pediatric institute & cleveland clinic children's

9500 Euclid Avenue, Cleveland, OH 44195 ClevelandClinic.org

15-OUT-342

Pediatric Institute & Cleveland Clinic Children’s

2014 Outcomes

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This project would not have been possible without the commitment and expertise of a team led by Vera Hupertz, MD, and Bryant M. Bond.

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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2

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

Outcomes 20142

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3Pediatric Institute & Cleveland Clinic Children’s 3

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 05

Institute Overview 06

Quality and Outcomes Measures

Pediatric Cardiology 10

Center for Pediatric and Adult Congenital 12

Heart Disease

Pediatric Critical Care 15

Pediatric Endocrinology 17

Pediatric Fit Youth Program 18

Pediatric Be Well Kids 19

Pediatric Gastroenterology 20

Pediatric General Surgery 26

Pediatric Hematology and Oncology 27

Pediatric Hospital Medicine 29

Pediatric Infectious Diseases 30

Neonatology 34

Pediatric Nephrology 37

Pediatric Neurology 39

Pediatric Orthopaedic Surgery 46

Pediatric Otolaryngology 50

Pediatric Palliative Care 52

Pediatric Primary Care 53

Pediatric Pulmonology 54

Pediatric Rheumatology 56

Cleveland Clinic Children’s Safety Improvements 57

Cleveland Clinic Children’s Hospital for Rehabilitation

Cleveland Clinic Children’s Center for Autism 59

Lerner School for Autism 60

Pediatric Behavioral Health 64

Pediatric Feeding Program 70

Pediatric Pain Rehabilitation Program 73

Pediatric Inpatient Rehabilitation Program — 75

WeeFIM® Outcomes

Patient Experience 76

Implementing Value-Based Care 77

Contact Information 78

About Cleveland Clinic 80

Resources 82

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Outcomes 20144

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Institute OverviewChairman’s Letter

Dear Colleagues,

Thank you for your interest in Cleveland Clinic Children’s 2014 outcomes. This annual publication is a testament to our commitment to tracking and reporting outcomes to continuously improve patient care.

I am pleased to be able to report an abundance of diverse clinical achievements by Cleveland Clinic Children’s caregivers in 2014, including:

• Launch of a Center for Pediatric Integrative Medicine to complement traditional medical care for young patients with refractory chronic conditions—oneofthefewpediatric-specificintegrativemedicine centers in the United States

• Near doubling of our pediatric solid-organ transplant volume over the prior year, including our highest-ever annual numbers of heart transplants (11) and intestinal transplants (3)

• Successful management of one of the nation’s largest populations of pediatric patients infected with enterovirus D68 during the outbreak of the rare respiratory virus

• Introductionofapediatricofficeonwheels—theSchool-BasedHealthCenter—thatregularlyvisits participating Northeast Ohio schools to meet students’ primary care needs

• Designation as one of the world’s 3 CDKL5 Centers of Excellence by the International Foundation for CDKL5 Research, which promotes progress on the rare neurologic disease linked to CDKL5 mutations

• Successful completion of 12 robotically assisted pediatric surgeries, our highest count to date

• Publication of research linking the cancer-related gene PTEN to a subtype of autism, opening the door to a more personalized treatment approach to autism in affected patients

We welcome your feedback, questions, and ideas for collaboration. Please contact me via email at [email protected] and reference the Cleveland Clinic Children’s book in your message.

Sincerely,

Giovanni Piedimonte, MD Chairman, Pediatric Institute Physician-in-Chief, Cleveland Clinic Children’s President,ClevelandClinicChildren’sHospitalforRehabilitation

Pediatric Institute & Cleveland Clinic Children’s 5

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Institute Overview

Cleveland Clinic has been caring for infants, children, and adolescents since its doors first opened in 1921. That history of pediatric caregiving has blossomed into Cleveland Clinic Children’s standing today as one of America’s leading and largest providers of comprehensive pediatric care. In 2014, Cleveland Clinic Children’s was recognized for top care in all 10 of the 10 specialties ranked by U.S. News & World Report in its “Best Children’s Hospitals” survey.

This reputation stems from premier programs in a wide range of subspecialties, including:

• Rehabilitation, featuring one of the nation’s few freestanding rehab hospitals for pediatric patients and the world’s only Pediatric Pain Rehabilitation Program accredited by the Commission on Accreditation of Rehabilitation Facilities

• Transplantation, offering the ability to perform any type of transplant — all solid organ types, dual-organ, multivisceral, cellular, and composite tissue — in pediatric patients

• Gastroenterology, leveraging unsurpassed volume and expertise in pediatric inflammatory bowel disease

• Urology and nephrology, where our pediatric specialists collaborate closely with their adult-care colleagues in Cleveland Clinic’s Glickman Urological & Kidney Institute, which includes the nation’s top-ranked urology program (U.S. News & World Report’s 2014 “Best Hospitals” survey)

• Surgery, offering a breadth and depth of surgical expertise and resources that few children’s hospitals can match

Cleveland Clinic Children’s deep roots support far-reaching branches: Its more than 300 physicians provide the full spectrum of primary, specialty, and subspecialty care to the largest patient population of any children’s hospital in Northeast Ohio. This is done through an integrated network comprising the children’s hospital on Cleveland Clinic’s main campus, Cleveland Clinic Children’s Hospital for Rehabilitation, and several regional hospitals — which collectively staff 429 pediatric beds — as well as more than 40 outpatient sites.

Outcomes 20146

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Cleveland Clinic Children’s Major Departments and Centers

Adolescent Medicine

Allergy and Immunology

Anesthesiology

Child Life Services

Community Pediatrics

Critical Care Medicine/Pediatric ICU

Dermatology

Endocrinology

Fetal Care/Special Delivery Unit

Gastroenterology

General Pediatrics

General Surgery

Genetics

Heart Disease — Pediatric and Congenital

Hematology, Oncology, and Blood & Marrow Transplantation

Hospital Medicine

Imaging

Infectious Diseases

Integrative Medicine

Neonatology

Nephrology

Neurology and Neurosurgery

Ophthalmology

Orthopaedic Surgery and Sports Medicine

Otolaryngology

Palliative Medicine

Plastic Surgery

Pulmonary Medicine

Rehabilitation — Children’s Hospital for Rehabilitation

• Department of Physical Medicine and Rehabilitation

• Center for Therapy Services

• Center for Developmental and Rehabilitative Pediatrics

• Center for Pediatric Behavioral Health

• Center for Autism

Rheumatology

Transplantation

Urology


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Institute Overview

Outpatient Visits by Department or Center

Allergy 9261

Behavioral Health 8145

Cancer Center 5485

Dermatology 15,949

Emergency Medicine 23,759

EMI Bariatric Surgery 217

Express Clinic 7754

Endocrinology 9339

Gastroenterology 14,782

General Pediatrics 388,591

Head and Neck 17,549

Heart Center 12,250

Hospital Medicine 4917

Infectious Diseases 894

Medical Genetics 633

Neonatology 1237

Nephrology 2316

Neurosciences 27,849

Nutrition 353

Obstetrics and Gynecology 30,443

Ophthalmology 26,834

Orthopaedics 45,738

Other 174,036

Pain Management 573

Pediatric Rehabilitation 1498

Physical, Occupational, and Speech Therapy 73,268

Pulmonary Medicine 3483

Rheumatology 3592

Surgery 7796

Urology 4004

Total outpatient visits 922,545

Outcomes 20148

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Surgical Cases

General Surgery 1299

Cardiothoracic Surgery 171

Total cases 1470

Pediatric Cardiology Procedures

Cardiac catheterization procedures 443

Pediatric echocardiograms 7022

Total cases 7465

Pediatric Gastroenterology Procedures

Pediatric endoscopy 951

Other diagnostic procedures 1401

Total cases 2352

Patient Days

Hospital 48,492

NICU 21,910

PICU 5183

Total days 75,585


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10 Outcomes 201410

Pediatric Cardiology

The Pediatric Cardiology Department participates in the National Pediatric Cardiology Quality Improvement Collaborative of the Joint Council on Congenital Heart Disease National Quality for some of its sickest patients, such as those with hypoplastic left heart syndrome (HLHS). The families of these infants, and others with similar single ventricle physiology lesions, receive extensive teaching from the department’s nurse practitioners, with daily phone or email monitoring of critical health parameters after the patients leave the hospital. This monitoring alerts physicians and nurses when infants may need to return to the hospital to avoid deterioration of their health or even sudden death. These data are also sent to the national collaborative, which is working to improve survival and quality of life of infants with HLHS during the interstage period between discharge from their initial open-heart surgery (stage 1 Norwood) and admission for a stage 2 bidirectional Glenn procedure. Several publications have already resulted from these collaborative data.1 The Pediatric Catheterization Laboratory remains committed to reducing patients’ radiation exposure. The newest lab includes leading-edge equipment with new detector technology — the Artis Q.zen (Siemens). This system uses a crystalline (vs standard amorphous) silicon detector, which reduces noise and includes technological advances that allow quality imaging at much lower radiation levels. Reducing radiation dosage by 25% is the goal of collaborative efforts in the American College of Cardiology quality improvement project, thereby reducing radiation risk for congenital heart patients.

Standard System (Artis zee) Artis Q.zen P Value

N 358 84

Radiation time, sec 22.43 ± 25.48 17.34 ± 22.79 0.09

Radiation dose, mGy 224.61 ± 410.92 112.21 ± 252.94 0.02

Patient weight, kg 46.79 ± 31.23 44.08 ± 29.97 NS

Comparison of Radiation Dose Between Standard Catheter Laboratory System and Artis Q.zena (N = 442)

NS = not significant aAll measurements are mean ± standard deviation.

Reference

1. Schidlow DN, Gauvreau K, Patel M, Uzark K, Brown DW. Site of interstage care, resource utilization, and interstage mortality: a report

from the NPC-QIC registry. Pediatr Cardiol. 2015 Jan;36(1):126-131.

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The Pediatric Cardiology Department continues to lead in the use of new, nonsurgical methods to treat congenital heart disease. The Melody® transcatheter pulmonary valve (Medtronic) is now in regular use as a pulmonary valve replacement, sparing many patients with previous open-heart surgeries the need for additional surgeries. Since June 2010 there have been 48 Melody valve placements in 47 patients. Forty-six continue to have good valve function and are free from reintervention; none have needed surgical intervention. One patient had significant Melody valve obstruction, which was treated with a second Melody valve placement almost 4 years later. Another developed endocarditis resulting in moderate Melody valve obstruction and is under medical treatment and observation.

As the only recognized pediatric and congenital heart disease transplant program in Northeast Ohio, the department continues to be a leader in advanced heart failure treatment and heart transplantation for children and patients with congenital heart disease. Eleven patients received heart transplants in 2014. Six children were treated with ventricular assist devices. Of those, 4 went on to heart transplantation, 1 recovered heart function, and 1 died.

Melody Valve Placement in the Pulmonary Position

Patients, N 47

Successful deployment 47 Valve failure: < 1 year 0/47 1 year 0/47 2 years 1/36a

3 years 0/23 4 years 1/9b

Characteristics of Heart Transplant Patients (N = 11)

Age 4 – 38 yearsa

Underlying pathology: Cardiomyopathy 6 Congenital heart disease 5

> 3 prior open heart surgeries 4

On ventricular assist device at time of transplant 4

Post-transplant death 0

Pediatric Heart Transplant Program

aValve failure due to endocarditis; under medical treatment and observation bValve failure due to obstruction; second Melody valve deployed successfully

aTen of 11 patients were under 18 years of age. One adult, age 38, with complex congenital heart disease was included in the analysis.

2010 – 2014

2014

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12

Congenital Heart Disease

Congenital heart disease affects an estimated 1 million people in America. Each year, approximately 1 in every 120 babies born in the United States has a congenital heart defect. In some cases, the disease is life-threatening at birth. However, many people with a congenital heart condition do not know about it for years. Experts at Cleveland Clinic have extensive experience in the diagnosis and treatment of patients with all forms of congenital heart disease. The Center for Pediatric and Adult Congenital Heart Disease’s services are further enhanced by the Special Delivery Unit. The unit provides in utero diagnosis of complex heart conditions and immediate treatment after birth. Patients with more complex congenital heart disease who have surgery often require additional treatment or procedures throughout their lifetime and, therefore, need follow-up care from a team of experts in congenital heart disease.

At least 10% of all congenital

heart conditions

are diagnosed in

adulthood.

Percutaneous Closure Procedures for Adult Congenital Heart Disease

Volume and Outcomes (N = 46)

2014

A total of 46 patients had percutaneous closure procedures at Cleveland Clinic in 2014. The success rate was 100%, and the mortality rate was 0% for both ASD and PFO closures.

Percutaneous ASD closures 18

Percutaneous PFO closures 28

Abbreviations: ASD = atrial septal defect, PFO = patent foramen ovale

Outcomes 201412


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13

Adult Congenital Heart Surgery In-Hospital Mortality

2014

The in-hospital mortality rate for adult congenital surgery at Cleveland Clinic in 2014 was 1.3%, compared with the expected rate of 2.2%. Many of these patients have very complex medical backgrounds and conditions, and have had multiple surgeries. 00

66

3%

22

44

PercentPercent

2%

ExpectedObserved

2.2%

1.3%

2013 2014Source: Data from the UHC Clinical Data Base/Resource ManagerTM used by permission of UHC. All rights reserved.

Adult Congenital Heart Surgery Volume and Type (N = 261)

2014

The largest subset of the 261 adult congenital surgeries performed at Cleveland Clinic in 2014 were aorta surgeries.

AAOCARepairAAOCARepair

AortaSurgeryAorta

SurgeryASD

RepairASD

RepairCABGCABGAortic

ValveSurgery

AorticValve

Surgery

HeartTransplant/

VAD

HeartTransplant/

VAD

MitralValve

Surgery

MitralValve

Surgery

OtherCongenital

CardiacSurgery

OtherCongenital

CardiacSurgery

SeptalMyectomy

SeptalMyectomy

PAPVRPAPVR PulmonicValve

Surgery

PulmonicValve

Surgery

TricuspidValve

Surgery

TricuspidValve

Surgery

VolumeVolume

100100

8080

6060

4040

2020

00

Abbreviations: AAOCA = anomalous aortic origin of a coronary artery, ASD = atrial septal defect, CABG = coronary artery bypass grafting, PAPVR = partial anomalous pulmonary venous return, VAD = ventricular-assist device

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


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14 Outcomes 201414


Pediatric Congenital Heart Surgery Volume and Type (N = 150)

2014

6060

VSDRepairVSD

RepairASD

RepairASD

RepairAV

CanalAV

CanalFontanFontan TOFTOFNorwoodNorwood Valve

ProcedureValve

ProcedurePAPA PDAPDA ECMOECMO VAD

InsertionVAD

InsertionOtherOtherHeart

TransplantHeart

TransplantASOASO Bidirec-

tionalGlenn

Bidirec-tionalGlenn

RV to PAConduitRV to PAConduit

VolumeVolume

4040

5050

3030

2020

1010

00

Cleveland Clinic surgeons performed 150 pediatric congenital surgeries in 2014. Procedures in the “other” category included truncus arteriosus repair and various procedures of varying complexity.

Abbreviations: ASD = atrial septal defect, ASO = arterial switch operation, AV = atrioventricular, ECMO = extracorporeal membrane oxygenation, PA = pulmonary arterioplasty, PDA = patent ductus arterio-sus ligation, RV = right ventricle, TOF = tetralogy of Fallot, VAD = ventricular assist device, VSD = ventricular septal defect

Pediatric Congenital Heart Surgery In-Hospital Mortality

2012 – 2014

Cleveland Clinic is committed to achieving the best possible outcomes for patients. The in-hospital mortality rate for pediatric congenital surgery patients has been reduced by more than 3 percentage points since 2012. 00

20122012 20132013

66

22

44

PercentPercent

1.4%

4.3%

20142014

0.7%

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Attending physicians in Cleveland Clinic’s 25-bed pediatric intensive care unit (PICU) provide around-the-clock in-house coverage, whereas only 54% of a reference group in similar facilities does so.a Implementation of 24/7 coverage by pediatric intensivists has been shown to reduce mortality, decrease length of stay (LOS), and improve decision-making and quality of care at the end of life. Additionally, at Cleveland Clinic, parents are invited to participate in multidisciplinary morning rounds. There were 1094 admissions to the PICU for the first 9 months of 2014. All mortalities, unplanned readmissions to the PICU within 24 hours of discharge, and hospital-acquired infections are reviewed by the department.aComparative data provided by Virtual PICU Systems LLC, a partnership of Children’s Hospital Los Angeles, the National Association of Children’s Hospitals and Related Institutions (part of Children’s Hospital Association), and the National Outcomes Center (Clinical Program Performance Report Pediatric Critical Care).

aData obtained from Virtual PICU Systems LLC

bFor the period Jan. 1, 2014, to Sept. 30, 2014

cStandardized mortality ratio is measured as the ratio of actual deaths to predicted deaths. The number of predicted deaths is calculated using the Pediatric Risk of Mortality III (PRISM III) score or the Pediatric Index of Mortality 2 (PIM 2) score, physiologic-based mortality-risk tools widely used to predict the intensive care outcomes of children. PIM 2 uses physiologic data from the first hour of admission to the PICU, though data from the immediate pre-ICU time frame may be used if the intensivist treated the patient prior to arrival in the PICU. Mechanical ventilation, whether the admission was elective, whether the patient was in the PICU primarily for postoperative recovery, the use of cardiac bypass, and the presence of certain high- and low-risk diagnoses are some other variables used to calculate the PIM 2. PRISM III uses data from the first 12 hours of admission to the PICU to predict risk of mortality, using the most extreme values documented during the data collection time. Compared with PRISM III, PIM 2 is less likely to be biased by the quality of treatment after admission to the PICU but may be subject to bias from different intervention thresholds.

dUsing PRISM III as an indicator of severity of illness, standardized LOS ratios are calculated by comparing the observed to expected length of stay.

Pediatric Critical Care

Pediatric Intensive Care Unit

Quality Measures

2010 – 2014

Quality Measuresa 2010 2011 2012 2013 2014b

Standardized mortality ratio based on PRISM IIId Cleveland Clinic 1.4 0.85 0.89 1.18 0.66 Reference group 1.01 0.97 0.94 0.95 0.95

Standardized mortality ratio based on PIM 2c

Cleveland Clinic 0.79 0.48 0.43 0.71 0.36 Reference group 0.89 0.85 0.81 0.81 0.82

Unplanned readmissions within 24 hours (%) Cleveland Clinic 0.99 0.47 0.74 1.48 0.73 Reference group 0.91 0.97 0.76 0.82 0.92

Standardized LOS ratio — based on PRISM IIId

Cleveland Clinic 1.62 1.82 1.43 0.93 1.10 Reference group 1.16 1.11 1.12 1.08 1.10

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16 Outcomes 201416

aBenchmark: National Healthcare Safety Network (NHSN) cdc.gov/nhsn/dataStat.html

Pediatric Critical Care

Hospital-Acquired Infections

2012 – 2014

2012 2013 2014 NHSN Benchmarka

Central line-associated bloodstream 1.5 0.92 0.82 1.2

infections (per 1000 central line days)

Catheter-associated urinary tract 1 0.9 1.88 2.5

infections (per 1000 Foley days)

Ventilator-associated pneumonia 0 0.61 0 0.7

(per 1000 ventilator days)

Clostridium difficile infections 0.7 0.49 0 N/A

(per 1000 patient days)

Respiratory viral infections (per year) 0 0 2 N/A

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Pediatric Endocrinology

Number of Admissions per Child Enrolled in the High-Risk Pediatric DKA Clinic

During 2013 physicians in Cleveland Clinic Children’s noted that a small percentage of patients with poorly controlled type 1 diabetes mellitus (T1DM) made up most of the admissions to the children’s hospital for diabetic ketoacidosis (DKA). As a result, a special clinic was developed for these children. During the clinic visit, the patient and family spend 45 minutes with each of the following:

• Pediatric diabetes doctor and nurse

• Pediatric dietitian

• Child psychologist

• Social worker

The 11 patients who attended the high-risk diabetes clinic as a group accounted for 22 admissions for DKA in the year before attending the clinics and only 11 admissions in the year following. Although the drop in admissions was encouraging, it was not a significant trend.

Continuing this intensive, multidisciplinary 3-hour clinic visit may further decrease the frequency of hospital admissions for DKA and improve the overall control of the patients’ T1DM.

Number of Admissions: Number of Admissions: Patient Year Before Clinic Year After Clinic

A 1 0

B 2 3

C 4 0

D 6 1

E 3 5

F 4 1

G 2 1

H 2 0

I 1 0

J 0 0

K 0 0

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18 Outcomes 201418

Fit Youth is a 12-week program for children and adolescents with high body mass index (BMI), ages 7 to 16, who work with their families to improve healthy living. The program, which started in 2005, is specifically designed for children and their parents. The program staff includes pediatricians, psychologists, dietitians, and exercise physiologists. They focus on the home becoming the place where it is easy to make healthy choices.

Because Fit Youth has a 10-year history, it is able to demonstrate the long-term sustainability of outcomes.

The data included in the 5-year sustainability box plot include 323 participants from 2005–2012. The average age of participants was 11.1, and 68% were female. The length of follow-up for each child was based on his or her BMI in relation to the ideal set forth in the European Prospective Investigation into Cancer and Nutrition.

Box plots show the change in BMI z-scores from the start of the program, by the length of the post-program follow-up. The boxes represent the 75th and 25th percentiles, and the horizontal lines within the boxes represent the medians. Whiskers extend to 1.5 times the interquartile range, and data beyond the whiskers are shown as dots.

Pediatric Fit Youth Program

Five-Year Sustainability (N = 323)

2005 – 2012

0.5

0.0

-2.5

-2.5

-1.5

-1.5

-0.5

Change in BMI Z-Score From Start of Fit Youth Program

Months

Length of Follow-Up

Fit YouthEnd

0 – 6 6 – 12

Years

1 – 2 2 – 3 4 – 53 – 4 5+

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Pediatric Be Well Kids

Cleveland Clinic Children’s established the Be Well Kids Clinic in April 2013 to provide long-term management for overweight and obese children. At this comprehensive, multidisciplinary clinic, children undergo an extensive baseline evaluation to determine obesity-related medical problems and then participate in a weight management program that involves dietary and behavioral modifications, exercise, and, when indicated, medications. More than half of the children that the Be Well Kids Clinic saw in 2014 were severely obese with a mean body mass index (BMI) percentile of 98.73% (range 89%–100%). Many of the patients have already developed complications from their obesity, with 45% having 2 or more comorbidities. In the Be Well Kids Clinic, children who had at least 3 visits with the team over the course of 1 year had significant decreases in BMI percentile and BMI z-score. Participants also decreased their cardiovascular risk as evidenced by improved triglycerides and triglyceride/high-density lipoprotein ratio, and improvement in alanine aminotransferase (ALT), a marker of nonalcoholic fatty liver disease. In addition to motivational interviewing and dietary counseling, the clinic prescribes specialized diets including the protein sparing modified fast (PSMF). From the time the clinic was established, 12 patients have followed this diet, which has led to loss of an average of 10.6% of initial body weight.

Patients With More Than 3 Visits Show Significant Improvement

2014

Be Well Kids Patients With > 3 Visits (N = 80) Initial Follow-Up

BMI % 98.73 98.20a

BMI 34.5 kg/m2 34.1 kg/m2

Average weight loss 1.4 kg

Be Well Kids Patients on PSMF (N = 12) Initial Follow-Up

Initial BMI 41.7 kg/m2 35.2 kg/m2e

Average weight loss 11.2 kg

Be Well Kids Patients With > 3 Visits Initial Follow-Up

ALT (N = 27) 30.48 U/L 23.96 U/Lb

TG (N = 28) 116.10 mg/dL 84.66 mg/dLc

TG/HDL ratio (N = 28) 3.05 2.10d

aP = 0.002

eP = 0.028

ALT = alanine aminotransferase, BMI = body mass index, HDL = high-density lipoprotein, PSMF = protein sparing modified fast, TG = triglycerides

bP = 0.006, cP = 0.05, dP = 0.03

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20 Outcomes 201420

Pediatric Gastroenterology

Pediatric Endoscopy In 2014, 945 pediatric patients underwent upper endoscopy, colonoscopy, or related procedures, representing a total of 1321 procedures. All procedures were performed in the pediatric ambulatory endoscopy unit, in the pediatric operating rooms, or at bedside. Most procedures were done under general anesthesia, which was administered by a pediatric anesthesiologist.

All patient records were reviewed for adverse events identified at the time of the procedure or that occurred ≤ 7 days after the procedure, including hemodynamic instability, significant medication reactions, significant gastrointestinal bleeding, or other serious procedural complications. Among all patients, only 1 adverse event was identified, a rate of 0.1%. A 21-month-old child (born at 30 weeks) with a

Number Percent

Procedures, including upper endoscopy with biopsy/esophageal 1321 dilatation/pyloric dilatation/foreign body removal, ileoscopy, colonoscopy with biopsy/polypectomy

Patients undergoing endoscopic procedures 945

Postprocedural adverse events ≤ 7 days after procedure 1 0.1

Unanticipated admission ≤ 7 days after procedure 4 0.4

Self-reported symptoms ≤ 7 days after procedure 36 3.8

Symptoms postprocedure resulting in emergency department evaluation 10 1.1

history of lung disease was admitted after an elective upper endoscopy for treatment of respiratory distress requiring reintubation in the operating room. The patient was treated with dexamethasone, observed in the pediatric intensive care unit overnight, and extubated the next morning. No other adverse events were identified.

Patient medical records were also reviewed to identify postprocedure symptoms self-reported by the patients ≤ 7 days after their procedure. In this group of patients, postprocedure symptoms including abdominal pain, chest pain, throat pain, nausea, vomiting, diarrhea, fever, dysphagia, or lightheadedness were reported in 3.8%. Patient reports of postprocedure symptoms continue to be reviewed annually; the 2014 percentage was similar to results from previous years.

Pediatric Endoscopic Procedures

2014

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The rate of completion of colonoscopies to the terminal ileum (TI) was reviewed in these patients as a quality indicator in pediatric endoscopy. Completion of colonoscopy to the TI is an essential part of a complete visual and histologic evaluation of the entire colon. It also identifies abnormalities in the TI. In 2014, 399 colonoscopies were performed in Cleveland Clinic Children’s patients. The most frequent indications for colonoscopy included abdominal pain with “red flag” symptoms of rectal bleeding, diarrhea,

Number Percent

Indications:

Abdominal pain with “red flags” 112 28.1

Crohn’s disease 78 19.5

Abdominal pain 76 19

Rectal bleeding 43 10.8

Ulcerative colitis 26 6.5

Diarrhea 19 4.8

Weight loss/failure to thrive 12 3

Anemia 55 13.8

Other 23 5.8

Colonoscopy complete to the terminal ileum 360 90

Colonoscopy with cecal intubation 376 94.2

Incomplete colonoscopy in patients with IBD limited by extent of disease 13 3.2

Incomplete colonoscopy due to inadequate preparation 10 2.5

Pediatric Colonoscopies (N = 399)

2014

iron-deficiency anemia, or weight loss (28.1%). Other indications included evaluation for graft vs host disease, protein-losing enteropathy, polyposis syndromes, or potential transplant (5.8%). Thirteen colonoscopies that were being done for the evaluation of inflammatory bowel disease (IBD) were limited to the colon because of the presence of marked intestinal inflammation or findings of colonic or distal ileal strictures.

IBD = inflammatory bowel disease

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22 Outcomes 201422


Pediatric Quality of Life in Patients With Inflammatory Bowel Disease Treated With Infliximab Health-related quality-of-life (HRQoL) assessments have been used to evaluate healthy children and to measure overall global health and effectiveness of therapy in children with a variety of chronic diseases. The Pediatric Quality of Life Inventory version 4.0 (PedsQL™ 4.0) is a pediatric-specific validated questionnaire that encompasses measurements of a child’s physical, emotional, social, and school functioning. This questionnaire, completed by patients and parents, has been validated in children ages 2–18.1,2

PedsQL 4.0 was measured as an important outcome in pediatric patients with Crohn’s disease and ulcerative colitis receiving infliximab, a chimeric monoclonal antibody against tumor necrosis factor, which is an inflammatory mediator in patients with IBD. Patients treated with infliximab typically receive infusions administered every 4–8 weeks as part of their ongoing therapy.

In 2014, PedsQL questionnaires were given to pediatric patients (≤ 18 years of age) with Crohn’s disease and ulcerative colitis receiving infliximab. Questionnaires were completed by patients and parent proxies to assess total

scores and psychosocial and physical domains of quality of life. PedsQL is scored on a 0–100 scale, with higher scores indicating better HRQoL.

PedsQL questionnaires were completed by 76 parents and 75 of their children. Of the 75 patients, 69 had Crohn’s disease and 7 had ulcerative colitis. In this group of patients, the average PedsQL patient-reported total scale score was 84.0 (± 13.6.), and parent-reported total scale score was 82.4 (± 13.5). Patients with IBD who had received long-term infliximab (therapy beginning before 2014), had higher PedsQL scores than those who began receiving infliximab in 2014. The patients with IBD receiving ongoing therapy with regularly administered infliximab infusions achieved an improved quality of life over time.

References

1. Varni JW, Limber CA, Burwinkle TM. How young can children reliably

and validly self-report their health-related quality of life?: an analysis of

8,591 children across age subgroups with the PedsQL 4.0 Generic

Core Scales. Health Qual Life Outcomes. 2007;5:1:1-13.

2. Varni JW, Limber CA, Burwinkle TM. Parent proxy-report of their

children’s health-related quality of life: an analysis of 13,878 parents’

reliability and validity across age subgroups using the PedsQL 4.0

Generic Core Scales. Health Qual Life Outcomes. 2007;5:2:1-10.

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Child-Reported HRQoL in Pediatric Patients With Inflammatory Bowel Disease on Infliximab (N = 75)

2014

Parent-Reported HRQoL in Pediatric Patients With Inflammatory Bowel Disease on Infliximab (N = 76)

2014

The bars represent the mean values of child-reported HRQoL scores (total, psychosocial, and physical). P values compare the patient-reported HRQoL on infliximab 1 year with those on infliximab > 1 year.

The bars represent the mean values of parent-reported HRQoL scores (total, psychosocial, and physical) for their children. P values compare the parent-reported HRQoL on infliximab < 1 year with those on infliximab > 1 year.

HRQoL = health-related quality of life

HRQoL = health-related quality of life

90

86

74

82

78

PedsQL

Total HRQoL(P = 0.034)

PsychosocialHRQoL

(P = 0.11)

Physical HRQoL(P = 0.016)

Newly beginning infliximabtreatment patients (N = 46)Long-standing infliximabtreatment patients (N = 29)

90

86

74

82

78

PedsQL

Total HRQoL(P = 0.045)

PsychosocialHRQoL

(P = 0.11)

Physical HRQoL(P = 0.034)

Newly beginning infliximabtreatment patients (N = 46)Long-standing infliximabtreatment patients (N = 30)

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24 Outcomes 201424


Influenza Vaccination Rates in Pediatric Patients With Bowel Disease Being Treated With Infliximab Annual influenza vaccination is recommended for all children with IBD, especially those who are immunocompromised because of their treatment with immunomodulators, including corticosteroids, methotrexate, thiopurines, and antitumor necrosis factor medications. Staff continues to discuss the importance of annual influenza vaccinations with patients, as well as offer the vaccination. In 2014 pediatric practitioners documented vaccination compliance rates in Cleveland Clinic Children’s patients with Crohn’s disease, ulcerative colitis, and indeterminate colitis receiving regular infliximab infusions. The goal was 100% compliance. The 2014 immunization rate is above the National Immunization Survey-Flu vaccination rate (2013–2014) of 58.9% for children ages 6 months–17 years.

The overall influenza immunization compliance rate was 89.3%. The rate of vaccination for patients whose family did not refuse vaccination was 98%.

Influenza Vaccination Compliance Rates in Pediatric Patients With IBD Being Treated With Infliximab (N = 159)

2014

Number Percent

Patients with IBD treated with infliximab 159

Patients offered influenza vaccine 157 99%

Influenza vaccine administration confirmed 142 89%

Patients declining influenza vaccine administration 14 9%

Patients lost to follow-up 2 1%

Influenza vaccine contraindicated 1 < 1%

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Cleveland Clinic Pediatric Intestinal Transplant and Multivisceral Transplant Program Since the inception of the Cleveland Clinic pediatric intestinal and multivisceral transplant program in the second half of 2012, a total of 30 patients with gut failure or complex abdominal pathology were referred for possible reconstructive surgery and visceral transplantation. To date a total of 4 patients received visceral transplantation— 2 intestinal and 2 multivisceral—including the intestine, duodenum and pancreas. All patients are currently alive with loss of 1 intestinal graft due to persistent rejection. Nutritional autonomy was achieved in all children with graft in place enjoying an unrestricted oral diet.

Surgical rehabilitation with autologous reconstruction and bowel lengthening was performed in another 6 of these pediatric patients who were referred for transplant with reduction or discontinuation of total parenteral nutrition in 50% of the cases.

Although 3 patients are currently on the waiting list for visceral transplantation, most of the remaining referred patients continue to be followed by our intestinal failure team for nutritional care and possible transplantation soon.

The causes of intestinal failure in pediatric patients are variable. The appropriate candidates for pediatric reconstruction and visceral transplant surgery include children with short bowel syndrome, congenital anomalies, gut malabsorption, necrotizing enterocolitis, intestinal atresia, midgut volvulus, gastroschisis, and motility disorders. Cleveland Clinic pediatric intestinal and multivisceral transplant services are highly integrated with Cleveland Clinic Children’s well-established pediatric intestinal rehabilitation and nutrition programs to deliver the optimal care for these complex pediatric patients with gut failure.

Main types of visceral transplantation include a. intestine alone, b. combined liver and intestine with pancreas, c. full multivisceral transplant that includes stomach, duodenum, pancreas, intestine, and liver, and d. modified multivisceral with exclusion of the liver.

a. c. b. d.

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26 Outcomes 201426

Pediatric General Surgery

The perforated and gangrenous appendicitis cases above show a higher average length of stay (ALOS) due to the complexity and morbidity of the disease when compared with nonperforated appendicitis. In 2014, the ALOS for the pectus excavatum patients decreased to 5.38 days from 6. In mid-2014 the program was redesigned to more easily accommodate all patients, especially those from out of town. The focus of the program maximizes the

Subjectively, the surgical team believes the patients with a single-port approach may experience less postoperative pain and a better cosmetic outcome. The patients’ acceptance of the procedures has been uniformly positive in both the appendectomy and cholecystectomy groups.

ALOS, Surgical Site Procedure Ports N Days Infections

Laparoscopic cholecystectomy Single 22 1 1 Four 7 1

Laparoscopic nonperforated appendectomy Single 104 0.92 1 Triple 26 0.92

Laparoscopic perforated appendectomy Single 15 6.3 3 Triple 22 6.9

Laparoscopic gangrenous appendectomy Single 5 3 3 Triple 7 2.3

Pectus excavatum 9 5.38 1

Robotics 9 N/A 1

ALOS = average length of stay

patient’s time by scheduling all tests and visits in 1 day. The redesign has been extremely well received by the patients seen in late 2014.

In 2013 robot-assisted pediatric surgery was an innovation topic. In 2014 it became a reality. All 9 patients treated at Cleveland Clinic Children’s did very well with no unexpected complications. There was 1 surgical site infection.

Number of Ports Used in Laparoscopic Cholecystectomy Number of Ports Used in Appendectomy

100

0

75

50

25

Percent

Single port29N =

Four port36

20142010

100

0

75

50

25

Percent

Single port168N =

Four port161

20142010

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Pediatric Hematology and Oncology

The data represent patients treated by the Department of Pediatric Hematology/Oncology with a primary diagnosis of fever or neutropenia.

Reference

1. Pizzo PA, Poplack DG, eds. Principles and Practice of Pediatric Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Time to Antibiotics (min) 2012 2013 2014

< 30 Not measured Not measured 79.0%

30 – 60 90.8% 93.7% 18.4%

> 60 9.2% 6.3% 2.6%

Fever and Neutropenia in Pediatric Hematology and Oncology Patients

Infection is one of the most common causes of morbidity and mortality in pediatric hematology and oncology patients. Fevers, especially in patients with neutropenia, can quickly become a medical emergency. For the past 30 years, the practice of initiating empiric antibiotics in patients with febrile neutropenia has significantly decreased morbidity and mortality.1

Hematology/Oncology and Blood & Marrow Transplantation Central Line-Associated Bloodstream Infection Rates

Central line-associated bloodstream infections (CLABSIs) are a cause of significant morbidity and mortality in patients and especially in pediatric oncology patients. The department has been actively working on decreasing the CLABSI rate by using guidelines and limiting line days.

Hematology/Oncology and BMT Inpatient CLABSI Rate Cleveland Clinic Main Campus (N = 7)

2013 – 2014 Combined

BMT = blood and marrow transplant CLABSI = central line-associated bloodstream infection NHSN = National Health Safety Network

aBenchmark: National Health Safety Network (NHSN), non-ICU inpatient rate

6

0

4

2

CLABSI/1000 CL Days

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

CLABSI rate per monthNHSN benchmark, non-ICU inpatient ratea

Cleveland Clinic Hematology-Oncology BMT target rate

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28 Outcomes 201428

Pediatric Hematology and Oncology

Pediatric Blood & Marrow Transplant Program The Pediatric Blood & Marrow Transplantation Program received accreditation from the Foundation for the Accreditation of Cellular Therapy in 2013, reinforcing a commitment to excellence in quality, research, and patient care. From 2011 to 2014, the program performed 19 allogeneic transplants for many malignant disorders, including:

• Acute lymphoblastic leukemia

• Acute myeloid leukemia

• Chronic myelogenous leukemia

• Juvenile myelomonocytic leukemia and nonmalignant disorders, such as:

• Fanconi anemia

• Severe aplastic anemia

• Immunodysregulation, polyendocrinopathy, enteropathy X-linked syndrome

• Congenital amegakaryocytic thrombocytopenia

Six transplants were matched related donors, 5 were matched unrelated donors, 6 were from single or double umbilical cord blood units, and 2 patients received a transplant from a haploidentical/mismatch related donor.

Patient Survival After Bone Marrow Transplant (N = 19)

2011 – 2014

00

100100

4040

6060

8080

2020

Survival (%)Survival (%)

0 126Months After Transplant

24 4818 30 36 42

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Asthma According to the Centers for Disease Control and Prevention, 9.3% of children in the US are diagnosed with asthma, which is a leading cause of pediatric admissions to hospitals nationwide. Good evidence supports standardization of asthma care via implementation of an inpatient care path to improve quality. This care path was implemented at main campus in 2006 and has been used at Cleveland Clinic’s regional hospitals over the years. Asthma is also the only pediatric diagnosis that has core measures developed for it.

Pediatric Hospital Medicine

Patients Ages 2 – 18 Main Campus Fairview Hospital Hillcrest Hospital

Inpatient encounters 124 43 12

Readmissions rate within 30 days, % 0.8 0 0

Average length of stay, days 1.90 1.65 1.42

Inpatient management plan of care, % 93 96.8 66

Asthma Care Path Reduces Length of Stay, Readmissions

2014

Using the asthma care path has resulted in 100% compliance with 2 of The Joint Commission’s core measures: use of systemic corticosteroids and use of asthma relievers (bronchodilators).

A high compliance rate with a third Joint Commission core measure, the home management plan of care, has been the most difficult to implement, and additional work needs to be done to increase compliance in the region. The asthma care path has resulted in a relatively shorter length of stay without adversely affecting quality-of-care outcomes or readmission rates.

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30

Compliance With Antibiotic Timing Guidelines and Percentage of Postoperative Infections After Cardiac, Spine Fusion, and Primary Neuro-Shunt Procedures by Quarter (N = 1101)

2009 – 2014

00

100100

4040

6060

8080

2020

PercentPercent

2009 2010 2011 2013 20142012

Infection ratePreoperative ATB on timeATB redosing at 4 hours

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Outcomes 201430

Pediatric Infectious Diseases

Pediatric Surgical Site Infections Cleveland Clinic Children’s has initiated several quality improvement projects directed at reducing pediatric surgical site infections. The Pediatric Institute has joined Ohio Solutions for Patient Safety, a collaborative of 8 children’s hospitals devoted to developing and sharing quality initiatives. As part of the collaborative, an enhanced surveillance program was initiated in 2009, aimed at tracking surgical site infection rates and compliance with measures to prevent these infections. Measures introduced include:

• Adding the need for antibiotics (ATBs) to the preoperative surgical safety checklist

• Adopting recommendations for optimal pediatric (mg/kg) dosing

• Changing recommended ATB redosing intervals for long procedures to every 3 hours (every 6 hours for vancomycin)

• Introducing in the OR an electronic reminder for ATB redosing

• Adding standard pediatric ATB doses to the OR Pixis® system

In Ohio, hospitals report pediatric surgical site infection rates for specific cardiac, neurologic, and orthopaedic surgery procedures to the public. The data presented below correspond to the procedure codes used for Ohio public reporting. At Cleveland Clinic Children’s, compliance with preoperative ATB guidelines was 91.4% in 2009, 98.2% in 2010, and 100% from 2011– 2014 for major cardiac, neurologic, and orthopaedic surgery procedures (P < 0.0001, for 2009–2010 vs 2011–2014). Correspondingly, the aggregate infection rate decreased from 6.1% in 2009 and 4.0% in 2010 to 1.0% in 2011, 1.2% in 2012, 1.3% in 2013, and 2.5% in 2014 (P < 0.001, for 2009–2010 vs 2011–2014).

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Use of Real-Time Electronic Database to Help Prevent Pediatric Surgical Site Infections

To enhance the ability to identify and track risk factors for surgical site infections, the Center for Pediatric Infectious Diseases and Quantitative Health Science have developed a real-time electronic database to retrieve information related to perioperative surgical prophylaxis. The database permits automation of the process of tracking compliance with recommended measures to prevent infection, including the correct ATB, correct initial dose, correct initial time, correct subsequent dose, and correct subsequent time.

For the ATB cefazolin (N = 623), robust compliance with ATB timing and initial dosing was noted; however, an optimized weight-based subsequent dose was inconsistently given. Starting in August 2013, the center shared data on cefazolin dosing with the surgical and anesthesia services and observed an increase in the quarterly compliance rate from 67.5% to 100% for the first time. Sustaining compliance is an ongoing effort.

In the same population, the use of vancomycin or clindamycin instead of cefazolin for surgical prophylaxis was associated with an increased risk of infection. Out of 682 pediatric spinal fusion procedures performed between 2006 and 2014, 52 patients followed an ATB regimen that did not contain cefazolin. In total there were 30 surgical site infections, for an overall infection rate of 4.4%. Among patients who received cefazolin, either alone or in combination with another ATB, the infection rate was 3.3% (21 of 630). For patients receiving vancomycin or clindamycin, the infection rate was 17.3% (9 of 52; P < 0.001). Quality improvement initiatives promoted the use of cefazolin-containing regimens, and in 2014 all patients undergoing spine fusion followed cefazolin-containing regimens.

Percent of Patients Receiving Cefazolin Prophylaxis at Optimized Dose and Correct Time During Pediatric Orthopaedic Spine Fusion Procedures (N = 623)

2007 – 2014

00

100100

4040

6060

8080

2020

PercentPercent

2009 20102007 2008 2011 2012 201420131Q 3Q 1Q 3Q 1Q 3Q 1Q 3Q 1Q 3Q 1Q 3Q 1Q 3Q 1Q 3Q

Cefazolin 60 minutes before incisionOptimized initial cefazolin dose

Cefazolin redosed at 4 hoursOptimized cefazolin redose

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32 Outcomes 201432

Pediatric Infectious Diseases

Appropriate Use of Antimicrobial Agents for Fever and Neutropenia Children with cancer present a unique population of patients because they are at great risk for infection during neutropenic periods. It is imperative that these children are evaluated and started on appropriate empiric antibiotics when they present with fever and neutropenia. It is also important that the ATBs they receive are broad enough to cover the likely pathogens and are used appropriately according to national standards of antimicrobial stewardship. The CDC has established guidelines for the use of vancomycin in these patients to ensure that this ATB

is not overused. Established guidelines for the use of gentamicin are in place as well, in order to control and minimize adverse effects of ATBs.

In 2014, 57 pediatric patients were admitted to Cleveland Clinic Children’s with a diagnosis of fever and neutropenia. Of these, 56% received monotherapy with either piperacillin-tazobactam or cefepime, which is the standard protocol. Twenty patients also received vancomycin as part of the initial antimicrobial regimen, and vancomycin use met the CDC guidelines in 18 of the 20 patients. Gentamicin was used initially in 4 of the 57 patients, and in all these patients, the use of gentamicin was deemed appropriate based on standard protocols.

Infections Following Pediatric Spine Fusion Procedures Overall and for Cefazolin-Containing Regimens (N = 682)

2006 – 2014

10

5

0

Surgical Site Infection Rate (%)

200659N =

200772

200888

200993

201074

201181

0 0

201271

201474

201370

2006 – 2014682

Cefazolin, alone or in combinationOverall

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Cleveland Clinic views annual influenza vaccination as a professional responsibility essential for patient safety, and it requires participation by all employees. For the 2014–2015 influenza season, compliance was measured as receipt of a vaccine by Dec. 15, 2014, or by receipt of a medical or religious exemption. Collective vaccination will reduce the likelihood that influenza will spread within the hospital.

Employee Influenza Vaccination Rates for the Pediatric Institute and Cleveland Clinic Children’s

2014 – 2015

Use of Antimicrobial Agents in Pediatric Patients Admitted With Fever and Neutropenia (N = 57)

2014

Compliance Rate (%) Vaccination Rate (%) Total Employees

Cleveland Clinic 92.9 91.2 43,701

Pediatric Institute/Cleveland Clinic Children’s 98.7 97.3 915

Autism school and outreach 97.6 96.0 125

Pediatric nursing units and Child Life Program 96.4 95.6 363

Pediatric residents and fellows 100.0 100.0 67

Monotherapy With Appropriate Total Piperacillin or Cefepime Vancomycin Vancomycin Gentamicin Gentamicin Appropriate Use

32 (56%) 20 (35%) 18 (90%) 4 (7%) 4 (100%) 55 (96 %)

Appropriate Appropriate indications: indications: Sepsis (7) Sepsis (4) Severe mucositis (7) CNE infection (2) Cellulitis (2)

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34 Outcomes 201434

Neonatology

Shrunken Risk-Adjusted Rates for Combined Mortality, Chronic Lung Disease, and Severe Retinopathy of Prematurity in Very Low Birth Weight Infants

Risk adjustment based on the Vermont Oxford Network (VON) provides a standard for 2013 shrunken risk-adjusted rates for mortality, chronic lung disease (CLD), and severe retinopathy of prematurity (ROP) in very low birth weight (VLBW) infants (those who weigh 501–1500 g) at each of Cleveland Clinic Children’s neonatal intensive care units (NICUs). Based on VON classification, our main campus NICU, which is reported below, is level 3C. The red dots show risk-adjusted rates for mortality, CLD, and ROP. The black lines show 95% of the upper and lower bounds.

Shrunken Risk-Adjusted Data for Mortality, Chronic Lung Disease, and Severe Retinopathy of Prematurity

2013

Mortality, CLD, and ROP are relevant outcomes that can be used to evaluate quickly the quality of a program. Shrunken risk-adjusted data provide a more consistent way to evaluate the performance of a unit and take into account volume and case mix. A standardized mortality rate and its upper and lower bounds indicate whether a center has more or fewer infants with observed outcomes vs expected outcomes given the characteristics of infants treated.

The results from Cleveland Clinic Children’s compare very favorably with the expansive VON database. A decreased mortality in the smallest of babies has been associated with a mild increase in CLD and severe ROP in one of the units, compared with previous years (data not shown). Evaluating data on a yearly basis helps identify opportunities for continued improvement.

N = number of infants treated at 3 campuses divided by total number of VLBW infants at risk

2.0

1.5

0.5

0.0

1.0

Risk-Adjusted Rates

Mortality CLD ROP

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Neonatal Intensive Care Unit Central Line-Associated Bloodstream Infection Rate/1000 Central Line Days

2012 – 2014

Neonatal Central Line-Associated Bloodstream Infections

The Ohio Perinatal Quality Collaborative is a consortium of neonatal units dedicated to reducing infections in infants 22–29 weeks’ gestational age. In 2008, Cleveland Clinic Children’s 3 NICUs implemented several initiatives for the prevention of late onset infections.

CLABSI = central line-associated bloodstream infection, NHSN = National Health Safety Network,

NICU = neonatal intensive care unit

aCleveland Clinic Children’s Enterprise includes 3 NICUs. bBenchmark: Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollack DA,

Sievert DM, Edwards JR. National Healthcare Safety Network (NHSN) report, data summary for

2013, Device-associated module. Am J Infect Control. 2013 Dec;41(12):1148-1166.

The 3 Cleveland Clinic NICUs’ combined mean CLABSI rate for 2012 was 1.3 per 1000 central line days, which decreased 0.8 per 1000 central line days, well below the NHSN rate of 1.2 per 1000 central line days in 2013 and 2014.

The NHSN CLABSI rate is calculated by combining birth weight and infection data from Level III NICUs. The NHSN rate of 1.2 per 1000 central line days is the mean for all patients from reporting NICU facilities.

1.5

0.5

1.0

0.0

Rate

2012 2013 2014

Cleveland Clinic Enterprisea

2013 NHSN NICU benchmark rateb

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36 Outcomes 201436

Neonatology

Results displayed as median (range). VLBW = very low birth weight

Neonatal Intensive Care Unit — Neurodevelopmental Outcomes Preterm and high-risk infants discharged from NICUs within Cleveland Clinic are referred to the NICU Follow-Up Clinic. The patients can be evaluated at Cleveland Clinic Children’s Hospital for Rehabilitation at Shaker Campus, Fairview Hospital, and Hillcrest Hospital. Babies are typically seen at 4, 8–12, and 18–24 months corrected age. Visits may start as early as 1 month after discharge and may extend to 3 years of age, depending on the child’s specific needs.

In 2014, neurodevelopmental testing using the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III), was completed in 98 patients who were 8–12 months of age and 169 patients who were 18–24 months of age. Cognitive, language (receptive and expressive), and motor (gross and fine) composite Bayley-III scores between

Neurodevelopmental Outcomes for Preterm and High-Risk Infants (N = 267)

2014

Infants < 12 Months Corrected Age Infants ≥ 12 Months Corrected Age

All Infants VLBW Infants All Infants VLBW Infants (N = 98) (N = 62) (N = 169) (N = 107)

Birth weight, g 1212.5 910 1310 1050 (480 – 4550) (480 – 1470) (486 – 4320) (550 – 1490)

Gestational age, wk 29 (23 – 40) 28 (23 – 33) 30 (22 – 41) 28 (22 – 37)

Corrected age at testing, mo 10.5 (8 – 11.5) 10.5 (8 – 11.5) 20 (12 – 30) 20 (12 – 24)

Bayley-III composite score Cognitive 105 (55 – 120) 100 (55 – 115) 100 (55 – 145) 100 (55 – 130) Language 91 (59 – 121) 90 (59 – 115) 94 (47 – 138) 94 (56 – 127) Motor 97 (46 – 139) 97 (46 – 124) 100 (46 – 127) 100 (46 – 121)

85 and 115 are considered normal. This assessment helps compare a child’s development with that of normally developing children of the same age. It can determine the need for further assessments or indicate specific therapeutic areas on which to focus, such as physical, occupational, and/or speech therapy.

Many NICU graduates are evaluated prenatally in Cleveland Clinic Children’s Fetal Care Center and diagnosed with conditions that place them at an increased risk for neurodevelopmental impairments. Many of these infants require frequent rehospitalizations, which is typical for this high-risk population. Some require ongoing surgical repairs of cardiac, gastrointestinal, and/or neurologic anomalies. To help these infants achieve their greatest neurodevelopmental potential, many are referred to therapy services. Although some infants have muscle tone problems by 2 years of age, most NICU graduates are thriving and have essentially normal neurodevelopment.

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Center for Comprehensive Pediatric Kidney Care The Judith M. Power Dialysis Center is in its 11th year of operation at Cleveland Clinic Children’s Hospital for Rehabilitation. The center provides pediatric hemodialysis and peritoneal dialysis to infants, children, adolescents, and young adults through 21 years of age. It remains the only pediatric dialysis center in northern Ohio affiliated with a pediatric transplant program.

The National Kidney Foundation’s Kidney Disease Outcomes Quality InitiativeTM guidelines provide the benchmarks to measure the quality of initiatives for patients who develop end-stage renal disease (ESRD).

Cleveland Clinic Children’s Hospital for Rehabilitation started 2014 with its highest volume to date — 16 hemodialysis patients and a 4-fold increase in transplant volume between 2013–2014. The

Pediatric Nephrology

peritoneal dialysis program continues to grow as well: Since the program was restarted in 2011, patient volume has increased > 500%. This increase in the ESRD population results in more children currently undergoing evaluation for kidney transplantation.

Hemodialysis adequacy is measured in 2 ways — with urea reduction ratio (URR) and Kt/V. Peritoneal adequacy is measured with Kt/V. Using both measurements, the dialysis center exceeds the national benchmarks.

Arteriovenous fistulas (AVFs) and grafts provide superior access when compared with tunneled and nontunneled catheters. In the 2nd half of 2013, the center experienced an influx of children with newly diagnosed ESRD in urgent need of dialysis who required catheter placement for access. In January 2014, 7 children (44%) had internal jugular hemodialysis catheters placed, 3 children went to peritoneal dialysis, and 1 returned to hemodialysis due to surgical issues. One child received a transplant, and AVFs were placed in 3 children, bringing the AVF rates to ≥ 70% for the last quarter of 2014.

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38 Outcomes 201438

Children on In-Center Hemodialysis: Benchmarked Data

2011 – 2014

Children on Home Peritoneal Dialysis Therapy: Benchmarked Data

2011 – 2014

2011 2012 2013 2014 (N = 11) (N = 11) (N = 11) (N = 11) Benchmark

HGB 10.9 11.5 10.7 10.8 10 – 12 g/dLa

Kt/V 1.76 1.81 1.81 1.79 > 1.4b

URR (%) 76 77.2 78 76.8 > 70b

AVF rate (%) 68.7 81.8 86.4 61 > 66b

2011 2012 2013 2014 (N = 0) (N = 1) (N = 3) (N = 6) Benchmark

HGB n/a 11.3 11.2 11.1 10 – 12 g/dLa

Kt/V n/a 2.7 2.1 2.1 > 1.7b

HGB = hemoglobin, Kt/V = clearance multiplied by time divided by volume of water in patient, URR = urea reduction ratio, AVF = arteriovenous fistula

aBenchmark: Range includes National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative kidney.org/professionals/kdoqi bBenchmark: National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative kidney.org/professionals/kdoqi

HGB = hemoglobin, Kt/V = clearance multiplied by time divided by volume of water in patient

aBenchmark: Range includes National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative kidney.org/professionals/kdoqi bBenchmark: National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative kidney.org/professionals/kdoqi

38

Pediatric Nephrology

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Pediatric Neurology

Epilepsy is a chronic condition with a wide array of symptoms and implications. Its main effects are determined by the recurrence, frequency, and severity of seizures. Cleveland Clinic’s Epilepsy Center is a national and international leader in the diagnosis and management of patients with epilepsy. The following outcomes highlight treatment results using the Epilepsy Center’s highly integrated, multidisciplinary approach. Seizure outcomes are reported both for the large subgroups of patients treated only with medications and for the relatively smaller subgroups also treated with epilepsy surgery.

100

80

60

40

20

0

LSSS Score Seizure SeverityScore

ImprovedInitial Follow-Up

Visit

Seizure Severity in Medically Treated Pediatric Epilepsy Patients (N = 605)

2007 – 2014

Seizure Frequency in Medically Treated Pediatric Epilepsy Patients (N = 715)

2007 – 2014

In the pediatric age group, seizure severity, as measured by the LSSS, improved significantly from the initial visit to the last follow-up in patients treated with medications alone, with mean LSSS score of 31.8 at initial visit compared to 14.5 at follow-up (P < 0.0001). N = number of patients with at least 6 months of follow-up. Mean duration of follow-up was 29.5 months. The standard box plots reflect the median and the 25th and 75th quartiles.

Pediatric patients also saw a reduction in seizure frequency: 70% of patients seen between 2007 and 2014 had a 50% or greater reduction in seizure frequency. Mean duration of follow-up was 29.9 months. The average seizure frequency at baseline in this patient cohort was 23 seizures per month.

Cleveland Clinic

Responder rate (≥ 50% reduction in seizure frequency) 70%

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40 Outcomes 201440

Pediatric Neurology

100

80

60

400 1 2 3 4 5 6 7 8 9 10 11 12

Years After Surgery

Seizure-Free (%)

Pediatric epilepsy patientsAdult epilepsy patientsCombined cohort

Long-Term Seizure-Freedom in Adult and Pediatric Patients Following Epilepsy Surgery (N = 2080)

Surgical Dates: 1996 – 2014

1. Engel J, Jr., Van Ness PC, Rasmussen TB, Ojemann LM. Outcome with respect to epileptic seizures. In: Engel J, Jr., ed. Surgical Treatment of the Epilepsies. 2nd ed. New York, NY: Raven Press; 1993:609-621.

Approximately 60% of patients with previously medically intractable epilepsy remained seizure-free 10 years after surgical treatment at Cleveland Clinic’s Epilepsy Center. Individual curves of seizure outcome show similar long-term chances of seizure-freedom in adult and pediatric patients who underwent epilepsy surgery at the center between 1996 and 2014.

Years After Surgery 1 Year 2 Years 5 Years 10 Years 12 Years

% seizure-free (combined cohort) 74% 69% 63% 61% 59%

% seizure-free (adult epilepsy) 75% 70% 64% 61% 61%

% seizure-free (pediatric epilepsy) 71% 67% 62% 60% 48%

Seizure Outcomes in Surgically Treated Adult and Pediatric Epilepsy Patients

Long-term chances of achieving and maintaining seizure-freedom following various types of epilepsy surgery are shown in the following graphs. Whenever possible, the Epilepsy Center’s data were compared with national published data. Seizure outcomes were classified using the widely accepted Engel classification1 of seizure-freedom (seizure-free = Engel class 1).

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100

80

60

40

20

00 1 2 3 4 5 6 7 8 9 10

Years After Surgery

Seizure-Free (%)

Cleveland Clinic Epilepsy CenterNational average

Temporal lobe epilepsy surgery is the most common type of brain surgery performed for the treatment of intractable epilepsy. The graph illustrates the percentage of adult and pediatric patients who were seizure-free up to 10 years following a temporal lobe resection. National averages represent a weighted average of studies conducted in the United States.1-7

1. Erickson JC, Ellenbogen RG, Khajevi K, Mulligan L, Ford GC, Jabbari B. Temporal lobectomy for refractory epilepsy in the U.S. military. Mil Med. 2005 Mar;170(3):201-205.

2. Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Shinnar S, Langfitt JT, Walczak TS, Pacia SV; Multicenter Study of Epilepsy Surgery. Predicting long-term seizure outcome after resective epilepsy surgery: the multicenter study. Neurology. 2005 Sep 27;65(6):912-918.

3. Kelley K, Theodore WH. Prognosis 30 years after temporal lobectomy. Neurology. 2005 Jun 14;64(11):1974-1976.

4. Yoon HH, Kwon HL, Mattson RH, Spencer DD, Spencer SS. Long-term seizure outcome in patients initially seizure-free after resective epilepsy surgery. Neurology. 2003 Aug 26;61(4):445-450.

5. Foldvary N, Nashold B, Mascha E, Thompson EA, Lee N, McNamara JO, Lewis DV, Luther JS, Friedman AH, Radtke RA. Seizure outcome after temporal lobectomy for temporal lobe epilepsy: a Kaplan-Meier survival analysis. Neurology. 2000 Feb 8;54(3):630-634.

6. Salanova V, Markand O, Worth R. Longitudinal follow-up in 145 patients with medically refractory temporal lobe epilepsy treated surgically between 1984 and 1995. Epilepsia. 1999 Oct;40(10):1417-1423.

7. Sperling MR, O’Connor MJ, Saykin AJ, Plummer C. Temporal lobectomy for refractory epilepsy. JAMA. 1996 Aug 14;276(6):470-475.

Long-Term Seizure-Freedom Following Temporal Lobe Epilepsy Surgery (N = 1100)


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42 Outcomes 201442

Pediatric Neurology

100

80

60

40

20

00 2 4 6 8 1210

Years After Surgery

Seizure-Free (%)

100

80

60

40

20

00 1 2 3 4 5

Years After Surgery

Seizure-Free (%)

2000 or afterBefore 2000

Frontal lobe resection is the second most commonly performed epilepsy surgery procedure. This type of epilepsy surgery is traditionally considered the most challenging. The graph below reflects seizure outcome in adult and pediatric patients with previously medically intractable frontal lobe epilepsy operated on between 1997 and 2014.

Long-Term Seizure-Freedom Following Frontal Lobe Epilepsy Surgery (N = 446)


Improvement in Frontal Lobe Epilepsy Surgical Outcomes Over the Years (N = 397)


Surgical outcomes of patients have improved over time, likely due to the introduction and use of advanced diagnostic (including high-resolution MRI, magnetoencephalography, and other postprocessing techniques) and surgical techniques (including stereotactic electroencephalography or SEEG). Close to one-half the patients operated on at Cleveland Clinic after 2000 are seizure-free after 5 years, compared with one-third of those operated on before 2000. Magnetoencephalography, several MRI postprocessing techniques, and SEEG were not available or routinely used before 2000.

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100

80

60

40

20

00 1 2 3 4 5 6 7 8

Years After Surgery

Seizure-Free (%)

Long-Term Seizure-Freedom Following Posterior Quadrant Resection (N = 155)

Surgical Dates: 1997 – 2014 Posterior quadrant resection is used to treat intractable epilepsy involving the posterior temporal, parietal, and/or occipital regions. The graph reflects the percentage of patients who continue to be completely seizure-free up to 8 years following a posterior quadrant resection.

100

80

60

40

20

00 1 2 3 4 5 6 7 8 9 10 11 12

Years After Surgery

Seizure-Free (%)

Long-Term Seizure-Freedom Following Hemispherectomy (N = 265)


Years After Surgery 1 Year 2 Years 5 Years 12 Years

% seizure-free 77 71 63 63

1. Moosa AN, Jehi L, Marashly A, Cosmo G, Lachhwani D, Wyllie E, Kotagal P, Bingaman W, Gupta A. Long-term functional outcomes and their predictors after hemispherectomy in 115 children. Epilepsia. 2013 Oct;54(10):1771-1779.

Patients, usually infants and young children, with life-threatening, catastrophic epilepsy may be candidates for hemispherectomy, one of the most complex types of epilepsy surgery. The graph reflects the percentage of patients who continue to be completely seizure-free up to 12 years following a hemispherectomy. Beyond improvements in seizure frequency, several other benefits were observed after hemispherectomy including reduction and elimination of seizure medications, functional improvement, and prevention of further decline in cognitive and language developments.1

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44 Outcomes 201444

Pediatric Neurology

There was a significant reduction in the frequency of emergency room (ER) visits, from a mean of 0.38 ER visits in 3 months preceding surgery to 0.1 after surgery (P < 0.0001), a more than 70% reduction in frequency of ER visits. N = pediatric patients with at least 6 months of follow-up. Mean duration of follow-up was 28 months.

Mean ER Visit Rate (per 3 Months)

Before AfterSurgery

0.4

0.3

0.2

0.1

0

1.0

0.8

0.6

0.4

0.2

0

Mean Hospitalization Rate (per 3 Months)

Before AfterSurgery

Pediatric Epilepsy: Effect of Treatment on Healthcare Utilization Treatment benefits for patients in the pediatric age group extended beyond the improvements seen in seizure frequency and severity.

Hospitalization Rates in Surgically Treated Pediatric Epilepsy Patients (N = 817)

2009 – 2014

Emergency Room Visits in Surgically Treated Pediatric Epilepsy Patients (N = 819)

2009 – 2014

Healthcare utilization improved significantly with epilepsy surgery. The number of hospitalizations decreased from a mean of 0.2 in the 3 months preceding surgery to a mean of 0.04 after surgery (P < 0.0001), an 80% reduction in frequency of hospitalizations. N = pediatric patients with at least 6 months of follow-up. Mean duration of follow-up was 28.1 months.

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100

80

60

40

20

0

Patients (%)

ImprovedStableWorsened

School DaysMissed

Total PedMIDASScore

Medication Use

Pediatric Headache Change in Headache Disability (N = 241)

Treatment Dates: January 2013 – December 2014

Among 241 pediatric patients treated for headache, 71% showed improvement in total PedMIDAS (Pediatric Migraine Disability Assessment), 63% showed improvement in number of school days missed due to headache in the preceding 3 months, and 69% showed improvement in number of headache medication doses used. Median duration of follow-up was 224 days (range, 91–656).

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46 Outcomes 201446

Pediatric Orthopaedic Surgery

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.

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

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

Pediatric Shoulder and Hand/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 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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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

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 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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48 Outcomes 201448

Pediatric Orthopaedic Surgery


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

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

Pediatric Hip, Knee, and Foot/Ankle Surgery, 2009 – 2014 Procedure 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 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

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)

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 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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50 Outcomes 201450

Pediatric Otolaryngology

Tympanostomy tube placement is one of the most common surgical procedures in the US. Tympanostomy tubes are commonly placed for recurrent acute otitis media and chronic otitis media with effusion. Postoperative sequelae are common and can include early postoperative otorrhea, recurrent otorrhea, chronic otorrhea, tube blockage, premature tube extrusion, and migration of the tube into the middle ear.

In 2014, 385 patients underwent tympanostomy tube placement by pediatric subspecialists at Cleveland Clinic’s Head & Neck Institute; 95% of tympanostomy tubes placed were short-term tubes. The following graphs present institute outcomes after tympanostomy tube placement in comparison with literature benchmarks.

Institute patients are seen 4–6 weeks after tube placement; any drainage within this time frame is considered early postoperative otorrhea. Literature benchmarks define early postoperative drainage as that occurring within 4 weeks after surgery. Even with the institute’s expanded time frame to identify drainage, its early postoperative otorrhea rate of 13.5% (52 of 385 patients) is less than the 16% rate (95% confidence interval [CI], 14.2–17.9) reported in the literature.1

The otorrhea index is defined as the total number of episodes of drainage divided by the total ventilation time. The institute’s otorrhea index is calculated from the 206 patients with follow-up extending past their first postoperative visit. These patients had a total of 186 episodes of otorrhea during 39,880 days of ventilation time, amounting to 0.14 episodes of drainage per month. This compares with Van Heerbeek’s otorrhea index of 0.047 episodes of drainage per month.2

Early Postoperative Otorrhea (N = 385)

2014

Otorrhea Index (N = 206)

2014

Short-Term Postoperative Complications of Tympanostomy Tubes

20

0

15

10

5

Percent

Literature rate

Otorrhea

0.4

0.0

0.3

0.2

0.1

Index

Literature rate

Otorrhea Episodes per Month

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51

The institute’s rate of migration of the tympanostomy tube into the middle ear is 0.1% (1 of 748 ears) and is comparable to a rate of 0.5% in the literature.1

Tube Migration Rate (N = 748)

2014

References

1. Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001 Apr;124(4):374-380. 2. Van Heerbeek N, De Saar GM, Mulder JJ. Long-term ventilation tubes: results of 726 insertions. Clin Otolaryngol Allied Sci.

2002 Oct;27(5):378-383.

1.0

0.0

0.5

Percent

Literature rate

Tube Migration

Early tube blockage is defined as occurring prior to the patient’s first postoperative appointment, which is typically 4–6 weeks after surgery; 4% (30 of 748) of tubes placed had an early blockage. This resulted in 7.5% (29 of 385) of patients experiencing early tube blockage, with 1 patient having bilateral blockage. The patency of 65% of tubes with early blockage was restored with peroxide drops or an antibiotic ear drop. After this early period, 11 institute patients experienced tube blockage for an overall rate of 6.1% during follow-up, which is comparable to the literature’s overall blockage rate of 6.9% (95% CI, 6.1–7.7).1

Premature tube extrusion is defined as occurring prior to the patient’s first postoperative appointment, which is typically 4–6 weeks after surgery. At the time of the patient’s first postoperative follow-up, 0.4% (3 of 748) of tubes had extruded early. This is comparable to the literature’s rate of 3.9% (95% CI, 1.6–7.9).1

Tube Blockage (N = 748)

2014

Premature Tube Extrusion Rate (N = 748)

2014

8

0

6

4

2

10Percent

Literature rate

Early TubeBlockagea

Overall TubeBlockage

aEarly tube blockage does not have a suitable literature comparison.

4

0

3

2

1

5Percent

Literature rate

Premature TubeExtrusion

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52 Outcomes 201452

Pediatric Palliative Care

Overall Perceived Benefit of Pediatric Palliative Care Involvement (N = 49)

2014

Individual Benefits of Pediatric Palliative Care Team (N = 53)

2014

Cleveland Clinic Children’s pediatric palliative care team continues to provide care to children of all ages with complex health conditions. Common conditions include congenital heart disease, neurologic disease, cancer, and those requiring vital assistive technology. Growing evidence demonstrates that families of children with chronic, complex conditions also benefit from involvement with palliative care. Early involvement of the team can improve the patient’s quality of life and overall symptom management. Not only is the pediatric palliative care team a resource for the patient and family, but also for the entire healthcare team — including the primary care physician, community therapist, caregivers, and subspecialists active in the patient’s care. To evaluate the current benefit of the pediatric palliative care team to Cleveland Clinic Children’s, a survey was distributed to physicians and advanced care providers.

80

0

60

40

20

Percent

Care Coordination Emotional Support forthe Healthcare Team

Team Support for End-of-Life Discussions

Team Support andAssistance for

Medical Decision-Making

Very usefulUsefulNeutral

60

0

304050

1020

Percent

Very Significant Significant Neutral

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Pediatric Primary Care

Childhood Immunizations

2011 – 2014

Adolescent Immunizations

2011 – 2014

Immunizations

With multiple outbreaks of vaccine-preventable disease reported in Ohio and nationally in 2014, timely childhood and adolescent immunization was even more critical to our ambulatory quality efforts. Staff continued its proven interventions including staff education, thoughtful previsit planning, reduced missed vaccination opportunities, and combined electronic and phone reminder systems.

0

80

60

20

40

20113406N =

20123596

20133887

20144368

Mean Percent

HEDISa

aBenchmark: The Healthcare Effectiveness Data and Information Set (HEDIS) consists of 81 measures across 5 domains of care. https://www.ncqa.org/HEDISQualityMeasurement.aspx

aBenchmark: The Healthcare Effectiveness Data and Information Set (HEDIS) consists of 81 measures across 5 domains of care. https://www.ncqa.org/HEDISQualityMeasurement.aspx

0

100

80

60

20

40

20113694N =

20123837

20133730

20143950

Mean Percent

HEDISa

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54 Outcomes 201454

Reduction in Annual In-Hospital Days (N = 137)

2014

Pediatric Aerodigestive, Voice, and Swallowing Clinic Since 2009, the Center for Pediatric Pulmonary Medicine has operated a multidisciplinary clinic for children with complex chronic health issues related to pulmonary diseases, airway clearance, digestive health, nutrition, voice, and swallowing disorders. The team includes staff from pediatric pulmonology, pediatric otolaryngology, pediatric gastroenterology, and pediatric psychiatry. Many therapy services including respiratory, speech, nutrition, and social work are also available. The multidisciplinary team provides a convenient, patient-centered experience for children whose complex medical conditions require input from multiple specialists. The goal is to provide a comprehensive ambulatory evaluation in which the patient and family can have assessments made in a single visit, and each clinician can assess patients at a single point in their care. This allows real-time collaboration among specialty providers who then are able to implement a prospective plan of care for the patient during subsequent months. It also allows for the coordination of surgical and diagnostic medical services that can be provided under a single anesthetic procedure. Most children in this clinic have a tracheostomy (with or without ventilator dependence) and feeding tubes and require assistive mobility devices. Children and their home caregivers visit the clinic on average 3 times per year. Current number of active patients: 137 Mean annual hospital days prior to enrollment in the Pediatric Clinic for Aerodigestive, Voice, and Swallowing (PCAVS): 19.9 Mean annual hospital days following enrollment in PCAVS: 7.7 PCAVS patients with reduced annual hospital days: 86% PCAVS patients with increased annual hospital days: 14%

Pediatric Pulmonology

0

50

40

30

10

20

0 – 20 41 – 60 61 – 80 81 – 10021 – 40

Reduction in Hospital Days

Percent

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Asthma Control Test Results by Severity Class (N = 69)

2014

Improvement in Poorly Controlled Patients at Follow-Up Visits According to Asthma Control Test (N = 212)

2014

Asthma Control Testing The Asthma Control Test (ACT) is a validated instrument used by the Center for Pediatric Pulmonary Medicine to assess asthma symptom control. It measures daytime and nocturnal symptom frequency and use of rescue beta-agonists, and encompasses functional assessment and self-assessment of activity-related symptoms. A composite score of test responses from the child and a parent is used for children ages 4–11 years, while children ≥ 12 years provide a self-assessment. The ACT provides a longitudinal measure of asthma control and divides patients into 3 asthma control categories:

• Well-controlled (score > 19) indicates achievement of a primary management objective.

• Not well-controlled (score 16–19) indicates a need for further clinical improvement.

• Poorly controlled (score < 16) indicates more severe functional impairment, elevated risk of exacerbation, and likelihood of increased use of health resources. Children referred to the Center for Pediatric Pulmonary Medicine for asthma management typically have more severe asthma and multiple comorbidities, and often have required the use of considerable health resources, including emergency department visits and multiple hospitalizations. In 2014, 17% of new pediatric asthma patients referred to the center were classified by ACT scores as being poorly controlled. After extensive education of patients and caregivers about asthma and development of new treatment plans at center visits, only 3% of patients remained in the poorly controlled category at follow-up. Of the patients who initially presented in the poorly controlled category, 70% achieved ACT scores that were in the well-controlled category at follow-up center visits. These levels of improvement have been associated with improved quality of life and decreased overall costs of asthma care.

Percent

0Initial visit Follow-Up Visit

60

40

20

100

80Poorly controlledNot well-controlledWell-controlled

Percent

0

60

40

20

100

80Poorly controlledNot well-controlledWell-controlled

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56 Outcomes 201456

Pediatric Rheumatology

Juvenile Idiopathic Arthritis Outcomes Differences in Disease Activity Outcomes in Patients With Juvenile Idiopathic Arthritis Juvenile idiopathic arthritis (JIA) patients may develop significant functional impairment if their disease is not properly identified and treated. Cleveland Clinic’s Center for Pediatric Rheumatology strives to provide patient-centered, outcome-directed care to children with JIA. The center follows national guidelines for JIA therapy and involves a multidisciplinary care team to give patients the best chance to achieve disease-free remission and to live life with minimal effects of JIA.

In 2014, Cleveland Clinic pediatric rheumatologists saw 2400 unique patients at its 3 outpatient pediatric rheumatology clinics, including main campus. The polyarticular subset of JIA is the most common chronic rheumatologic disease seen in our referral, second opinion-based practice. Polyarticular JIA patients are reported in the medical literature to have poor functional outcomes, which are related to having ongoing active disease activity.

In an effort to improve outcomes, the center’s rheumatology team has implemented the tracking of juvenile arthritis activity, allowing for real-time assessment of disease activity by incorporating active joint count, range of motion measures, and physician and patient global measures. The team has created a computerized screening tool — Pain Risks, Outcomes, and Barriers Evaluation (PROBE) — to assess JIA patients’ pain and to determine risk factors for higher pain scores. These outcomes will help the center’s staff focus on and improve the quality of care it provides to children and their families.

Using a piloted screening tool, the team collected PROBE data on 198 patients with JIA in 2014 (30% of 2014 total JIA visits). Staff then compared the following measures of disease activity in 66 unique JIA patients seen in 2014 with data collected retrospectively from the patients’ initial Cleveland Clinic visit: number of active joints, number of joints with limited range of motion, and erythrocyte sedimentation rate. Quantification of the number of joints with limited range of motion served as a marker of functional disability.

JIA Outcomes for Patients With Baseline and PROBE Data (N = 66)

2014

ESR = erythrocyte sedimentation rate; PROBE = Pain Risks, Outcomes, and Barriers Evaluation

This pre-post JIA care comparison analysis is a representative 2014 outcome sample calculation of significantly lowered JIA disease activity and functional outcome measures achieved in treated JIA patients.

Change From Initial Visit P Value Initial Visit 2014 PROBE to 2014 PROBE for Change

Female, N (%) 52 (79)

Age (years), median (range) 13 (2 – 20)

Years of treatment at Cleveland Clinic (range) 2.8 (0.3 – 10.8)

Active joint count, mean (SD) 7.4 (8.9) 1.7 (2.9) – 6.1 (10.3) < 0.001

Limited joint count, mean (SD) 2.7 (4.6) 1.2 (3.4) – 1.7 (4.3) 0.010

ESR (mm/hr), mean (SD) 17.0 (20.9) 8.1 (6.5) – 9.2 (21.1) < 0.001

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Cleveland Clinic Children’s Safety Improvements

30-Day Readmissions

Thirty-day readmissions are defined as patients who are admitted to any Cleveland Clinic hospital within 30 days of a discharge from Cleveland Clinic’s main campus. The readmission rate is the number of readmissions divided by the number of discharges. Following a steady rise in the readmission rate from 2011 through 2013, Cleveland Clinic Children’s initiated several projects that have begun to improve results. Extensive analysis revealed that the sickest and most complex patients were most likely to be readmitted. Steps taken in 2014 included care coordination projects for selected gastrointestinal (GI), hematology/oncology, and general pediatric patients; pediatric GI and hematology/oncology readmissions huddles to proactively address readmission risks; and development of tools in the electronic medical record to flag high-risk patients and more effectively share care status with the entire team of caregivers.

Venothromboembolisms

Venothromboembolisms (VTEs), or blood clots, are a risk factor in certain medical conditions. The risk is exacerbated when patients are immobile. In 2011, Cleveland Clinic Children’s piloted a process to screen patients for VTE risk based on several clinical factors. Those factors were validated through a literature review, and a screening tool was added to the electronic medical record. Screening was limited to 12–17-year-old patients, because evidence indicates that prophylactic measures such as pressure stockings or anticoagulants can be safely used with that population. An early challenge was ensuring consistent screening of these patients. In 2014, staff increased screening tool use by making it mandatory during the admission assessment for all 12–17-year-old patients. As a result, screening rates have increased from just 20% to 80% of patients; most patients not screened had emergent considerations. During this time, the VTE rate was reduced by > 50%.

Metric 2011 2012 2013 2014

30-day readmission rate, % 11.6 12.3 14.0 12.6

Venothromboembolisms 6 7 4 2

Serious safety events 7 6 3 0

ICU CLABSIs 12 10 5 2

Adverse drug events 5 0 0 0

CLABSI = central line-associated bloodstream infection, ICU = intensive care unit

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58 Outcomes 201458

Cleveland Clinic Children’s Safety Improvements

Serious Safety Events

A serious safety event is defined as a variation from practice that results in moderate to severe patient harm. As part of improving safety, Cleveland Clinic Children’s has trained more than 3000 caregivers in techniques designed to empower everyone to prevent patient harm. These techniques include a daily review of hospitalwide safety risks. Since 2011, there has been an 80% decrease in serious safety events, with a corresponding 50% increase in reporting of safety risks by caregivers.

ICU Central Line-Associated Bloodstream Infections

Since 2011, ICU central line-associated bloodstream infections (CLABSIs) have been reduced in the sickest patients by more than 80%. This reduction can be traced to the adoption of consistent techniques for assessing and maintaining lines, with emphasis on sterile techniques when accessing patient lines. The simplest and most effective technique is the use of good hand hygiene practices by all caregivers.

Adverse Drug Events

Adverse drug events are breaches in medication safety that result in substantial patient harm. Since 2011, several interventions have been designed to reduce the possibility of medication errors, including implementation of pumps that alert caregivers to incorrect or hazardous dosages, linking of anticonstipation medications to opiate administration, consultation between pharmacists and physicians, and a comprehensive medication safety plan in the pediatric ICU.

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Improvement in Social Difficulties of SPIES Program Participants (N = 48)

2008 – 2014

Cleveland Clinic Children’s Center for Autism Social Thinking Program

The Social Thinking Practice and Instruction Enhances Socialization (SPIES) program is designed to improve social behavior in children with high functioning autism spectrum disorder. The program includes child therapy and parent instruction during 20 weekly sessions (instructional phase), culminating in skill generalization during a 6-week inclusive summer camp. Children who have participated in the 1st year often return in subsequent years for booster sessions and continued skill generalization during the inclusive summer camp.

Forty-eight youth ages 6–12 years with high functioning autism spectrum disorder have participated for at least 1 year in the SPIES program. The data below show improvements in social difficulties from the beginning of the program to the end of instruction, and to the end of the summer camp.

90

80

60

Number of Social Difficulties

2008 – 2009 2009 – 2010 2010 – 2011 2011 – 2012 2012 – 2013 2013 – 2014

Pre-ProgramPre-CampPost-Camp

50

70

Cutoff for normal social behavior


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60

Parent Satisfaction With Educational Planning

2012 – 2015

100

80

0

60

40

20

Percent

Overall EducationalPlanning

Child's Progress Collaboration at theTeam Meeting

2012 – 2013 (N = 53)2013 – 2014 (N = 14)2014 – 2015 (N = 16)

Outcomes 201460


Parents and legal guardians of Lerner School students continue to report high rates of satisfaction with their child’s overall educational progress, scheduling the IEP team meeting, and team collaboration in developing and implementing the IEP in the 2012–2013 through 2014–2015 school years.

Lerner School for Autism — Educational Goal Achievement Students attending the Lerner School at the Cleveland Clinic Center for Autism receive an Individualized Education Plan (IEP) each year. This plan typically consists of 60–120 educational objectives to be addressed for each student during each school year. In the 2013–2014 school year, students achieved an average of 77% of their IEP goals. While this is a slight drop in percentage achieved, the actual number of goals achieved increased. In many special education settings, it is common for children to achieve < 50% of their educational goals with only 8–12 total goals achieved. The high level of achievement at the Lerner School also occurred despite the challenging behavior of many of the students that inhibits learning. Additionally, even when educational goals were not achieved, all students showed significant progress toward these goals, and they were often completed in the beginning of the next school year.

Percent of Educational Goals Achieved in Students Attending the Lerner School for Autism (N = 315)

2008 – 2014

0

100

80

60

20

40

2008 – 2009 2010 – 20112009 – 2010 2011 – 2012 2012 – 2013 2013 – 2014

School Year

Percent

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61

Improvement in Preschool Outcomes During the Past 7 Years (N = 127)

2008 – 2014

Lerner School for Autism — Preschool Placement Outcomes

The preschool program provides year-round, early, intensive behavior intervention for young children who are diagnosed with autism spectrum disorder. Children as young as 18 months through 6 years receive 30+ hours per week of intervention through partnership of the education team and the child’s parents. Using the science of applied behavior analysis and child development principles, an individualized curriculum is designed to teach communication, social interaction, play, and a range of functional and adaptive skills.

Since the program opened in 2002, 127 students have graduated. Most children who have exited the preschool program over the past decade have been placed either in mainstream educational settings with minimal or no supports or in special education placements that do not require intensive behavioral intervention or 1-to-1 aide services. Few students continue to need intensive behavioral intervention. Previous studies of intensive behavioral intervention programs for preschoolers have found rates of less intensive support placements of approximately 30%–50%.These outcomes indicate that young children with autism who attend the Lerner preschool program experience substantial improvements in their ability to function independently in their future educational placements, resulting in decreased resource use and cost to the public education system.

Over the past 7 years an increasing percentage of preschoolers have exited to less intensive placements where intensive behavioral intervention is no longer required for student success.

52

68

62

64

60

54

56

58

2008 20102009 2011 2012 2013 2014

Year of Exit From Program

Percent


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62

Lerner School for Autism — Functional Behavioral Assessments Challenging behaviors, such as aggression, self-injury, and property destruction, are common in children with autism spectrum disorder and greatly inhibit their ability to participate in education. Understanding what children are attempting to achieve by engaging in challenging behavior (behavioral functions) is important to initiating the appropriate treatment. There are four main behavioral functions: 1) escaping demands, 2) inappropriately gaining others’ attention, 3) trying to get something tangible that the child wants, and 4) visual stimulation behavior. Each of these functions requires a very different treatment approach. For example, if a child is exhibiting challenging behavior to escape demands, the optimal treatment is getting the child to complete at least a portion of the demand and make an appropriate request for a break. If a child is exhibiting challenging behavior to inappropriately gain attention, the optimal treatment is a combination of planned ignoring of the inappropriate attempt while also teaching the child how to gain attention appropriately and providing frequent attention when the child is well-behaved. Understanding exactly what behavioral functions are feeding the challenging behavior requires the expertise of a certified behavior analyst conducting a comprehensive assessment process that includes parent interviews, child observation, teacher questionnaires, and many other procedures. This process can be time-consuming, further delaying the child’s access to a meaningful education. During the past year, the Lerner School hired an additional behavior analyst to assist with this process. The school streamlined several procedures for referral of a child with challenging behavior and enhanced the assessment methods used. As a result, decreases in the time from referral to initiation of a functional behavioral assessment and time from assessment to initiation of the appropriate treatment have been greatly reduced. The school anticipates further reductions as it continues to streamline processes and reduce the backlog of children waiting for a comprehensive assessment.

Time From Behavior Problem Referral to Comprehensive Functional Assessment

2013 – 2015

Time From Functional Assessment to Initiation of Appropriate Behavioral Treatment

2013 – 2015

0

100

80

60

20

40

2013 – 2014 2014 – 2015

Days

0

350

300

250

100

150

50

200

2013 – 2014 2014 – 2015

Days

Outcomes 201462


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63

aN/A = Data not yet available or not acquired during years indicated ABA = Applied Behavioral Analysis M (SE) = mean, standard error

Lerner School Outcomes — IEP Achievement, Parent Satisfaction With the IEP, and Preschool Placement

The number and proportion of IEP goals achieved each year is a key metric, which quantifies the success of the applied behavior analysis-based education each student receives. Also important is parent satisfaction with the IEP process, as parents are key contributors to understanding what the next steps are for their child’s learning and what goals they have for their child’s future. The preschool program represents a crucial time of early intervention for individuals with autism. Early intervention has been shown to result in substantial cognitive and functional gains in children with autism; as many as 30%–50% of children who receive early intervention graduate to less intensive future placements, such as mainstream public school settings. Thus, tracking preschool program placements after graduation is also key to understanding Lerner School education and treatment effectiveness.

2008 – 2009 2009 – 2010 2010 – 2011 2011 – 2012 2012 – 2013 2013 – 2014 2014 – 2015 M (SE) M (SE) M (SE) M (SE) M (SE) M (SE) M (SE)

IEP N = 67 78 49 70 75 43 Number of 34 (2.1) 34 (2.4) 68 (2.7) 73 (2.5) 70 (2.4) 75 (5.2) N/Aa goals achieved Proportion of 51 (2.6) 59 (2.6) 86 (1.9) 85 (1.2) 80 (1.3) 77 (2.0) N/A goals achieved (%)

Parent Satisfaction N = 0 0 0 0 53 14 16 Overall educational N/A N/A N/A N/A 79 92 96 progress (%) Scheduling the N/A N/A N/A N/A 91 100 100 team meeting Team collaboration (%) N/A N/A N/A N/A 100 100 100

Preschool Placement (%) No support 18 15 22 22 19 20 20 Minimal support 25 25 19 17 20 18 17 Less intensive support 14 19 20 25 26 29 31 ABA support 43 42 39 36 36 33 33


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64 Outcomes 201464


Extent to Which Child and Parent Benefited From Summer Treatment Program and Summer Treatment for Adolescents Program (N = 40)

Parents’ Responses to: Would You Recommend or Resend Your Child to the Summer Treatment Program? (N = 40)

Pediatric Behavioral Health

Summer Treatment Program for Adolescents With ADHD Cleveland Clinic Children’s offers the Summer Treatment Program (STP) and Summer Treatment Program for Adolescents (STPA) designed for children and youth with attention-deficit/hyperactivity disorder (ADHD), ages 6–11 and 12–14 years. The 7-week program is an intensive behavioral intervention that improves specific target behaviors associated with ADHD. In 2014, 40 students participated in the STP, and 10 students participated in the STPA. The following graphs show results from the parent satisfaction and behavioral improvement ratings from the STP and STPA.

100

80

0 0 0

60

40

20

Percent

Child Parent

Much

Somewhat

Little

100

80

0 00

60

40

20

Percent

Recommend Resend

Much

Somewhat

Little

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Overall Behavior Improvement of Children After Completion of the Summer Treatment Program (N = 40)

100

80

0

60

40

20

Percent

0

Much

Somewhat

Little

Transfer to Action Program for College Students With Learning Differences

Cleveland Clinic Children’s offers Transfer to Action (TTA) groups designed and implemented for students at Notre Dame College with learning differences (e.g., ADHD, dyslexia). The yearlong program consists of 12 sessions throughout the fall and spring academic semesters. In 2014, 46 TTA students completed a questionnaire that assessed progress toward academic, social, and personal goals.

Skill Improvement After TTA Training in College Students With Learning Differences (N = 46)

0 10020 40 8060Percent

Making friends

Time management

Asking/answering questions

Taking care of self

Setting goals

Following through w/ goals

Study strategies

Solving problems

Organization ImprovedUnchangedWorseNo response

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66 Outcomes 201466


Social Skills Training for Children With ADHD Cleveland Clinic Children’s Hospital for Rehabilitation offers age-appropriate social skills training for children and adolescents with ADHD, ages 6–14 years. Groups meet 90 minutes per week for 7 weeks, and sessions are facilitated by the ADHD Center for Evaluation and Treatment staff. Behavioral techniques and interventions are simultaneously taught to caregivers and parents. The most frequently targeted skills are following instructions, accepting limits, interrupting appropriately, listening during conversations, and making and keeping friends.

Social Skill Improvement Ratings in Children Aged 6 – 14 years with ADHD After 7 Weeks of Training (N = 17)

0 10020 40 8060Percent

ImprovedNever a problemNeeds improvement

Making/keeping friends

Listening during conversations

Interrupting appropriately

Accepting limits

Following instructions

Responding to teasing

Participating in a group

Solving problems/negotiating

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67

Behavioral Gastroenterology Program The Behavioral Gastroenterology Program is a joint initiative between the departments of Pediatric Gastroenterology and Pediatric Behavioral Health to provide comprehensive medical and psychological care to patients with complex needs. Children and adolescents generally present with abdominal pain or other functional gastrointestinal (GI) disorders (48%), toileting and constipation difficulties (34%), or challenges coping with a chronic GI disease (15%). Treatment goals and interventions vary based on the presenting concerns of each child but often will target:

• Decreased somatic symptoms

• Improved physical and psychosocial functioning

• Decreased depression symptoms

• Decreased anxiety symptoms

Children’s Somatization Inventory Somatic complaints were assessed at the onset and conclusion of treatment by the Children’s Somatization Inventory (CSI-24), a self-report measure of the subjective intensity of the child’s somatic symptoms. Higher scores reflect increased frequency and intensity of overall somatic complaints. Patients reported an average 47% improvement in somatic symptoms.

aBenchmark: Meesters C, Muris P, Ghys A, Reumerman T, Rooijmans M. The Children’s Somatization Inventory: Further evidence for its reliability and validity in a pediatric and a community sample of Dutch children and adolescents. J Pediatr Psychol. 2003;28(6):413-422.


Average Reduction in Somatic Symptoms (N = 41)

20

15

10

0

5

CSI-24 Symptom Score

Treatment Onset Treatment Conclusion

Somatic symptomsClinical thresholda

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68

20

15

10

0

5

Severity of Disability


Functional disabilityClinical thresholda

Outcomes 201468


Functional Disability Inventory The Functional Disability Inventory (FDI) measures the degree to which children experience difficulty in physical and psychosocial functioning due to their physical health status, with higher scores reflecting more substantial disability. Patients who began treatment with elevated levels of functional disability reported by parent-proxy showed an average 48% improvement in physical and psychosocial functioning at the end of treatment.

aBenchmark: Kashikar-Zuck S, Flowers SR, Claar RL, Guite JW, Logan DE, Lynch-Jordan AM, Palermo TM, Wilson AC. Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain. Pain. 2011 Jul;152(7):1600-1607.

Average Reduction in Functional Disability (N = 16)

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Depression Depression symptoms were evaluated by The Center for Epidemiological Studies-Depression Scale for Children (CES-DC), a self-report measure with higher scores indicating more depression symptoms. Adolescents who began treatment with elevated levels of depression symptoms reported an average 35% improvement in symptoms at the end of treatment.

Anxiety Anxiety symptoms were evaluated by the Screen for Childhood Anxiety Related Emotional Disorders (SCARED), a self-report measure with higher scores representing increased symptoms of anxiety. Adolescents who began treatment with substantially elevated levels of anxiety symptoms reported an average 35% improvement in symptoms at the end of treatment.

aBenchmark: Weissman MM, Orvaschel H, Padian N. Children’s symptom and social functioning self-report scales: Comparison of mothers’ and children’s reports. J Nerv Ment Dis. 1980 Dec;168(12):736-740.

aBenchmark: Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baucher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-1236.

Average Reduction in Depression Symptoms (N = 17)

Average Reduction in Anxiety Symptoms (N = 24)

25

15

10

0

5

CES-DC Symptom Score

20


Depression symptoms Clinical thresholda

30

20

10

0

SCARED Symptom Score


Anxiety symptomsClinical thresholda

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70

Pediatric Feeding Program Data were collected on all patients treated in the Pediatric Feeding Disorders Program from 2012 to 2014. To be included in the treatment group, patients had to complete either 9 consecutive months of treatment or 15 sessions (whichever came first), with a break of no more than 6 weeks between sessions. Data were collected and measured at the following points: 1) after 9 months or 15 sessions, 2) after 18 months or 30 sessions, and 3) at discharge if discharge occurred > 18 months after initiation of treatment. The average length of treatment for patients in the group whose treatment was > 18 months (N = 47) was 25 months from initiation of treatment. A decrease in sample size between groups at each treatment interval occurred because patients either discontinued treatment or were discharged from the program when treatment goals were met.

Patients were categorized into 2 treatment groups, and outcomes were compared within each group, as outlined below. All patients received treatment from an interdisciplinary team that included practitioners from psychology, occupational therapy, speech therapy, and nutrition.

General outpatient treatment group — Patients in the general outpatient treatment group were treated solely in the outpatient clinic.

Intensive treatment group — Patients in the intensive treatment program received treatment 5 days per week, approximately 6 to 7 hours per day for an average period of 8–10 weeks. Treatment included 4–6 feeding sessions per day. These patients also typically received outpatient treatment before and/or after the intensive treatment program.

Outcomes 201470


Percentage of Patients With Oral Motor/Sensory Deficits

2012 – 2014

100

80

0

40

20

60

Percent

GeneralOutpatient

Initial treatment session (N = 258)

9 months of treatment (N = 190)


> 18 months of treatment (N = 47)

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71

Resistant feeding behaviors included aggression, intentional gagging and vomiting, tantrums, and spoon batting. Patients in both treatment groups demonstrated reductions in resistant feeding behavior as they progressed through treatment.


Upon initial evaluation for treatment within the Pediatric Feeding Disorders Program, patients’ oral motor and oral sensory skills for their ability to manage age-appropriate food textures are assessed. Deficits in these areas are categorized by patients demonstrating gagging, spillage, or expulsion of foods from the oral cavity during meals, pocketing food in the cheek or under the tongue, and the inability to chew/manage age-appropriate textures. Patients in both treatment groups demonstrated significant reductions in oral motor and oral sensory difficulties over the course of treatment.

100

80

0

40

20

60

Percent

GeneralOutpatient

Initial treatment session (N = 258)



> 18 months of treatment (N = 47)

Admission (N = 23)

Discharge (N = 23)

IntensiveTreatment

Percentage of Patients with Resistant Feeding Behaviors

2012 – 2014

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72 Outcomes 201472


At the initiation of outpatient treatment, children were receiving an average of 86% of calories from supplemental NG/GT tube feedings. By 9 months of treatment, tube feeding had been reduced by an average of 15%. By 18 months of treatment, there was a 26% reduction on average, and at > 18 months of treatment, there was an average reduction of 58%. Upon admission to the intensive treatment program, children were receiving an average of 91% of calories from supplemental NG/GT tube feedings. At the time of discharge from the intensive treatment program, tube feedings had been reduced by an average of 56%. Seven children from outpatient treatment and 12 children from the intensive treatment program continued to require supplemental feeds at the time of discharge; however, all of these children had significant medical and/or developmental complexities that may have precluded complete NG/GT wean.

To evaluate oral feeding/intake, patients’ percentage of total calorie intake provided from supplemental nasogastric/gastrostomy (NG/GT) feeds was measured at initiation of treatment or admission to the intensive program and again at established treatment intervals or discharge from the intensive treatment program.

Decreased Dependence on Nasogastric or Gastrostomy Supplementation

Average Reduction of Nasogastric or Gastrostomy Tube Supplementation

2012 – 2014

60

40

0

20

Reduction (%)

928N =

1829

> 1811

Intensive Program Discharge13

Months of Outpatient Treatment or Intensive Program Discharge

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Pediatric Pain Rehabilitation

The Pediatric Pain Rehabilitation Program at Cleveland Clinic Children’s Hospital for Rehabilitation is designed for children and adolescents whose chronic pain interferes with normal activities. As a result of their pain, these children do not attend school, interact with peers, or participate in normal activities. The program focuses on helping children manage their pain and on restoring daily activity. Both inpatients and day patients receive pediatric subspecialty care and behavioral health and rehabilitation therapies in an individualized, coordinated manner.

In 2014, a total of 114 patients were seen, compared with 110 in 2013. This represents a 4% increase in patient volume over last year. In 2014, 65% of patients were from out of state.

The Bath Adolescent Pain Questionnaire (BAPQ), also a self-report measure, is a 61-item tool designed specifically to assess the multidimensional impact of chronic pain on adolescents. The BAPQ’s internal consistency, comparative validity, and temporal reliability are well-established. The tool is administered at the beginning of the program and at 1 month after its completion. The physical functioning, pain-specific anxiety, and social functioning subscales are used in outcome analyses. For all metrics, patients showed improvement in their average score 1 month after completion of the program. Discussion of BAPQ outcomes appears on page 74.

Pain Severity (Self-Report)

2013 – 2014

10

6

8

0

4

2

Score: 0 (no pain) to 10 (maximum pain)

2014114

2013110

Pretreatment

1-month follow-up

N =

Patients are asked to rate the pain they experienced during the past 24 hours on a scale of 0 (no pain) to 10 (maximum pain). Pain severity ratings are obtained at the beginning of the 3-week pain rehabilitation program and at 1-month follow-up. One-month follow-up assessment for 2014 revealed an average 20% decrease in pain severity, compared with a 12% decrease in 2013.

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74 Outcomes 201474


In 2014, patients reported an average 53% improvement in physical functioning, based on the BAPQ, compared with an average of 49% improvement in 2013. consistent with the improvements seen in 2012 and past years.

Based on the BAPQ, patients seen in 2014 reported an average 35% improvement in social functioning, compared with an average of 33% in 2013.

In 2014, patients reported an average 43% decrease in pain-specific anxiety, based on the BAPQ. Data from 2013 revealed an average 54% decrease.

Physical Functioning (BAPQ)

2013 – 2014

Social Functioning (BAPQ)

2013 – 2014

Pain-Specific Anxiety (BAPQ)

2013 – 2014

28

16

20

24

0

12

8

4


Pretreatment

1-month follow-up

2014114

2013110N =

32

16

24

0

8


Pretreatment

1-month follow-up

2014114

2013110N =

16

12

0

4

8

Score: 0 (best) to 32 (worst)

2014114

2013110

Pretreatment

1-month follow-up

N =

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Pediatric Inpatient Rehabilitation Program — WeeFIM Outcomes

The WeeFIM II® System, a pediatric version of the Functional Independence MeasureTM (FIM) System, documents and tracks functional performance in children and adolescents with acquired or congenital disabilities by measuring a child’s need for assistance and the severity of disability. It also provides a method of evaluating outcomes for pediatric rehabilitation and habilitation programs.

Children’s Hospital for Rehabilitation WeeFIM Length-of-Stay Efficiency Score

2008 – 2014

aThe national benchmark is calculated from a database of WeeFIM performance measures of like facilities housed by Uniform Data System for Medical Rehabilitation. udsmr.org

The WeeFIM national database provides reports comparing individual programs against national benchmarks. The outcomes of children treated at Cleveland Clinic Children’s Hospital for Rehabilitation compare favorably with the national benchmarks.

The WeeFIM length-of-stay efficiency score is the most important measure of the effectiveness of a rehabilitation program because it indicates how quickly a program is able to improve a child’s functional abilities.a The Children’s Hospital for Rehabilitation’s score has been consistently above the national benchmark.

Rate

3

1

0

2

Children’s Hospital for RehabilitationBenchmarka

N =201052

200961

201350

201164

201260

201460

200851

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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 — Pediatric Institute & Cleveland Clinic Children’s

CG-CAHPS Assessmenta 2013 – 2014

Inpatient Survey Overall Assessment 2013 – 2014

Inpatient Survey — Pediatric Institute & Cleveland Clinic Children’s

Patient Experience — Pediatric Institute & Cleveland Clinic Children’s

100

80

0

60

40

20

Best Response (%)

Hospital Rating(% Very Good)

Recommend Hospital(% Very Good)a

aResponse options: Very Good, Good, Fair, Poor, Very Poor

Source: Press Ganey, a national hospital survey vendor

2014 (N = 334)

National average: % patients selecting “very good” response optionOctober 2012 – September 2013

2013 (N = 208)

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; No

Source: Press Ganey, a national hospital survey vendor

100

80

0

60

40

20

Percent Best Response

AppointmentAccess

(% Always)c

Primary Care

(% Always)c

Specialty Care

(% Yes, Definitely)d

Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff

(% Always)c

Test ResultsCommunication(% Always)c

2013 (N = 4020)2014 (N = 3877)

CG-CAHPS 2013 database average(all practices)b

Doctor Communication

N/A

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Cleveland Clinic — Implementing Value-Based Care

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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Outcomes 201478

Contact Information

Cleveland Clinic Children’s Appointments

216.444.KIDS (5437) 800.223.CARE (2273), extension 45437 (4KIDS) Cleveland Clinic Children’s Referrals

855.733.3712 On the Web at clevelandclinicchildrens.org

Staff Listing

For a complete listing of Cleveland Clinic Children’s staff, please visit clevelandclinic.org/staff.

Publications

Cleveland Clinic Children’s staff authored 211 publications in 2014.

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

Locations

For a complete listing of Cleveland Clinic Children’s locations, please visit clevelandclinicchildrens.org.

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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/childrens-hospital?utm_campaign=children-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/childrens-hospital?utm_campaign=children-url&utm_medium=offline&utm_source=redirect


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

http://my.clevelandclinic.org/patients-visitors/international?utm_campaign=gps-url&utm_medium=offline&utm_source=redirect

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 201480

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 201482

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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This project would not have been possible without the commitment and expertise of a team led by Vera Hupertz, MD, and Bryant M. Bond.

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

15-OUT-342


2014 Outcomes


pediatric institute & cleveland clinic children's

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