Patient Visits

2010 − 2014

0

60

50

40

20

30

10

70

Total Visits (in Thousands)

201052,276

201154,110

201257,755N =

201465,556

201361,861

Cleveland Clinic regional practices Cleveland Clinic main campus

0

1200

1000

800

400

600

200

1400

Number of Patients

20101324

20111153

20121100N =

20141110

20131096

Outcomes 201442

Rheumatology Overview

Since the beginning of

the BIOLOGIC SUMMITS

in 2005, this local

meeting has grown into

an international event.

In 2015, more than 400

attendees will gather

in Cleveland. More

impressively, each SUMMIT

has been repurposed and

posted at ccfcme.org/

rheumcme and is available

free to all. As of 2014, the

R. J. Fasenmyer Center for

Clinical Immunology has

issued more than 36,000

hours of continuing medical

education credit for this

remarkable meeting.

97972_CCFBCH_Rev0_1-96.pdf 42 7/22/15 10:43 AM

43

Volume of New Granulomatosis With Polyangiitis (Wegener’s) Patient Visits

2010 − 2014

Most Common Conditions Treated in 2014a

Condition Volume

Rheumatoid arthritis 5367

Osteoporosis 5192

Connective tissue diseases 3645

Osteoarthritis 3451

Soft tissue rheumatism 2629

Vasculitis 2267

Fibromyalgia 2163

Chronic pain syndromes 1007

Immunodeficiency diseases 941

Unspecified arthritis 749

Psoriatic arthritis 705

Gout 667

Spinal diseases 632

Polymyalgia rheumatica 570

Sprains 530

Ankylosing spondylitis 410

Diseases of the eye 371

Volume of Visits of Patients With Rare Disorders in 2014

Diagnosis Volume

Giant cell arteritis 258

Sarcoidosis 154

Familial Mediterranean fever 134

Common variable immunodeficiency 122

Takayasu disease 99

Behcet syndrome 80

Hypermobility syndrome 41

Ehlers-Danlos syndrome 27

Cerebral arteritis 19

Erythema nodosum 12

Inclusion body myositis 6

Mononeuritis multiplex 3

ªExcludes Cleveland Clinic family health centers

0

100120

8060

2040

140

Number of Patients

2010134

2011112

201281N =

201496

201389


97972_CCFBCH_Rev0_1-96.pdf 43 7/22/15 10:43 AM

44

Volume of Medication Infusions Cleveland Clinic Main Campus — Outpatient

2010 – 2014

Medication 2010 2011 2012 2013 2014

Intravenous immunoglobulin (Gammagard®) 428 528 563 666 641

Infliximab (Remicade®) 680 608 555 580 623

Rituximab (Rituxan®) 158 322 355 494 556

Abatacept (Orencia®) 525 489 361 351 334

Zoledronic acid (Reclast®) 348 375 366 321 262

Tocilizumab (Actemra®) 32 67 159 186 177

Belimumab (Benlysta®) 0 41 82 127 131

Pegloticase (Krystexxa®) 0 8 65 39 70

Cyclophosphamide (Cytoxan®) 20 20 21 9 25

Methylprednisolone (Solu-Medrol®) 10 10 6 14 16

Ibandronate (Boniva®) 16 34 16 9 8

Basiliximab (Simulect®) 0 10 10 0 0

Pamidronate (Aredia®) 6 5 7 2 0

Volume of New Psoriatic Arthritis Patient Visits

2010 − 2014

0

100

150

50

200

Number of Patients

2010129

2011158

2012134N =

2014135

2013129

Outcomes 201444

Rheumatology Overview

97972_CCFBCH_Rev0_1-96.pdf 44 7/22/15 10:43 AM

45

Percentage of Cardiac Transplant Patients Who Had a DXA Scan

2001 − 2014

Percentage of Lung Transplant Patients Who Had a DXA Scan

2001 − 2014

DXA = dual energy x-ray absorptiometry DXA = dual energy x-ray absorptiometry

Glucocorticoid use is associated with bone loss and fractures. The 2010 American College of Rheumatology guidelines on glucocorticoid-induced osteoporosis recommend a DXA scan for patients on glucocorticoid therapy for 3 months or more. Cardiac transplant recipients receive glucocorticoids for more than 3 months after surgery to prevent organ rejection. Fewer than 15% of transplant patients had DXA scans before or within 6 months after transplant in 2001. Collaboration between the Transplant and Osteoporosis centers since 2001 has significantly improved the frequency of DXA scans in cardiac transplant patients before or within 6 months after transplant surgery.

Lung transplant recipients receive glucocorticoids for more than 3 months after surgery to prevent organ rejection. Collaboration between the Transplant and Osteoporosis centers since 2001 has resulted in a continued high frequency of DXA scans in lung transplant patients before or within 6 months after transplant surgery.

100

80

60

40

20

Percent

0200186

2010122

2011107

2012104N =

201398

2014106

100

80

60

40

20

Percent

02001134

201048

201155

201244N =

201353

201455


Transplant

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46

Percentage of Osteoporosis Patients Started on Denosumab Who Received Continued Therapy at Specified Intervals

2010 − 2014

Denosumab (Prolia®) is a medication for patients with low bone mass who are at high risk for fracture. Once treatment is started, current guidelines recommend treatment at 6-month intervals. Delays in treatment result in loss of effect. After initiation of therapy with denosumab, a second dose was administered to 68.9% of patients at 6 months ± 30 days, to 78.1% within 6 months ± 60 days, and to 82.4% within 6 months ± 90 days. Of those who received a second

dose, a third dose was administered to 72.8% of patients at 6 months ± 30 days, to 81.2% within 6 months ± 60 days, and to 86.1% within 6 months ± 90 days. For those who received continued treatment, the rate of subsequent injections increased over time through the eighth dose. Systematic methods to monitor drug dosing at recommended intervals are needed to improve compliance with established guidelines.

Percentage of Osteoporosis Patients Started on Denosumab Who Continued Osteoporosis Therapy (N = 602)

2010 − 2014

Adherence to an oral bisphosphonate regimen is poor, with < 50% of patients on therapy at 1 year. Adherence to an injectable medication regimen is a function of patient acceptance and systems measures in practice to ensure patient scheduling. Of 602 patients receiving their first dose of denosumab, 496 (82.4%) received a second dose of medication. Of the 106 patients not receiving a second dose of denosumab, approximately 20% received another osteoporosis medication.

100

80

60

40

20

Percent

0Second Dose Denosumab

100

80

60

40

20

Percent

0Second Dose

602Third Dose

389Fourth Dose

242Fifth Dose

140Sixth Dose

73Seventh Dose

32Eighth Dose

11N =

6 months ± 30 days6 months ± 60 days6 months ± 90 days

Outcomes 201446

Osteoporosis

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47

Percentage of Patients Treated With Denosumab Who Had Vitamin D and Calcium Testing Prior to Treatment (N = 2475)

2010 – 2014

Percentage of Osteoporosis Patients Started on Zoledronic Acid Who Received Continued Therapy at Specified Intervals

2010 − 2014

Denosumab (Prolia) is a treatment for osteoporosis given as an injection every 6 months. It has been associated with hypocalcemia, which is more common in patients with preinjection hypocalcemia and vitamin D deficiency. A serum calcium and vitamin D test is suggested within the preceding year to reduce the risk of hypocalcemia: 80.9% and 92.2% of patients had serum calcium testing in the preceding 180 and 365 days, respectively, while 87.9% and 91.2% of patients had vitamin D testing in the preceding 180 and 365 days, respectively.

Zoledronic acid (Reclast®) is a medication for patients with low bone mass who are at high risk for fracture. Once treatment is started, current guidelines recommend treatment at 1-year intervals. Delays in treatment may result in loss of effect. After initiation of therapy with zoledronic acid, a second dose was administered to 61.7% of patients at 1 year ± 30 days, to 74.5% within 1 year ± 60 days, and to 80.8% within 1 year ± 90 days. Of those who received a second dose, a third dose was administered to

74.5% of patients at 1 year ± 30 days, to 80.4% within 1 year ± 60 days, and to 86.7% within 1 year ± 90 days. Of those who received a third dose, a fourth dose was administered to 80.8% of patients at 1 year ± 30 days, to 86.7% within 1 year ± 60 days, and to 95.7% within 1 year ± 90 days. Systematic methods to monitor drug dosing at recommended intervals are needed to improve compliance with established guidelines.

100

80

60

40

20

Percent

0180 365

Days Prior to Infusion

Serum calciumVitamin D

100

80

60

40

20

Percent

0Second Dose

1113Third Dose

542Fourth Dose

140N =

1 year ± 30 days1 year ± 60 days1 year ± 90 days


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48

Percentage of Osteoporosis Patients Started on Zoledronic Acid Who Continued Osteoporosis Therapy (N = 1113)

2010 − 2014

Adherence to oral bisphosphonate medication is poor, with < 50% of patients on therapy at 1 year. Adherence with an infusible medication is a function of patient acceptance and systems measures in practice to ensure patient scheduling. Of 1113 patients receiving their first dose of zoledronic acid, 900 (80.9%) received a second dose of medication. Of the 213 patients not receiving a second dose of zoledronic acid, approximately 25% were changed to another osteoporosis medication.

Percentage of Patients Treated With Zoledronic Acid Who Had Renal Function Testing Prior to Infusion (N = 1517)

2010 − 2014

Zoledronic acid (Reclast) infusion for osteoporosis is not recommended for patients with a glomerular filtration rate ≤ 35 mL/min. During the period 2010–2014, 96.4% of patients had renal function testing with a creatinine and estimated glomerular filtration rate within 365 days prior to infusion.

A chart survey of 20 patients who did not have an estimated glomerular filtration rate in the electronic medical record revealed that all 20 had labs done outside Cleveland Clinic, which were documented in the chart prior to zoledronic acid infusion.

100

80

60

40

20

Percent

0Second Dose Zoledronic Acid

48 Outcomes 2014

Osteoporosis

100

80

60

40

20

Percent

090 180 365


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49

Percentage of Patients on Glucocorticoids Treated With Osteoporosis Medications (N = 1800)

2009 − 2014

Percentage of Patients Treated With Zoledronic Acid Who Had Vitamin D Testing Prior to Infusion (N = 3811)

2010 − 2014

DXA = dual energy x-ray absorptiometry, FRAX = World Health Organization Fracture Risk Assessment Tool

American College of Rheumatology guidelines for glucocorticoid-induced osteoporosis (GIO) recommend treatment based on duration and dose of steroid therapy and absolute fracture risk for major osteoporotic fractures using the FRAX tool (World Health Organization Fracture Risk Assessment Tool). Treatment is recommended for most patients with a 10-year absolute fracture risk of major osteoporotic fractures ≥ 10%.

National Osteoporosis Foundation guidelines in the US recommend treatment if the FRAX 10-year risk is ≥ 20%. Patients on glucocorticoids for > 90 days were examined by absolute fracture risk categories for major osteoporotic fractures. In patients with a 10-year risk for fracture ≥ 20%, 59.1%, 65.5%, and 70.9% were on therapy for GIO at 90, 180, and 365 days, respectively.

100

80

60

40

20

Percent

090 180 365


100

80

60

40

20

Percent

090 180 365

FRAX® < 10% FRAX 10% – 20%FRAX > 20%

Days Post DXA


Zoledronic acid (Reclast) infusion for osteoporosis may be associated with hypocalcemia after infusion. Patients with hypovitaminosis D are at high risk for hypocalcemia. Obtaining a vitamin D level is considered standard of care for patients prior to infusion. More than 91% of patients undergoing infusion had a vitamin D level measured within 365 days before infusion.

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50

Percentage of Patients With Low Bone Mass (T-Score ≤ – 2.5) and High Fracture Risk by FRAX Who Were Treated With Osteoporosis Medications

2009 − 2014

DXA = dual energy x-ray absorptiometry, FRAX = World Health Organization Fracture Risk Assessment Tool

Current guidelines recommend treatment of patients with low bone mass, with a T-score ≤ – 2.5 at the hip or lumbar spine, or patients who have a 10-year absolute fracture risk as calculated by FRAX of ≥ 20% for major osteoporotic fracture or ≥ 3% for hip fracture. Patients were reviewed who were not on treatment at the time of a bone density scan and had low bone mass or high fracture risk, who were then placed on therapy for osteoporosis with medications (bisphosphonates, denosumab, raloxifene, and teriparatide). For the period 2009–2014, more than 80% of patients were placed on medication within 90 days, with small increases in treatment after that time up to 365 days. For the periods 2009–2013 and 2009–2014, treatment rates have trended higher.

100

80

60

40

20

Percent

090 180 365

2009 – 2012 (N = 317) 2009 – 2013 (N = 424)2009 – 2014 (N = 436)

Days Post DXA

50

Osteoporosis

Cleveland Clinic’s dual energy x-ray absorptiometry (DXA) registry enrolled its first patient in 2009. The

ability to combine bone density registry data with the World Health Organization’s FRAX 10-year absolute

fracture risk, osteoporosis medications, and glucocorticoid use has created a powerful tool for quality

improvement and outcomes. A collaboration with the University of Alabama will combine DXA registries

and allow linkage of patients with Medicare claims data. Enrollment in Cleveland Clinic’s DXA registry

through 2014 totals more than 55,000 patients.

Outcomes 2014

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51

Percentage of Gout Patients Treated With Urate-Lowering Therapy Who Reached Target Uric Acid Level (N = 2143)

2001 − 2014

2001 – 2011 73.8% 12.6% 13.6%2001 – 2012 73.9% 12.7% 13.4%2001 – 2013 73.2% 13.3% 13.5%2001 – 2014 71.6% 13.5% 14.9% Patients in this cohort had a diagnosis of gout, had at least 2 visits with a Cleveland Clinic rheumatologist, and were prescribed a uric acid-lowering agent (allopurinol or febuxostat). The recommended target uric acid level was ≤ 6.0 mg/dL. Between 71.6% and 73.9% of patients had a uric acid level of ≤ 6.0 mg/dL between 2001 and 2014, demonstrating successful treatment to reach the target level. Additionally, 12.6% to 13.5% of patients had a uric acid level between 6.1 mg/dL and 7.0 mg/dL, demonstrating acceptable levels. Between 13.4% and 14.9% of patients did not achieve target levels, with uric acid levels > 7.0 mg/dL.

The percentage of patients who achieved target plus acceptable uric acid levels remains stable; however, substantial numbers of patients are undertreated with urate-lowering therapy.

100

80

60

40

20

Percent

0≤ 6.0 mg/dL 6.1 – 7.0 mg/dL

Uric Acid Level

> 7.0 mg/dL

2001 – 20112001 – 20122001 – 20132001 – 2014


Gout

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52

Percentage of Tophaceous Gout Patients Treated With Urate- Lowering Therapy Who Reached Target Uric Acid Level (N = 131)

2001 − 2014

2001 – 2011 75.3% 9.4% 15.3%2001 – 2012 77.1% 9.5% 13.3% 2001 – 2013 79.5% 8.6% 12.0% 2001 – 2014 77.1% 9.5% 13.0%

Patients in this cohort had a diagnosis of tophaceous gout, had at least 2 visits with a Cleveland Clinic rheumatologist, and were prescribed a uric acid-lowering agent (allopurinol or febuxostat). The recommended target uric acid level was ≤ 6.0 mg/dL. Between 75.3% and 79.5% of patients had a uric acid level of ≤ 6.0 mg/dL between 2001 and 2014, demonstrating successful treatment to reach the target level. Additionally, 8.6% to 9.5% of patients had a uric acid level between 6.1 mg/dL and 7.0 mg/dL, demonstrating acceptable levels. Between 12.0% and 15.3% of patients did not achieve target levels, with uric acid levels > 7.0 mg/dL.

The percentage of patients with tophaceous gout who reached uric acid levels < 7.0 mg/dL was similar to the percentage of patients in the entire gout cohort; however, substantial numbers of patients are undertreated with urate-lowering therapy.

100

80

60

40

20

Percent

0≤ 6.0 mg/dL 6.1 – 7.0 mg/dL

Uric Acid Level

> 7.0 mg/dL

2001 – 20112001 – 20122001 – 20132001 – 2014

Outcomes 201452

Gout

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53

Number of Gout Patients Treated With Pegloticase Who Reached Target Uric Acid Level

2013 – 2014

Pegloticase (Krystexxa®) is a pegylated uricase indicated for the treatment of chronic gout in adult patients resistant to conventional therapy. It is given as an IV infusion every 2 weeks. Anaphylaxis and immune reactions can occur and are based on formation of antibodies. The antibodies result in a loss of effect of the drug, which has been shown to precede the reactions in 91% of cases. Typically, uric acid levels fall below 1 mg/dL; with loss of effect, uric acid levels are higher. This has led to the recommendation that a uric acid level be checked before each infusion. Treatment should be discontinued if uric acid rises to 6 mg/dL or greater on 2 consecutive tests. In 2013, 34 pegloticase infusions were performed in 5 patients; serum uric acid was checked prior to infusion in all cases and was < 6 mg/dL in all tests. No infusion reactions occurred. In 2014, 70 pegloticase infusions were performed in 7 patients; 68 had a uric acid level checked, and 66 were < 6 mg/dL. In the 2 with uric acid levels > 6 mg/dL, pegloticase was discontinued.

80

60

40

20

Number of Infusions

0Infusions Serum Uric Acid

Checked Serum Uric Acid < 6 mg/dL

2013 (N = 34)2014 (N = 70)


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54

Percentage of Rheumatoid Arthritis Patients Taking Disease-Modifying Antirheumatic Drug Therapy (N = 17,715)

2010 − 2014

American College of Rheumatology guidelines recommend that rheumatoid arthritis patients be treated with disease-modifying antirheumatic drug (DMARD) therapy. More than 99% of rheumatoid arthritis patients who were seen in the Department of Rheumatology at least 2 times during the years 2010, 2011, 2012, 2013, and 2014 were treated with DMARD therapy. Reasons for not prescribing DMARD therapy for the small percentage of patients not on DMARDs included disease remission, refusal of treatment, and contraindications to DMARD therapy. In any given year, 93% to 95% of patients were on a DMARD.

100

80

60

40

20

Percent

020103201

20113432

20123605N =

20133640

20143837

Outcomes 201454

Rheumatoid Arthritis

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55

Percentage of Rheumatoid Arthritis Patients Treated With Methotrexate Who Were Prescribed Folic Acid (N = 8644)

2007 − 2014

Methotrexate is an effective and frequently used medication for the treatment of rheumatoid arthritis. Long-term therapy is usually required for effective treatment. Methotrexate side effects are a common reason for discontinuation. A Cochrane Review1 of 6 randomized controlled trials demonstrated that concomitant use of folic acid reduced gastrointestinal toxicity, abnormal transaminase elevation, and patient withdrawal symptoms from methotrexate with no reduction in efficacy. Use of folic acid should be considered in all patients with rheumatoid arthritis. More than 88% of patients were prescribed folic acid; a chart review of a subset of patients who did not receive a folic acid prescription showed frequent use of over the counter preparations.

Percentage of Newly Diagnosed Patients With Rheumatoid Arthritis Starting Biologic DMARDs Who Had Tuberculosis Testing

2013 – 2014

Reference1. Shea B, Swinden MV, Tanjong Ghogomu E, Ortiz Z, Katchamart

W, Rader T, Bombardier C, Wells GA, Tugwell P. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev. 2013 May 31;5:CD000951.

Reference1. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM,

Moreland LW, O’Dell J, Winthrop KL, Beukelman T, Bridges SL Jr, Chatham WW, Paulus HE, Suarez-Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625-639.

The 2012 Update of the 2008 American College of Rheumatology (ACR) Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis1 recommends tuberculosis (TB) screening before using biologic agents to identify latent TB infection (LTBI). The ACR recommends the tuberculin skin test or interferon-γ release assays as the initial test in all rheumatoid arthritis patients starting biologic agents, regardless of risk factors for LTBI. In 2013, 91% (73 of 81) and in 2014, 93% (102 of 109) of patients had TB testing.

DMARDs = disease-modifying antirheumatic drugs

100

80

60

40

20

Percent

02013

812014109N =

100

80

60

40

20

Percent

02007810

20081033

20091036

20101180N =

2011 2012 20141188 1191 1088

20131118


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56

Patients with HIV/AIDS should have a rapid plasma reagin for syphilis yearly and screening for hepatitis B and C at the baseline visit. All patients had hepatitis screening at baseline, and 85% to 100% had screening for syphilis during 2011–2014. These outcomes are based on guidelines prepared by the National Committee for Quality Assurance, HIV Medicine Association, Infectious Diseases Society of America, and HIV/AIDS Workgroup, and are the standard of care for HIV patients.

100

80

60

40

20

Patients (%)

0Rapid Plasma Reagin Yearly Hepatitis B/C Screen at Baseline

2011201220132014

Outcomes 201456

Immunodeficiency

Percentage of Patients With HIV/AIDS Who Obtained Lab Tests per Recommended Guidelines (N = 85)

2011 – 2014

Percentage of Patients With HIV/AIDS Who Obtained Lab Tests per Recommended Guidelines (N = 85)

2013 – 2014

Patients with HIV/AIDS should have testing for tuberculosis at the baseline visit; 74% of patients in the cohort had tuberculosis testing in 2013 and 88% in 2014. The goal of treatment is viral suppression to a level < 400 copies/mL: 94% of patients had a documented viral load < 400 copies/mL in 2013, and 99% in 2014; 68% of patients had a viral load < 400 copies/mL on every test in 2013, and 91% in 2014. These outcomes are based on guidelines prepared by the National Committee for Quality Assurance, HIV Medicine Association, Infectious Diseases Society of America, and HIV/AIDS Workgroup, and are the standard of care for HIV patients.

100

80

0

60

40

20

Patients (%)

Viral Load< 400 Copies/mL

Viral Load< 400 Copies/mL

All Tests

TuberculosisTesting

20142013

97972_CCFBCH_Rev0_1-96.pdf 56 7/22/15 10:43 AM


Percentage of CVID Patients Who Meet Diagnostic, Evaluation, and Treatment Guidelines

2013 – 2014

CVID = common variable immunodeficiency, CT = computed tomography, LFT = liver function tests, PFT = pulmonary function testing

The diagnosis of common variable immunodeficiency (CVID) requires low levels of IgG, low IgA or IgM, and poor response to vaccines. Replacement immunoglobulin therapy is recommended regardless of infectious history, and expert consensus suggests that trough levels be > 500 mg/dL to prevent infections. Pulmonary function testing (PFT) or a computed tomography (CT) scan of the chest, liver function tests (LFT), and creatinine levels are recommended as yearly follow-up testing. B-cell subsets are recommended at the time of diagnosis because of their value in predicting future clinical course. These current guidelines are based on expert panel recommendations formulated through the Immune Deficiency Foundation as well as published recommendations of experts in the field.

100

80

0

60

40

20

Patients (%)

Low IgG andLow IgA or IgM

B-Cell Subset VaccinationTesting

PFT or CT LFT and Creatinine

ImmunoglobulinTreatment

Trough IgG> 500 mg/dL

2014 (N = 50)2013 (N = 26)

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58

Cardiovascular Risk in Psoriatic Arthritis Using Serum Paraoxonase and Arylesterase Activities (N =134)

2011 − 2014

Psoriatic diseases are chronic inflammatory illnesses that affect both the skin and joints and are associated with increased cardiovascular (CV) morbidity and mortality not fully explained by known traditional CV risk factors. Inflammatory biomarkers such as C-reactive protein and erythrocyte sedimentation rate, which are traditionally used as measures of atherosclerotic burden, are confounded by systemic inflammatory disease. Research has shown that decreasing enzymatic activity of the paraoxonase-1 (PON-1) family of high-density lipoprotein (HDL) associated antioxidant enzymes may be used as a measure of oxidative stress and serve as a surrogate for increased CV

disease burden in patients with psoriatic disease. PON-1 enzymes promote the antiatherogenic and antiinflammatory properties of HDL. The PON-1 assays from 134 patients in the Cardiometabolic Outcome Measures in Psoriatic Arthritis Study (COMPASS) demonstrated decreasing antioxidant associated enzymatic activity with increased Framingham risk scores stratified into low (< 10%), intermediate (10% to 20%), and high (> 20%) risk for cardiovascular disease. This study will increase understanding of the accelerated pathogenesis of atherosclerosis in psoriatic disease and provide biomarkers to improve CV risk stratification and identify therapeutic targets for CV disease prevention.

150

120

90

60

30

Arylesterase Activity (µmol/min/mL)

0< 10% 10% to 20% > 20%Healthy Controls

Framingham Risk Score

800

640

480

320

160

Paraoxonase Activity (nmol/min/mL)

0< 10% 10% to 20% > 20%Healthy Controls

Framingham Risk Score

Outcomes 201458

Psoriatic Arthritis

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59

Percentage of Psoriatic Arthritis Patients Taking Disease-Modifying Antirheumatic Drug Therapy (N = 2427)

2010 − 2014

Treatment Patterns in Psoriatic and Rheumatoid Arthritis: Use of Biologic DMARDs

2010 − 2014

American College of Rheumatology guidelines recommend that psoriatic arthritis patients be treated with disease-modifying antirheumatic drug (DMARD) therapy. More than 99% of psoriatic arthritis patients who were seen in the Department of Rheumatology at least 2 times during the years 2010, 2011, 2012, 2013, and 2014 were treated with DMARD therapy. Reasons for not prescribing DMARD therapy for the small percentage of patients not on DMARDs included disease remission, refusal of treatment, and contraindications to DMARD therapy. In any given year, between 88% and 95% of patients were on a DMARD.

A comparison was made of DMARD treatment patterns for rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Nonbiologic DMARDs are oral agents (methotrexate, leflunomide, azathioprine, sulfasalazine), while biologic DMARDs are subcutaneous or intravenous medications and are monoclonal antibodies targeting inflammatory cytokines or cells (tumor necrosis factors, IL-1, B-cell). A majority of RA and PsA patients received DMARD therapy (93% RA; 91% PsA). More patients with PsA received biologic plus nonbiologic DMARD combination therapy (20% RA; 30% PsA).

Treatment patterns differed with nonbiologic DMARD monotherapy used in 68% of RA patients vs 37% of PsA patients. RA patients rarely (5%) received biologic DMARD monotherapy, which was provided to 25% of PsA patients.

These outcomes represent DMARD therapy utilization in patients with RA and PsA seen at an academic health center, but may not be representative of general treatment patterns across the US because of clinical factors resulting in selection bias. These outcomes may provide valuable data on practice patterns that may inform clinical trials, decision-making in biologic choice, and differences in response to agents commonly used in RA and PsA treatment.

70605040

20

Percent

10

30

0Biologic

OnlyNonbiologic

OnlyBoth Neither

Rheumatoid arthritis (N = 18,729)Psoriatic arthritis (N = 2427)



100

80

60

40

20

Percent

02010 2011 2012 2013 2014447 475 500N = 497508

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6060

100

80

60

40

20

Percent

0Patients With Tuberculosis Testing

20132014

Outcomes 201460

Psoriatic Arthritis

The 2012 Update of the 2008 American College of Rheumatology (ACR) Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents1 recommends tuberculosis (TB) screening before using biologic agents to identify latent TB infection (LTBI). The ACR recommends the tuberculin skin test or interferon-γ release assays as the initial test in all patients starting biologic agents, regardless of risk factors for LTBI. One hundred percent (57 of 57) of newly diagnosed psoriatic arthritis patients in 2013 and 2014 had TB testing.

Reference1. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, Moreland LW,

O’Dell J, Winthrop KL, Beukelman T, Bridges SL Jr, Chatham WW, Paulus HE, Suarez-Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625-639.


Percentage of Newly Diagnosed Patients With Psoriatic Arthritis Starting Biologic DMARDs Who Had Tuberculosis Testing (N = 57)

2013 – 2014

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61

Percentage of Psoriatic Arthritis Patients Treated With Methotrexate Who Were Prescribed Folic Acid (N = 763)

2010 − 2014

Reference1. Shea B, Swinden MV, Tanjong Ghogomu E, Ortiz Z, Katchamart W, Rader T, Bombardier C, Wells GA,

Tugwell P. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev. 2013 May 31;5:CD000951.

Methotrexate is an effective and frequently used medication for the treatment of psoriatic arthritis. Long-term therapy is usually required for effective treatment. Methotrexate side effects are a common reason for discontinuation. A Cochrane Review1 of 6 randomized controlled trials in rheumatoid arthritis demonstrated that concomitant use of folic acid reduced gastrointestinal toxicity, abnormal transaminase elevation, and patient withdrawal symptoms from methotrexate with no reduction in efficacy. This recommendation is likely to apply to methotrexate use in other conditions such as psoriatic arthritis. More than 87% of patients were prescribed folic acid; a chart review of a subset of patients who did not receive a folic acid prescription showed frequent use of over the counter preparations.

100

80

60

40

20

Percent

0

N =2010152

2011166

2012135

2013 2014147 163


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62 Outcomes 201462

Vasculitis

Idiopathic Aortitis (N = 196)

1996 – 2012

Idiopathic aortitis is a rare diagnosis that may occur in the context of a primary systemic vasculitis, as part of a systemic autoimmune disease, or in isolation. In patients with focal isolated aortitis (FIA), surgery alone may be curative. Although new vascular lesions may develop, the risk of progression to systemic disease is uncertain.

Of 7551 patients who underwent thoracic aortic surgery between 1996 and 2012, 196 had biopsy-proven aortitis: 129 had FIA, and the remainder had giant cell arteritis, Takayasu arteritis, and other systemic diseases.

250

200

0

150

100

50

Number of Patients

Aortitis BiopsyProven196

Focal IsolatedAortitis

129

Giant CellArteritis

42

TakayasuArteritis

14

Other

11N =

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Focal Isolated Aortitis (N = 73)

1996 – 2012

For 73 patients with focal isolated aortitis (FIA), a minimum of 6 months of follow-up was available (median 45 months; range, 6–201 months). Twenty-three patients (31.5%) developed a systemic disease: giant cell arteritis in 21; Takayasu arteritis in 1; and other in 1. When compared with patients with known systemic disease at surgery, patients with FIA were less likely to develop symptoms (P = 0.01), but were no different with respect to development of inflammatory markers, new vascular lesions determined by imaging, need for further vascular surgery, aortic dissection, or likelihood of death.

80

70

60

0

50

40

30

20

10

Number of Patients

Focal IsolatedAortitis

73

Progressed toSystemic Disease

23

Giant CellArteritis

21

TakayasuArteritis

1

Other

1N =

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64 Outcomes 201464

Fibromyalgia

Depression in Fibromyalgia Cohort (N = 305)

2008 − 2014

Bipolar Disorder in Fibromyalgia Cohort (N = 305)

2008 − 2014

Fibromyalgia (FM) is a biopsychosocial disorder with a prevalence of 2% to 4% in the general population. Both depression and bipolar disorder are reported to be increased in FM patients. Of 305 FM patients seen between 2008 and 2014, > 88% were diagnosed with depression (a score ≥ 5) based on the Patient Health Questionnaire (PHQ-9), with 59.7% having a moderate or greater level (PHQ-9 ≥ 10).

Bipolar disorder, as measured with the Mood Disorder Questionnaire (MDQ ≥ 7), occurred with a 4-fold higher rate in FM patients than in the general population (16.4% vs 3.7%).

PHQ-9 = Patient Health Questionnaire

25

20

30

15

10

Percent

5

0Mild

(PHQ-9 5 – 9)Moderate/Severe(PHQ-9 15 – 19)

Severe(PHQ-9 ≥ 20)

Moderate(PHQ-9 10 – 14)

0

20

15

10

5

Percent

Fibromyalgia Cohort General Population

Mood Disorder Questionnaire ≥ 7

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Effect of Depression on Pain and Fatigue in Fibromyalgia Cohort (N = 305)

2008 − 2014

Effect of Depression on Bipolar Disorder in Fibromyalgia Cohort (N = 305)

2008 − 2014

Increasing levels of depression were associated with increasing prevalence of FM symptoms, including pain and fatigue, as measured with the Fibromyalgia Impact Questionnaire (FIQ).

Patients with increasing severity of depression based on PHQ-9 scores had an increased frequency of bipolar disorder (MDQ > 7).

FIQ = Fibromyalgia Impact Questionnaire, PHQ-9 = Patient Health Questionnaire

MDQ = Mood Disorder Questionnaire, PHQ-9 = Patient Health Questionnaire

50

40

30

20

10

Percent

0None Mild

(PHQ-9 5 – 9)Moderate

(PHQ-9 10 – 14)Moderate/Severe(PHQ-9 15 – 19)


Bipolar disorder MDQ > 7

10

8

0

6

4

2

Score

FIQ fatigueFIQ pain

None Mild(PHQ-9 5 – 9)

Moderate(PHQ-9 10 – 14)

Moderate/Severe(PHQ-9 15 – 19)


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66

Percentage of Patients With Progressive Systemic Sclerosis Who Obtained Yearly Pulmonary Function Testing and Echocardiograms (N = 867)

2010 − 2014

The American College of Rheumatology provided guidelines for detection of pulmonary hypertension (PH) in connective tissue diseases, including progressive systemic sclerosis (PSS).1 The key recommendation stated that all patients with PSS should be screened for PH with pulmonary function tests (PFTs), including single-breath diffusing capacity for carbon monoxide; transthoracic echocardiogram (echo); and measurement of N-terminal protein natriuretic peptide (NT-proBNP), performed annually. The percentage of patients having PFTs and echos ranged from 24% to 33% between 2010 and 2014. A chart review of 20 patients who did not obtain a PFT every year (5 PFTs years 2010–2014) showed that 1 patient had morphea, 1 patient had PFTs performed outside Cleveland Clinic, 16 patients had 1 to 4 PFTs, and only 2 patients (10%) had no PFTs performed. A chart review of 20 patients who did not obtain an echo every year (5 echos years 2010–2014) showed that 18 patients had 1 to 4 echos, 1 patient had systemic lupus erythematosus, and only 1 patient (5%) had no echo. It appears that most patients had a PFT or echo performed during the 5-year period; only a quarter had yearly testing.

Reference1. Khanna D, Gladue H, Channick R, Chung L, Distler O, Furst DE, Hachulla E, Humbert M, Langleben D, Mathai SC,

Saggar R, Visovatti S, Altorok N, Townsend W, FitzGerald J, McLaughlin VV; Scleroderma Foundation and Pulmonary Hypertension Association. Recommendations for screening and detection of connective tissue disease-associated pulmonary arterial hypertension. Arthritis Rheum. 2013 Dec;65(12):3194-3201.

80

60

100

40

20

Pulmonary Function Testing (%)

02010 2012 2013 20142011

80

60

100

40

20

Echocardiogram (%)

02010 2012 2013 20142011

Outcomes 201466

Progressive Systemic Sclerosis

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67

Percentage of Scleroderma Patients With Gastroesophageal Reflux Disease Treated With Antisecretory Medications (N = 327)

2013 – 2014

The American Gastroenterological Association Institute Medical Position Panel1 recommends antisecretory drugs for the treatment of patients with gastroesophageal reflux disease syndromes, based on their ability to heal esophagitis and provide symptomatic relief. In these uses, proton pump inhibitors are more effective than histamine 2 receptor antagonists, which are more effective than placebo. This recommendation is graded A, strongly recommended based on good evidence that it improves important health outcomes. During 2013 and 2014, between 97.5% and 98.5% of patients were on antisecretory medications.

Reference1. Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM,

Johnson SP, Allen J, Brill JV. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008 Oct;135(4):1383-1391.

100

80

60

40

20

Percent

0Antisecretory Agent

Interstitial Lung Disease in Patients With Anti-PM-Scl Antibody (N = 42)

1999 – 2014

ILD = interstitial lung disease, PM-Scl = anti-PM-Scl antibody

Patients with anti-PM-Scl antibody (PM-Scl) can present with several phenotypes including polymyositis, dermatomyositis, progressive systemic sclerosis (PSS), scleromyositis, or sclera-dermatomyositis. Pulmonary artery hypertension (PAH) occurs in PSS but the incidence in patients with PM-Scl has not been rigorously examined. All patients with PAH were diagnosed by right-heart catheterization (RHC). Forty-two patients with PM-Scl were reviewed. Five (11.9%) had RHC-confirmed PAH. The incidence of PAH in PSS is 7.8% and in the general population is 0.0015%. Of the 5 patients with PAH, 3 were mild (pulmonary artery pressure 25–40 mm Hg) and 2 were moderate (41–55 mm Hg). Of the 42 patients, 27 had interstitial lung disease and 4 had PAH. Patients with anti-PM-Scl antibodies frequently have PAH and should be screened for its presence.

50

30

40

20

10

Number of Patients

0PM-Scl Cohort

42ILD27N =

No ILD15


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68

Pulmonary Artery Hypertension in Patients With Anti-PM-Scl Antibody (N = 42)

1999 – 2014

PAH = pulmonary artery hypertension, PM-Scl = anti-PM-Scl antibody

45

20

25

30

35

40

15

5

10

Number of Patients

0PM-SclCohort

42

PAH

Mild PAH(25 – 40 mm Hg)

Moderate PAH(41 – 55 mm Hg)

5N = 3 2

Outcomes 201468

Progressive Systemic Sclerosis

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69

Effect of Persistent Headache on Pain Using the European Quality of Life Questionnaire in Patients With Reversible Cerebral Vasoconstriction Syndrome (N = 40)

2014

Impact of Persistent Headache in a Cohort of Patients With Reversible Cerebral Vasoconstriction Syndrome (N = 35)

2014

Reversible cerebral vasoconstriction syndrome (RCVS) comprises a group of diverse conditions characterized by reversible multifocal narrowing of the cerebral arteries with no evidence of vasculitic brain pathology. RCVS is associated at presentation with acute-onset, severe, recurrent headaches, often termed “thunderclap.” Thunderclap headaches do not recur, but many patients develop persistent headaches. Of the RCVS cohort, 35 patients were evaluated for headaches after initial presentation using the Headache Impact Test (HIT-6™), which measures the patient’s ability to function in multiple situations. More than 50% of patients had persistent headaches that impacted their ability to function.

25

20

15

10

5

Number of Patients

0Headache Impact Test-6 Score

< 55 Some/little/none55 – 59 Substantial≥ 60 Severe

60

50

70

30

40

10

20

Percent

0No Pain Moderate Pain Severe Pain

0

Slight Pain

Persistent headacheNo headache


Reversible Cerebral Vasoconstriction Syndrome

Long-Term Outcomes After Reversible Cerebral Vasoconstriction Syndrome

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70 Outcomes 201470

European Quality of Life Questionnaire in Patients With Reversible Cerebral Vasoconstriction Syndrome (N = 40)

2014

The European Quality of Life Questionnaire (EQ-5D™) is a standardized measure of health status and provides a simple measure of health for clinical appraisal. The EQ-5D is composed of 5 dimensions: mobility, self-care, leisure, pain, and anxiety. Each dimension has 5 levels. The majority of patients rated their health status as “no problem” although significant decline in quality of life occurred in some patients. Patients with persistent headache had significantly higher levels of generalized pain as measured with the EQ-5D.

Reversible Cerebral Vasoconstriction Syndrome

40353025201510

0

Number of Patients

0 0 005

Mobility Self-Care Leisure Pain Anxiety

No problemSlightMildModerateSevere

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71

0.7

0.4

0.5

0.6

0.3

0.2

0.1

ng/mL

0Control All RCVS Ischemic RCVS Hemorrhagic RCVS


Blood-Brain Barrier Disruption as Measured With Astrocyte Protein S100B in Reversible Cerebral Vasoconstriction Syndrome (N = 10)

2014

The blood-brain barrier disruption has been linked to a variety of neurologic disorders. Astrocyte protein S100B is considered an important peripheral blood marker of disruption of the blood-brain barrier. S100B protein levels are elevated in patients with reversible cerebral vasoconstriction syndrome (RCVS) during the ictal phase vs controls. The lack of elevated levels with hemorrhagic vs ischemic RCVS may suggest a different mechanism of brain injury in the subsets of RCVS.

RCVS = reversible cerebral vasoconstriction syndrome

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72 Outcomes 201472

Osteoarthritis

Quality of Life in Patients With Osteoarthritis and Obesity After Bariatric Surgery and Nonsurgical Weight Loss (N = 67)

2007 – 2012

SF-36 = Short Form Health Survey

Obesity is a strong risk factor for development and progression of knee osteoarthritis (OA). The potential benefits of massive weight loss, as seen after bariatric surgery, have not been well studied. The study objective was to examine whether massive weight loss after bariatric surgery is associated with improved OA symptoms and quality of life (QOL), compared with medical management alone in obese patients.

A total of 150 patients were screened for clinical and radiographic evidence of OA within the Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial (2007–2011). The STAMPEDE trial examined the effects of bariatric surgery vs medical management alone in obese patients with diabetes: 100 patients received bariatric surgery (50 received sleeve gastrectomy and 50 received Roux-en-Y gastric bypass), and 50 patients were medically managed.

QOL scores were collected before and 12 months after intervention. OA was defined by physician diagnosis at an office visit and/or radiographic evidence of OA (joint space narrowing and osteophytes) of the hip, knee, ankle, or foot. The change in 12-month postintervention Short Form Health Survey (SF-36) scores between the surgical group and the medically managed group were compared.

Sixty-seven patients with OA had baseline and follow-up data available for review; 49 patients were in the surgery group and 18 patients were in the medical group. There was a statistically significant difference in body mass index (BMI) change, during 12 months, between the surgical group and the medical group (BMI − 9.12 and − 2.24, respectively). There was a significantly greater improvement in the surgical group compared with the medical group in SF-36 domains of physical functioning, general health, and overall physical health scores. There was no significant difference between the groups in pain or role physical scores.

25

20

15

10

5

SF-36 Differences (Surgical vs Nonsurgical Patients)

0Physical Functioning

(P = 0.03)General Health(P < 0.001)

Physical Health Summary(P = 0.004)

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73

100

80

60

40

20

Percent

0Cutaneous Organ

Involvement Fever Sicca Headache Arthritis Oral

UlcersLymphadenopathy


Autoinflammatory Disease

Outcomes in Patients With Phenotypes Suggestive of NOD2-Associated Autoinflammatory Disease (N = 143)

2009 – 2014

NAID = NOD2-associated autoinflammatory disease, NOD2 = nucleotide-binding oligomerization domain containing 2

Autoinflammatory diseases are characterized by episodes of inflammation, without high titers of autoantibodies, and derive from genetic variants of the innate immune system. Nucleotide oligomerization domain containing 2 (NOD2) is the coding region for a family of intracellular proteins that play an essential role in apoptosis, necrosis, and inflammation. NOD2 sequence variants are associated with Crohn’s disease, Blau syndrome, and NOD2 autoinflammatory disease (NAID). The cohort of patients had clinical phenotypes suggestive of NAID, based on periodic disease occurrence and recurrent fever of unknown

origin and/or dermatitis (N = 143). Sixty-seven patients (47%) were found to have 1 or more NOD2 variants, and 54 of 67 patients (81%) had NAID. The clinical manifestations included cutaneous erythematous patches and plaques; oligoarthritis/polyarthritis/arthralgia; recurrent fever; organ involvement, most often gastrointestinal; and sicca-like symptoms. NOD2-associated autoinflammatory disease is an emerging entity that is a genetically multisystem disease frequently associated with NOD2 genetic variants and may be more common than previously thought.

150

120

90

60

30

Number of Patients

0Inflammatory Phenotype NOD2 + Genotype NAID Diagnosis

143 67 54N =

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74 Outcomes 201474

Infusion Center

Infusion Reactions in Patients Treated With Biologic and Nonbiologic Therapies in a Rheumatology Infusion Center

2013 – 2014

The Rheumatology Infusion Center administered 2826 infusions in 2013 and 2835 infusions in 2014. Both biologic and nonbiologic medications were used to treat a large number of rheumatic diseases. Infusion reactions can be serious complications and require established protocols to guarantee appropriate premedication, infusion rates, and treatment for drug reactions to ensure patient safety. In 2013, reactions occurred in 48 of 2826 infusions (1.7%), and were mild in 19, moderate in 28, and severe in 1 infusion. In 2014, reactions occurred in 50 of 2835 infusions (1.8%), and were mild in 5, moderate in 43, and severe in 2 infusions. Only 1 patient was not able to complete his infusion (0.035%) in both 2013 and 2014.

1.6

0.8

1.0

1.4

1.2

0.6

0.4

0.2

Percent

0.0Mild Moderate Severe

2013 (N = 2826) 2014 (N = 2835)

19 5 28 43 1 2N =

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Patient Experience in a Rheumatology Infusion Center (N = 100)

2014

Infusions for patients with rheumatic diseases are performed in an 8-bed Rheumatology Infusion Center. In 2014, there were > 2800 infusions. A patient questionnaire was given to 100 consecutive patients using a 1–5 scale (1 = poor, 5 = outstanding), requesting their experience in 4 domains: infusion staff (helpful, communication, coordinated care, expertise, responsiveness), preinfusion visit (provider explanation of infusion, education, waiting room, wait-time, provider visit, transition to infusion center), infusion center (comfort, amenities, privacy, design, experience), and process (ease of check-in, scheduling, parking). Infusion staff scored 4.99, preinfusion visit scored 4.93, infusion center scored 4.90, and process scored 4.73. Most negative comments related to the process (especially parking). Patient questionnaires are important tools to assess and improve the experience for patients who often have serious and sometimes life-threatening rheumatic diseases.

4.0

5.0

4.5

1.5

2.5

3.0

3.5

2.0

1.0

0.5

Likert Scale (0 – 5)

0.0Infusion

StaffPreinfusion

VisitInfusionCenter

Process

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76 Outcomes 201476

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 — Orthopaedic & Rheumatologic Institute

CG-CAHPS Assessmenta 2013 – 2014

Patient Experience — Orthopaedic & Rheumatologic Institute

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 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 CG-CAHPS database from 2172 medical practices in 2013.cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No

Source: Press Ganey, a national hospital survey vendor

100

80

0

60

40

20

Percent Best Response

CG-CAHPS 2013 database average(all practices)b

AppointmentAccess

(% Always)c

DoctorCommunication

(% Yes, Definitely)d

Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff


Test ResultsCommunication

(% Yes)e

2013 (N = 5161)2014 (N = 10,253)

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HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Orthopaedic & Rheumatologic Institute

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

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013,from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no


2014 (N = 630)

National averageall patientsa

2013 (N = 535)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes

Doctor Communication

Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 630)National average all patientsb

2013 (N = 535)

aExcept 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 vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

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78 Outcomes 201478

Cleveland Clinic — Implementing Value-Based Care

Cleveland Clinic Overall Mortality Observed/Expected Ratio

2013 – 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.

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.

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.

Cleveland Clinic Central Line-Associated Bloodstream Infection — ICU Rate per 1000 Line Days

2013 – 2014

Improve the Patient Experience of Care

1.0

0.0Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

0.8

0.6

0.4

0.2

O/E Ratio

Cleveland ClinicCleveland Clinic target

2.5

0.0

2.0

1.5

1.0

0.5

Rate per 1000 Line Days


Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

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Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1000 Eligible Patients

2013 – 2014

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.

Source: Data reported from the National Database for Nursing Quality Indicators® (NDNQI) with permission from Press Ganey.

Source: Data from the UHC Clinical Data Base/Resource ManagerTM used by permission of UHC. All rights reserved.

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.

Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult)

2013 – 2014

Rate per 1000 Patients


10

0

8

6

4

2

Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

5

0

4

3

2

1

Percent

Cleveland ClinicNDNQI 50th percentile(academic medical centers)

Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

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8080

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

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 2013cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No


100

80

0

60

40

20

Best Response (%)

AppointmentAccess

(% Always)c

Primary Care

(% Always)c

Specialty Care


Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff


Test ResultsCommunication

(% Yes)e

2013 (N = 64,792)2014 (N = 124,521)

CG-CAHPS 2013 database average(all practices)b



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8181

HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Cleveland Clinic

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

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no


2014 (N = 10,369)

National averageall patientsa

2013 (N = 10,730)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes


Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 10,369)National average all patientsb

2013 (N = 10,730)

aExcept 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 vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

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82

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?

• 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.

Focus on Value

HomeRetail Venues

Integrated Care Model

Outpatient Clinics

IndependentPhysicianOffices

Skilled NursingFacilities Rehabilitation

Facilities

Community-BasedOrganizations

Post-Acute(other)

AmbulatoryDiagnosis & Treatment

Hospitals

Emergency

Care System

MyChart


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83

CMI = case mix index aTotal discharges Source: Data from the UHC Clinical Data Base/Resource ManagerTM

used by permission of UHC. All rights reserved.

a2015 ACO 90th percentile bLower is better

Cleveland Clinic All-Cause 30-Day Readmission Rate to Any Cleveland Clinic Hospital

2013 – 2014

Select Accountable Care Organization Performance Measures

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.

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.

Reduce the Cost of CareImprove Population Health

Percent of DischargesPercent of Discharges Case Mix Index

0.0

3.0

1.5

00

1818

99

1212

1515

66

33

Q1 Q2

201352,104Na =

201450,755

Q3 Q4 Q1 Q2 Q3 Q4

Cleveland Clinic rateCleveland Clinic CMIUHC academic medical centers CMI

Measure Cleveland Clinic 2014 Cleveland Clinic Performance (%) Goala (%)

Pneumococcal 84.9 100 vaccination

Colorectal 72.3 100 cancer screening

Mammography 77.5 ≥ 99.6 screening

Hemoglobin 20.5 ≤ 10b A1c > 9%

Hypertension 69.3 ≥ 79.7 control

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84 Outcomes 2014

Innovations

Abatacept (CTLA4-Ig) for the Treatment of Relapsing, Nonsevere, Granulomatosis With Polyangiitis (Wegener’s) (ABROGATE)

Relapses occur in over 50% of patients with granulomatosis with polyangiitis (Wegener’s) (GPA), which can result in organ damage and require long-term glucocorticoid therapy. There is an unmet need to identify treatment options for nonsevere relapsing GPA.

An open-label trial of abatacept funded by the National Institutes of Health was conducted by the Vasculitis Clinical Research Consortium (VCRC). In this study of 20 patients with nonsevere relapsing GPA, abatacept was well tolerated and led to disease remission and reduction in glucocorticoids in a large percentage of patients.

Based on these results, an international multicenter, randomized, double-blind, placebo-controlled trial to evaluate the efficacy of abatacept in patients with relapsing nonsevere GPA will start in 2015. This trial will be conducted collaboratively by the VCRC and the European Vasculitis Society (EUVAS).

Screening for Eligibility

Early Termination or Common Close

Randomized Treatment Period Prednisone +

Continued maintenance + Abatacept or Placebo

Nonsevere relapse Nonsevere worsening No remission Month 6

Remission Severe relapse

Open Label Extension Period Prednisone +

Continued maintenance + Abatacept

T t

iere r

Exten

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Managing Comorbidities of Psoriatic Arthritis: New Guidelines Provide First Expert Recommendations

To provide comprehensive care to patients with psoriatic arthritis (PsA), clinicians must be aware of pertinent multiple comorbidities and extraarticular/cutaneous manifestations. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) updated its 2009 treatment guidelines with a section on managing comorbidities and extraarticular manifestations in patients with PsA.1 Evidence-based recommendations from systematic literature reviews focused on the more common comorbidities and their impact on treatment of PsA.2 These include:

• Cardiovascular disease3 • Obesity, metabolic syndrome, and diabetes3 • Inflammatory bowel disease• Autoimmune ophthalmic disease • Osteoporosis (increased prevalence in PsA patients)• Liver disease (particularly nonalcoholic fatty

liver disease)• Kidney disease

Concomitant circumstances common in PsA include chronic viral infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus) and vaccinations.

References1. Ogdie A, Schwartzman S, Eder L, Maharaj AB, Zisman D, Raychaudhuri SP, Reddy SM, Husni E. Comprehensive treatment of psoriatic arthritis:

managing comorbidities and extraarticular manifestations. J Rheumatol. 2014 Nov;41(11):2315-2322.

2. Ogdie A, Schwartzman S, Husni ME. Recognizing and managing comorbidities in psoriatic arthritis. Curr Opin Rheumatol. 2015 Mar;27(2):118-126.

3. Lin YC, Dalal D, Churton S, Brennan DM, Korman NJ, Kim ES, Husni ME. Relationship between metabolic syndrome and carotid intima-media thickness: cross-sectional comparison between psoriasis and psoriatic arthritis. Arthritis Care Res (Hoboken). 2014 Jan;66(1):97-103.

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100,000

10,000

1000

100

10

1

Mean Level Log Scale (ng/mL)

0GM-CSF IFN-˜ TNF-° IL-1˛ IL-2 IL-6 IL-8 IL-10 IL-12

0.65 0.46 0.27 0.64 0.50 0.50 0.55 0.43 0.51

No infectionProbable infectionDefinite infection

86 Outcomes 2014

Innovations

Analysis of Cytokine Profiles in the Diagnosis of Periprosthetic Joint Infections of the Shoulder

Improved diagnosis of shoulder periprosthetic joint infection (PJI) will lead to better decision-making regarding treatment in revision surgery. This study evaluated the efficacy of synovial fluid cytokine analysis in the diagnosis of shoulder PJI. Nine proinflammatory cytokines were measured in synovial fluid obtained from 37 patients undergoing revision shoulder arthroplasty, using an immunoassay technique. All cytokines showed increasing levels as the likelihood of infection increased. GM-CSF and IL-1ß demonstrated the

strongest correlations; IL-6 and IL-8 showed the largest magnitude of elevations. Synovial fluid cytokine profile analysis may improve the diagnostic accuracy of shoulder PJI and may help guide treatment decision-making. This work has been selected for the 2015 Charles S. Neer Award in Basic Science Research.

Synovial Fluid Cytokine Levels by Infection Category

Mean synovial fluid cytokine levels (ng/mL) based on infection category. The white numeric ratios represent the Kendall tau rank correlation for the association between infection category and each cytokine.

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NOD2-Associated Autoinflammatory Disease (NAID) an Emerging Disorder: Insights From the Largest Published Cohort Study

NAID Essentials

“NOD2” refers to the nucleotide-binding oligomerization domain containing a member of a gene family that encodes intracellular proteins with N-terminal caspase recruitment domains (CARDs) involved in the inflammatory response and apoptosis. NOD2 genetic variants are associated with Crohn’s disease, Blau syndrome, and NAID. A new category of autoinflammatory disease associated with NOD2 gene mutations, designated as NAID, was previously reported that is characterized by periodic fever, dermatitis, polyarthritis, and sicca-like and gastrointestinal

symptoms. A large cohort study1 has recently underscored the association between the new entity and certain NOD2 genetic mutations (IVS8 + 158 and/or R702W). NAID is a new disorder, and its clinical phenotype and genotypic profile are distinct from Crohn’s disease and Blau syndrome.

Reference1. Yao Q, Myles J, Shen B, McDonald C. NOD2-associated

autoinflammatory disease: an exploratory study of its pathogenesis. Rheumatology (Oxford). 2014 May;53(5):958-960.

Schematic representation of the NOD2 gene and protein structures. Coding exons are represented by blocks connected with lines representing introns. (See text for abbreviation expansions.)

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Staff Listing

For a complete listing of Cleveland Clinic’s Orthopaedic & Rheumatologic Institute staff, please visit clevelandclinic.org/staff.

Publications

Orthopaedic & Rheumatologic Institute staff authored 214 publications in 2014.

For a complete list, go to clevelandclinic.org/outcomes.

Locations

For a complete listing of Orthopaedic & Rheumatologic Institute locations, please visit clevelandclinic.org/orthorheum.

Orthopaedic & Rheumatologic Institute Appointments

216.444.2606 or 800.223.2273, ext. 42606 Orthopaedic & Rheumatologic Institute Referrals

855.REFER.123 (855.733.3712) On the Web at clevelandclinic.org/orthorheum

Outcomes 201488

Contact Information

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http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/about-cleveland-clinic/quality-patient-safety/treatment-outcomes.aspx?utm_campaign=outcomes-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/orthopaedics-rheumatology?utm_campaign=orthorheum-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/orthopaedics-rheumatology?utm_campaign=orthorheum-url&utm_medium=offline&utm_source=redirect

Institute Overview

Additional Contact Information General Patient Referral

24/7 hospital transfers or physician consults

800.553.5056 General Information

216.444.2200 Hospital Patient Information

216.444.2000 General Patient Appointments

216.444.2273 or 800.223.2273 Referring Physician Center and Hotline

855.REFER.123 (855.733.3712)

Or email [email protected] or visit clevelandclinic.org/refer123 Request for Medical Records

216.444.2640 or 800.223.2273, ext. 42640 Same-Day Appointments

216.444.CARE (2273)

Global Patient Services/ International Center

Complimentary assistance for international patients and families

001.216.444.8184 or visit clevelandclinic.org/gps Medical Concierge

Complimentary assistance for out-of-state patients and families

800.223.2273, ext. 55580, or email [email protected] Cleveland Clinic Abu Dhabi

clevelandclinicabudhabi.ae Cleveland Clinic Canada

888.507.6885 Cleveland Clinic Florida

866.293.7866 Cleveland Clinic Nevada

702.483.6000 For address corrections or changes, please call

800.890.2467


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https://www.clevelandclinicabudhabi.ae/en/pages/default.aspx

Overview

Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 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 is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1400-bed 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. 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.

The Cleveland Clinic Model

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. 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. 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 201490

About Cleveland Clinic

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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.


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http://my.clevelandclinic.org/

http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

Referring Physician Center and Hotline

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. 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; [email protected]

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]

Medical Records Online

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 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 201492

Resources

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http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services

http://my.clevelandclinic.org/online-services/mychart.aspx?utm_campaign=mychart-url&utm_medium=offline&utm_source=redirect

http://www.clevelandclinicmeded.com/

http://my.clevelandclinic.org/services/cancer/clinical-trials-research?utm_campaign=cancertrialapp-url&utm_medium=offline&utm_source=redirect

mailto:eclevelandclinic.org

mailto:[email protected]



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

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Notes

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Notes

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Notes

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This project would not have been possible without the commitment and expertise of a team led by Carlos Higuera-Rueda, MD; Chad Deal, MD; Robert Overman, MPH; Charvelle Metcalf, MEd, MS; June Cassano, BSN, MBA; and Greg Strnad, MS. Graphic design and photography were provided by Cleveland Clinic's Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015

Measuring Outcomes Promotes Quality Improvement


9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org

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Orthopaedic & Rheumatologic Institute

2014 Outcomes


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