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Ob/Gyn & Women’s Health Institute
This project would not have been possible without the
commitment and expertise of a team led by Kenneth
Edelman, MD, MBA; Laurie Haskett; Scott Jahn, MBA;
Lin Mei, MS; Milena Radeva; and Nancy Talbot.
Graphic design and photography were provided by
Cleveland Clinic’s Center for Medical Art and Photography.
2016
© The Cleveland Clinic Foundation 2017
9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org
Outcomes
17-OUT-415
108376_CCFBCH_17OUT415_Rev1_acg.indd 1-3 9/25/17 2:55 PM
Measuring Outcomes Promotes Quality Improvement
Clinical Trials
Cleveland Clinic is running more than 2200 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 200 active clinical trials available to cancer
patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp
Healthcare Executive Education
Cleveland Clinic has programs to share its expertise in operating a
successful 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.
clevelandclinic.org/executiveeducation
Consult QD Physician Blog
A website from Cleveland Clinic for physicians and healthcare
professionals. Discover the latest research insights, innovations, treatment
trends, and more for all specialties. 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
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Ob/Gyn & Women’s Health Institute
108376_CCFBCH_17OUT415_Rev1_acg.indd 4-6 9/27/17 11:47 AM
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 (medicare.gov/hospitalcompare), 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:
OutcomesBooksFeedback@ccf.org.
To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.
108376_CCFBCH_17OUT415_Rev1_acg.indd 1 9/19/17 5:00 PM
Dear Colleague:
Welcome to this 2016 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 Reports (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 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 2 9/19/17 5:00 PM
what’s inside
Chairman’s Letter 04
Institute Overview 05
Quality and Outcomes Measures
Benign Gynecology 08
Reproductive Endocrinology and Infertility 11
Urogynecology 15
Gynecologic Oncology 20
Breast Disease 40
Specialized Women’s Health 50
Maternal-Fetal Medicine 52
Obstetrics 56
Surgical Quality Improvement 61
Institute Patient Experience 62
Cleveland Clinic — Implementing Value-Based Care 64
Innovations 72
Contact Information 74
About Cleveland Clinic 76
Resources 78
Ob/Gyn & Women’s Health Institute 3
108376_CCFBCH_17OUT415_Rev1_acg.indd 3 9/19/17 5:00 PMD
Chairman’sLetter
Chairman Letter
I appreciate your interest in our Ob/Gyn & Women’s Health Institute
and taking the time to glance through our 2016 outcomes report.
Each year we collect and analyze vital data, not just to satisfy our
curiosity, but to ensure that we are indeed improving the quality
of care we provide and quality of life for our patients. We remain
devoted to excellence and innovation in all aspects of our work --
clinical care, research, and education. We believe our consistently
high rankings by U.S. News & World Report (No. 3 in the nation
in 2016) reflect this dedication and hard work.
Significant achievements for our institute in 2016 include:
• 0.1% elective induction rate for deliveries < 39 weeks
gestation
• Maintained a primary cesarean rate for low-risk, nulliparous,
vertex, singleton births below the HealthyPeople.gov 2020
target of 23.9%
• Decreased all cause 30-day readmissions by 2.0% to 10.4%
• Maintained a low surgical-site infection rate for hysterectomies
(0.01%) enterprise-wide
In addition, Cleveland Clinic’s new Transgender Surgery & Medicine
Program provides comprehensive psychiatric, medical, and surgical
care for transgender, gender fluid, and gender non-conforming adults
and adolescents. In 2016, over 200 patients were cared for through
this program. Cecile Unger, MPH, MD, serves as the program
Director.
I welcome your feedback, questions, and ideas for collaboration.
Please contact me via email at OutcomesBooksFeedback@ccf.org,
and reference the Ob/Gyn & Women’s Health Institute book in
your message.
Sincerely,
Tommaso Falcone, MD
Chairman, Ob/Gyn & Women’s Health Institute
Professor of Surgery, Cleveland Clinic Lerner College of Medicine
4 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 4 9/19/17 5:00 PMInstitute Overview
Cleveland Clinic’s Ob/Gyn & Women’s Health Institute is committed to Cleveland Clinic’s
providing world-class care for women of all ages. In 2016, the institute’s
gynecology program was again ranked third in the nation by U.S. News gynecology program
& World Report, the top-ranked program in Ohio. The institute offers a
full complement of women’s health services, including general obstetric/ is ranked No. 3
gynecologic care and screenings; advanced minimally invasive procedures
for uterine fibroids and endometriosis; complex oncologic surgery for
in the nation by
breast and gynecologic malignancies; management of fetal anomalies;
U.S. News &
management of complex surgical mesh complications; and innovative
approaches to cryopreservation of gametes and ovarian tissue. The institute World Report.
also has specialty clinics for gynecologic infectious disease, pediatric
gynecology, chronic pelvic pain, and women’s medical weight management.
Its 151 obstetrician/gynecologists and 18 certified nurse midwives see
patients at the main campus, at Cleveland Clinic regional hospitals and
family health centers across northeast Ohio, and at Cleveland Clinic Florida.
The institute’s staff participates in resident, fellow, and medical student
education at Cleveland Clinic Lerner College of Medicine. A unique
residency training program offers tracking into subspecialty areas.
Fellowships are offered in women’s health, gynecologic oncology,
urogynecology/reconstructive pelvic surgery, and reproductive endocrinology.
A new Global Health Research Program allows residents and fellows
to participate in research.
Cleveland Clinic’s specialty services include team-based lesbian, gay,
bisexual, and transgender healthcare services, including transgender
consultations for medical and surgical gynecologic care. The Gyn Oncology
Program offers genomic tumor profiling, which identifies and targets
genomic alterations for clinically approved or investigational treatments.
Hyperthermic intraperitoneal chemotherapy (HIPEC) is offered after
surgical debulking for qualified patients with certain pelvic cancers.
Ob/Gyn & Women’s Health Institute 5
108376_CCFBCH_17OUT415_Rev1_acg.indd 5 9/19/17 5:00 PMInstitute Overview
36 — Number 2016 Volumes
of locations at Outpatient Visits (Epic Reports)
which the Ob/Gyn & Obstetrics & Gynecology 133,464
Regional obstetrics and gynecology 241,207
Women’s Health WHI TOTAL VISITS 374,671
Institute staff provide Breast Services
comprehensive care Screening mammograms 67,842
Screening mammograms resulting in call-back 10,176
Surgical Procedure Distribution
General obstetrics and gynecology 7304
Gynecologic oncology 1756
Urogynecology 746
Reproductive endocrinology 1045
Maternal-fetal medicine 234
Hysteroscopy (RCM)
Operative - outpatient
Ablation 360
Myomectomy 212
Polyps 1512
Sterilization 13
Diagnostic - office 930
Diagnostic - outpatient 232
Hysterectomy (including cancer patients) (Optime)
Abdominal 449
Vaginal 477
Laparoscopic 699
Robotic 275
6 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 6 9/19/17 5:00 PMIncontinence and Prolapse (Visiquate) 374,671
Prolapse 360 — Number of
Incontinence 225
Incontinence and prolapse 395 outpatient visits
In Vitro Fertilization to the Ob/Gyn &
Egg retrievals (excluding oocyte donor and surrogate) 383 Women’s Health
Intrauterine insemination 1223
Institute in 2016
Deliveries (Pro Rev Stats)
Deliveries 9842
Perinatal Testing Performed by Cleveland Clinic Staff (RCM)
Dopplers 3130
Amniocentesis 82
Biophysical profiles 5858
Chorionic villus sampling 56
Nuchal translucency 6552
Gynecology Ultrasound 20,034
Servi
aServ
bIncl
Ob/Gyn & Women’s Health Institute 7
108376_CCFBCH_17OUT415_Rev1_acg.indd 7 9/19/17 5:00 PMBenign Gynecology
Unless otherwise specified, outcomes Surgical Site Infection for Abdominal Hysterectomy (Benign and Malignant)
reported here relate to care by (N = 1891)
2013 – 2016
gynecology staff practicing in Cleveland
Rate per 100 Surgeries
Clinic facilities in northeast Ohio.
5
4
In 2011, an interdisciplinary project
team was formed to identify risk 3
points for infection during the
perioperative period. Action steps 2
were implemented to reduce these
1
risks, resulting in lower surgical site
infection rates in hysterectomy cases. 0
2013 2014 2015 2016
N= 566 330 513 482
Procedures to Treat Uterine Fibroids (N = 1726)
2013 – 2016
Percent Uterine fibroid Myomectomy Hysterectomy
Cleveland Clinic provides several embolization
treatment options for uterine 100
fibroids, including uterine fibroid 80
embolization, myomectomy, 60
and hysterectomy.
40
20
0
2013 2014 2015 2016
N= 361 502 408 455
Surgical Approach for Myomectomy (N = 898)
2014 – 2016
Percent
Laparoscopic/robotic Vaginal Abdominal
100
80
60
40
20
0
2013 2014 2015
N= 283 321 268
8 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 8 9/19/17 5:00 PM
Percent
Laparoscopic/robotic Vaginal AbdominalHysterectomy Following Myomectomy or Uterine Fibroid Embolization
2011 – 2016
Percent
8
Myomectomy
7
UFE
6
5
4
3
2
1
0
0 6 12 18 24 30 36
Months After Surgery
Numbers at Risk:
Myomectomy
N = 1406 1375 1366 1230 1112 971 817
UFE
N = 177 177 174 156 140 123 108
UFE = uterine fibroid embolization
Between 2011 and 2016, 177 patients underwent uterine fibroid embolization
(UFE) and had at least 1 year of follow-up. The figure illustrates the percentage
of these patients who subsequently underwent hysterectomy relative to the time
of their initial procedure. The number of patients at risk represents those patients
with the indicated length of follow-up who did not have a hysterectomy. The
3-year hysterectomy rate following UFE for Cleveland Clinic gynecologic surgeons
is approximately 3.8%.
Between 2011 and 2016, 1406 patients underwent myomectomy and had at
least 1 year of follow-up. The figure illustrates the percentage of these patients
who subsequently underwent hysterectomy relative to the time of their initial
procedure. The number of patients at risk represents those patients with the
indicated length of follow-up who did not have a hysterectomy. The 3-year
hysterectomy rate following myomectomy for Cleveland Clinic gynecologic
surgeons is approximately 5.3%.
Ob/Gyn & Women’s Health Institute 9
108376_CCFBCH_17OUT415_Rev1_acg.indd 9 9/19/17 5:00 PMBenign Gynecology
Endometriosis Treatment (N = 4743)
2013 – 2016
Percent
100
80
Medical treatment
60
Surgical (no hysterectomy)
40 Hysterectomy
20
0
2013 2014 2015 2016
N= 948 1242 1260 1293
Medical treatment is the primary method used for treating endometriosis.
When surgical methods are used, hysterectomy is seldom the course of
action taken.
10 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 10 9/19/17 5:00 PMReproductive Endocrinology and Infertility
While success rates for in vitro fertilization (IVF) continue to improve over time, patient age remains the strongest
predictor of success. Cleveland Clinic’s In Vitro Fertilization Laboratory employs cutting edge technology for the
culture, growth, and assessment of embryos. The laboratory’s extensive database allows tracking and analysis of
morphologic features that indicate which embryos are most likely to result in pregnancies. The EmbryoScope®
time-lapse system, introduced to the laboratory in 2012, enables continuous monitoring of embryo growth with
time-lapse imaging, further enhancing the ability to select embryos most likely to implant successfully. The research
laboratory has also been instrumental in developing and advancing novel technologies for cryopreservation of
embryos, oocytes, and individually selected sperm.
Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing in
Cleveland Clinic facilities in northeast Ohio.
IVF Success Rates
IVF Cycle Outcomes With Transfer of Day 5 Cleavage and Blastocyst Stage Embryos
2016
Patient Age (Years)
< 35 35 – 37 38 – 40 41 – 42 > 42
Retrievals 176 96 59 24 28
Transfers 95 58 31 9 6
Average embryos transferred 1.4 1.7 1.9 2.4 2.3
Clinical pregnancy ratea 62% 52% 58% 56% 33%
Implantation rateb 51% 42% 37% 27% 7%
a
Clinical pregnancy determined by presence of fetal heart on ultrasound
b
Implantation rate per embryo transferred to the uterus
Ob/Gyn & Women’s Health Institute 11
108376_CCFBCH_17OUT415_Rev1_acg.indd 11 9/19/17 5:00 PMReproductive Endocrinology and Infertility
Day 5 Blastocyst Stage Embryo Transfers Resulting in Pregnancy (N = 112a)
2016
Percent
60
40 Triplets (or more)
Twins
Singleton
20
0
< 35 35 – 37 38 – 40 41 – 42
Patient Age (Years)
Nb = 59 30 18 5
aIncludes 6 day 3 transfers
bPregnancies
IVF Cycle Outcomes With Frozen Embryo Transfers IVF Success Rates With Donor Oocytes
2016 2016
Patient Age (Years) < 38 ≥ 38 Transfers 23
Average embryos transferred 1.3
Thaws 243 80
Clinical pregnancy ratea 57%
Transfers 238 76
b
Implantation rate 48%
Survival 94% 95%
aClinical pregnancy determined by presence of fetal heart on ultrasound
Average embryos transferred 1.4 1.5 bImplantation rate per embryo transferred to the uterus
Implantation ratea 51% 38%
Clinical pregnancy rateb 60% 53%
Singleton pregnancies 65% 20%
Twin pregnancies 13% 2%
Triplet pregnancies 1% 0%
aImplantation rate per embryo transferred to the uterus
bClinical pregnancy determined by presence of fetal heart on ultrasound
12 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 12 9/19/17 5:00 PMFresh Embryo Transfer Pregnancy Rate (N = 254)
2015
Percent
80
70
60
50
40
30
20
10
0
< 35 35 – 37 38 – 40 41 – 42
Patient Age (Years)
N= 128 61 51 14
Frozen Embryo Transfer Pregnancy Rate (N = 232)
2015
Percent
80
70
60
50
40
30
20
10
0
< 35 35 – 37 38 – 40 41 – 42
Patient Age (Years)
N= 117 47 55 13
Ob/Gyn & Women’s Health Institute 13
108376_CCFBCH_17OUT415_Rev1_acg.indd 13 9/19/17 5:00 PMReproductive Endocrinology and Infertility
IVF and Live Births
Fresh Embryo Transfer Live Birth Rate (N = 254)
2015
Percent
80
70
60
50
40
30
20
10
0
< 35 35 – 37 38 – 40 41 – 42
Patient Age (Years)
N= 128 61 51 14
Frozen Embryo Transfer Live Births (N = 232)
2015
Percent
80
70
60
50
40
30
20
10
0
< 35 35 – 37 38 – 40 41 – 42
Patient Age (Years)
N= 117 47 55 13
14 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 14 9/19/17 5:00 PMUrogynecology
Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing
in Cleveland Clinic facilities in northeast Ohio.
Surgical Case Approach (N = 3899)
2012 − 2016
Procedures
1000
800
600 Abdominal
Laparoscopic/robotic
400 Vaginal/perineal
200
0
2012 2013 2014 2015 2016
N= 772 848 820 723 736
Adverse Events Within 30 Days of Urogynecologic Surgery (N = 3311)
2013 − 2016
Rate per 1000 Surgeries
10
8
6 Deep vein thrombosis
Pulmonary embolism
4 Small bowel obstruction
2
0 0
0
2013 2014 2015 2016
N =
a
876 850 802 783
aTotal number of urogynecologic surgical procedures per year
Ob/Gyn & Women’s Health Institute 15
108376_CCFBCH_17OUT415_Rev1_acg.indd 15 9/19/17 5:00 PMUrogynecology
Three-Year Prolapse Reoperation Percentage (N = 1765)
2009 – 2015
Percent Between 2009 and 2015, 1765
10 patients underwent prolapse surgery
and had at least 1 year of follow-
8 up. The figure at left illustrates
the percentage of these patients
6 who had a reoperation for prolapse
relative to the time of their initial
4 surgery. The number of patients
at risk represents those patients
2 with the indicated length of follow-
up who did not have a prolapse
0
0 6 12 18 24 30 36 reoperation. The 3-year prolapse
reoperation rate for Cleveland
Months After Surgery Clinic urogynecologic surgeons is
Number at
Risk = 1765 1748 1736 1613 1477 1330 1177 approximately 2.6%.
Three-Year Sling Revision Rate (N = 1846)
2009 – 2015
Percent Between 2009 and 2015,
10 1846 patients received
incontinence (sling) surgery and
8 had at least 1 year of follow-up.
The figure at left illustrates the
6 percentage of these patients who
had sling revision urethrolysis
4 relative to the time passed after
their initial surgery. The number
2 of patients at risk represents those
patients with the indicated length
0
0 6 12 18 24 30 36 of follow-up who have not had
sling revision. The 3-year sling
Months After Surgery revision rate for Cleveland Clinic
Number at
Risk = 1846 1583 1578 1449 1298 1147 1002 urogynecologic surgeons is 2.2%.
16 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 16 9/19/17 5:00 PMUrinary Incontinence Procedures Following Sacrospinous Fixation, Uterosacral Suspension,
and Minimally Invasive Sacrocolpopexy
2009 – 2016
Percent
8
Minimally invasive sacrocolpopexy
7 Sacrospinous fixation
Uterosacral suspension
6
5
4
3
2
1
0
0 6 12 18 24 30 36
Months After Surgery
Number at Risk:
Minimally invasive sacrocolpopexy
201 176 165 160 151 135 124
Sacrospinous fixation
310 280 261 236 212 189 163
Uterosacral suspension
549 502 457 420 368 332 287
• A total of 201 patients underwent minimally invasive abdominal sacrocolpopexy. Using survival modeling,
the cumulative incidence for transurethral bulking or midurethral sling placement (with adjustment for loss
to follow-up) was 7.5% over 3 years.
• A total of 310 patients underwent sacrospinous fixation. Using survival modeling, the cumulative incidence
for transurethral bulking or midurethral sling placement (with adjustment for loss to follow-up) was 3.6%
over 3 years.
• A total of 549 patients underwent uterosacral ligament vaginal vault suspension. Using survival modeling,
the cumulative incidence for transurethral bulking or midurethral sling placement (with adjustment for loss
to follow-up) was 2.2% over 3 years.
Ob/Gyn & Women’s Health Institute 17
108376_CCFBCH_17OUT415_Rev1_acg.indd 17 9/19/17 5:00 PMUrogynecology
30-Day Readmission Ratea Inpatient Following Urogynecologic Surgery (N = 311)
2013 – 2016
Rate per 100 Surgeries Severity Index
6 4
3
4
Readmission rate
2 Benchmarkb
Severity indexc
2
1
0 0
2013 2014 2015 2016
N= 188 55d 35d 33
aThese data are prepared using the Vizient Clinical Database.
Data from the Vizient Clinical Data Base/Resource Manager™ used by permission of Vizient. All rights reserved.
bBenchmark derived from review of peer organization members of Vizient for surgical cases performed for MS-DRGs 748, 749,
and 750. Data from the Vizient Clinical Data Base/Resource Manager™ used by permission of Vizient. All rights reserved.
cThe 3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for
severity of illness and risk of mortality. solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-and-
Services/Products-List-A-Z/APR-DRG-Software.
dIn 2014 and 2015, the number of inpatient admissions was reduced due to payer reclassification of the majority of major
surgery admissions to outpatient status (less than a 2 midnight stay). Patients meeting criteria for inpatient admission had
more complex surgeries and more comorbidities than patients meeting criteria for discharge at less than a 2 midnight stay.
18 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 18 9/19/17 5:00 PMLength of Staya Following Inpatient Urogynecologic Surgery (N = 311)
2013 – 2016
Days Severity Index
4 4
3 3
Observed LOS
2 2 Expected LOS
Severity indexb
1 1
0 0
2013 2014 2015 2016
Nc = 188 55 35 33
LOS = length of stay
a
These data are prepared using the Vizient Clinical Database. Data from the Vizient Clinical Data Base/Resource Manager™
used by permission of Vizient. All rights reserved.
b
The 3M™ All Patient Refined Diagnosis Related Groups (APR DRG)Classification System is used for adjusting data for
severity of illness and risk of mortality. solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-
and-Services/Products-List-A-Z/APR-DRG-Software.
c
Total number of surgical cases performed for MS-DRGs 748, 749, and 750. In 2014 and 2015, the number of inpatient
admissions was reduced due to payer reclassification of the majority of major surgery admissions to outpatient status (less
than a 2 midnight stay). Patients meeting criteria for inpatient admission had more complex surgeries and more comorbidities
than patients meeting criteria for discharge at less than a 2 midnight stay.
Ob/Gyn & Women’s Health Institute 19
108376_CCFBCH_17OUT415_Rev1_acg.indd 19 9/19/17 5:00 PMGynecologic Oncology
Unless otherwise specified, outcomes reported here relate to care by gynecology staff practicing in Cleveland Clinic
facilities in northeast Ohio.
The advent of robotic-assisted laparoscopy has prompted an increase in minimally invasive procedures in the gynecologic
subspecialties. Cleveland Clinic gynecologic oncology surgeons strive to provide the best care for patients while using
minimally invasive procedures when possible.
Surgical Case Approach for Complex Benign and Malignant Cases (N = 6071)
2013 – 2016
Number of Procedures
2000
1500
Laparoscopic/robotic
Abdominal
1000 Vaginal/perineal
500
0
2013 2014 2015 2016
N= 1411 1488 1414 1758
New Surgical Cancer Case Distribution (N = 1506)
2013 – 2016
Percent
100
80
Vulvar
60 Uterine
Ovarian
40 Cervical
20
0
2013 2014 2015 2016
N= 246 358 430 472
20 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 20 9/19/17 5:00 PMPrimary Cytoreduction for Ovarian Cancera (N = 114) Length of Staya and Severity Index Following Inpatient
2013 – 2016 Gynecologic Oncology Surgery (N = 2981)
Suboptimally debulked 2014 – 2016
Percent Optimally debulked
100 Days Severity Index
8 Observed LOS 4
80 Expected LOS
Severity Indexb
6 3
60
40 4 2
20 2 1
0
2013 2014 2015 2016 0 0
2014 2015 2016
N= 37 33 28 16
Nc = 1308 877d 796d
aData exclude patients who received chemotherapy
prior to primary cytoreduction
LOS = length of stay
a
These data are prepared using the Vizient Clinical Database.
Data from the Vizient Clinical Data Base/Resource Manager™
used by permission of Vizient. All rights reserved.
bThe 3M™ All Patient Refined Diagnosis Related Groups
(APR DRG) Classification System is used for adjusting
data for severity of illness and risk of mortality.
solutions.3m.com/wps/portal/3M/en_US/Health-Information-
Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG-
Software
cTotal number of surgical cases for gynecologic malignancy
identified by MS-DRGs 734, 735, 736, 737, 738, 739,
740, 741, 754, 755, and 756.
dIn 2015 and 2016, the number of inpatient admissions was
reduced due to payer reclassification of the majority of major
surgery admissions to outpatient status (less than a 2 midnight
stay). Patients meeting criteria for inpatient admission had more
complex surgeries and more comorbidities than patients meeting
criteria for discharge at less than a 2 midnight stay.
Ob/Gyn & Women’s Health Institute 21
108376_CCFBCH_17OUT415_Rev1_acg.indd 21 9/19/17 5:00 PMGynecologic Oncology
30-Day Readmission Ratea and Severity Index Following 30-Day Mortality Ratea and Severity Index Following
Inpatient Gynecologic Oncology Surgery (N = 2981) Inpatient Gynecologic Oncology Surgery (N = 2981)
2014 – 2016 2014 – 2016
Rate per 100 Surgeries Severity Index Rate per 100 Surgeries Severity Index
8 Readmission rate 4 Observed LOS 4
4
Readmission benchmarkb Expected LOS
Severity Indexc Severity Indexb
6 3 3 3
4 2 2 2
2 1 1 1
0 0 0 0
2014 2015 2016 2014 2015 2016
Nd = 1308 877e 796 Nc = 1308 877d 796
aThese data are prepared using the Vizient Clinical Database. aThese data are prepared using the Vizient Clinical Database.
Data from the Vizient Clinical Data Base/Resource Manager™ Data from the Vizient Clinical Data Base/Resource Manager™
used by permission of Vizient. All rights reserved. used by permission of Vizient. All rights reserved.
bBenchmark derived from review of peer organization members bThe 3M™ All Patient Refined Diagnosis Related Groups (APR
of the Vizient for surgical cases for gynecologic malignancy DRG) Classification System is used for adjusting data for severity
identified by MS-DRGs 734, 735, 736, 737, 738, 739, 740, of illness and risk of mortality.
741, 754, 755, and 756. solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/
cThe 3M™ All Patient Refined Diagnosis Related Groups (APR HIS/Products-and-Services/Products-List-A-Z/APR-DRG-Software
DRG) Classification System is used for adjusting data for severity cTotal number of surgical cases for gynecologic malignancy
of illness and risk of mortality. identified by MS-DRGs 734, 735, 736, 737, 738, 739,
solutions.3m.com/wps/portal/3M/en_US/Health-Information- 740, 741, 754, 755, and 756.
Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG-
dIn 2015 and 2016, the number of inpatient admissions was
Software
dTotal
reduced due to payer reclassification of the majority of major
number of surgical cases for gynecologic malignancy
surgery admissions to outpatient status (less than a 2 midnight
identified by MS-DRGs 734, 735, 736, 737, 738, 739,
stay). Patients meeting criteria for inpatient admission had more
740, 741, 754, 755, and 756.
complex surgeries and more comorbidities than patients meeting
eIn 2015 and 2016, the number of inpatient admissions was criteria for discharge at less than a 2 midnight stay.
reduced due to payer reclassification of the majority of major
surgery admissions to outpatient status (less than a 2 midnight
stay). Patients meeting criteria for inpatient admission had more
complex surgeries and more comorbidities than patients meeting
criteria for discharge at less than a 2 midnight stay.
22 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 22 9/19/17 5:00 PMRadiation oncologists and medical oncologists at Cleveland Clinic work in close collaboration to treat patients
with gynecologic cancers. Gynecologic tumor sites include the vulva, vagina, cervix, uterine body, and uterine
adnexa. Standard radiation treatment employs high-dose-rate brachytherapy and external beam radiotherapy.
Cervical Cancer
Five-Year Overall Survival of Patients With Cervical Cancera (N = 386)
2007 – 2015
Survival (%)
100 Cleveland Clinic
National comparisonb
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk = 318 246 203 149 97
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bNational comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance,
Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. http://seer.cancer.
gov/statfacts/html/cervix.html. Accessed on Mar. 29, 2017.
Ob/Gyn & Women’s Health Institute 23
108376_CCFBCH_17OUT415_Rev1_acg.indd 23 9/19/17 5:00 PMS
Gynecologic Oncology
Historically cervical cancer was subdivided into stage IA (microinvasive carcinoma), which can be treated
by a simple hysterectomy, and stage IB (more than microinvasive carcinoma), which is treated with radical
surgery or radiation therapy.
Five-Year Overall Survival of Patients With Stage IA and IB Cervical Cancera (N = 154)
2007 – 2015
Survival (%)
100 Stage IA CC (N = 41)
Stage IA AJCCb
Stage IB CC (N = 113)
80 Stage IB AJCCb
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IA 35 31 26 18 13
Stage IB 104 92 78 60 39
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
aIncludes
patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bComparison
group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the
American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer
Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
24 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 24 9/19/17 5:00 PMSections from TCI to be inserted following the paragraph above
In 1994, cervical cancer was further subdivided into stage IA1, IA2, IB1, and IB2 to better estimate
the risk of recurrence and survival. This is reflected in the Cleveland Clinic data listed below.
Five-Year Overall Survival of Patients With Stage IA1, IA2, IB1, and IB2 Cervical Cancera (N = 145)
2007 – 2015
Survival (%)
100 Stage IA1 (N = 26)
Stage IA2 (N = 14)
Stage IA REFb
Stage IB1 (N = 77)
80
Stage IB2 (N = 28)
Stage IB REFb
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IA1 20 20 17 11 6
Stage IA2 14 11 9 7 7
Stage IB1 74 63 52 38 26
Stage IB2 23 23 20 17 9
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bComparison group data from the American Cancer Society, as reported in: Survival rates for cervical cancer, by stage.
American Cancer Society Web site. Retrieved from: https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/survival.
html#written_by. Updated Dec. 5, 2016. Accessed on Apr. 13, 2017.
Ob/Gyn & Women’s Health Institute 25
108376_CCFBCH_17OUT415_Rev1_acg.indd 25 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage IB by Treatment Modalitya (N = 73)
2007 – 2015
Survival (%)
100 Stage IB S+C+R (N = 27)
Stage IB S+R (N = 9)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IB S+C+R 27 23 18 13 11
Stage IB S+R 8 7 4 3 2
C = chemotherapy, R = radiation, S = surgery
a
Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
Following surgery for stage I cervical cancer, certain patients have high risk factors (including lymph node
metastasis, extension beyond the cervix, and positive margins) or intermediate risk factors (including large tumor
size, presence of lymph-vascular space invasion, and extended cervical stromal invasion) that require radiation
therapy of the pelvis. The graph above demonstrates that those patients with the lowest risk factors have the best
outcomes. Patients treated with adjuvant radiation and concurrent chemotherapy had a better overall survival rate
than those treated with radiation only.
26 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 26 9/19/17 5:00 PMFive-Year Overall Survival of Patients With Stage IIA and IIB Cervical Cancera (N = 59)
2007 – 2015
Survival (%)
100 Stage IIA CC (N = 14)
Stage IIA AJCCb
Stage IIB CC (N = 45)
Stage IIB AJCCb
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIA 13 10 9 5 4
Stage IIB 42 35 31 22 13
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
a
Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
b
Comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of
Surgeons and the American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG,
Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
Ob/Gyn & Women’s Health Institute 27
108376_CCFBCH_17OUT415_Rev1_acg.indd 27 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage IIIB and IVA Cervical Cancera (N = 97)
2007 – 2015
Survival (%)
100 Stage IIIB CC (N = 87)
Stage IIIB AJCCb
Stage IVA CC (N = 10)
Stage IVA AJCCb
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIIB 68 43 34 28 19
Stage IVA 8 4 2 2 1
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bComparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the
American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer
Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
28 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 28 9/19/17 5:00 PMEndometrial Cancer
Five-Year Overall Survival of Patients With Endometrial Cancera (N = 2269)
2007 – 2015
Survival (%)
100 Cleveland Clinic
National comparisonb
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk = 1985 1616 1234 865 547
a
Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bNational comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance, Epi-
demiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. http://seer.cancer.
gov/statfacts/html/corp.html. Accessed on Mar. 30, 2017.
Ob/Gyn & Women’s Health Institute 29
108376_CCFBCH_17OUT415_Rev1_acg.indd 29 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage IA and IB Endometrial Cancera (N = 1294)
2007 – 2015
Survival (%)
100 Stage IA CC (N = 961)
Stage IA AJCCb
Stage IB CC (N = 333)
90 Stage IB AJCCb
80
70
60
50
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IA 869 716 531 351 186
Stage IB 312 277 226 187 139
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bComparison group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and
the American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC
Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
30 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 30 9/19/17 5:00 PMFive-Year Overall Survival of Patients With Stage II Endometrial Cancera (N = 116)
2007 – 2015
Survival (%)
100 Cleveland Clinic
National comparisonb
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk = 103 83 66 49 32
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bNational comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access
to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program,
National Cancer Institute. http://seer.cancer.gov/statfacts/html/corp.html. Accessed on Mar. 30, 2017.
Ob/Gyn & Women’s Health Institute 31
108376_CCFBCH_17OUT415_Rev1_acg.indd 31 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage II Endometrial Cancer by Treatment Modalitya (N = 101)
2007 – 2015
Survival (%)
100 Stage II S+C+R (N = 28)
Stage II S+R (N = 51)
Stage II S (N = 22)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage II S+C+R 27 23 21 16 10
Stage II S+R 46 41 33 28 20
Stage II S 16 10 8 3 1
C = chemotherapy, R = radiation, S = surgery
a
Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
32 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 32 9/19/17 5:00 PMFive-Year Overall Survival of Patients With Stage III and IV Endometrial Cancera (N = 458)
2007 – 2015
Survival (%)
100 Stage III (N = 317)
Stage IV (N = 141)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage III 266 187 138 88 55
Stage IV 93 61 38 21 12
a
Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
Ob/Gyn & Women’s Health Institute 33
108376_CCFBCH_17OUT415_Rev1_acg.indd 33 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage III and IV Endometrial Cancer by Treatment Modalitya (N = 398)
2007 – 2015
Survival (%)
100 Stage III and IV S+C+R (N = 165)
Stage III and IV S+R (N = 52)
Stage III and IV S+C (N = 127)
Stage III and IV C (N = 54)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Percent Survival (Number at Risk)
Stage III and IV S+C+R 151 109 77 48 23
Stage III and IV S+R 44 38 33 26 23
Stage III and IV S+C 104 69 41 20 13
Stage III and IV C 41 25 20 9 5
C = chemotherapy, R = radiation, S = surgery
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
34 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 34 9/19/17 5:00 PMOvarian Cancer
Five-Year Overall Survival of Patients With Ovarian Cancera (N = 847)
2007 – 2015
Survival (%)
100 Cleveland Clinic
National comparisonb
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk = 702 528 360 223 136
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bNational comparison represents relative survival after diagnosis from Fast Stats: An interactive tool for access
to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program,
National Cancer Institute. http://seer.cancer.gov/statfacts/html/ovary.html. Accessed on Mar. 30, 2017.
Ob/Gyn & Women’s Health Institute 35
108376_CCFBCH_17OUT415_Rev1_acg.indd 35 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage IA, IB, and IC Ovarian Cancera (N = 171)
2007 – 2015
Survival (%)
100 Stage IA CC (N = 99)
Stage IA AJCCb
Stage IB CC (N = 10)
Stage IB AJCCb
90 Stage IC CC (N = 62)
Stage IC AJCCb
80
70
60
50
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IA 90 78 58 40 28
Stage IB 9 8 5 4 3
Stage IC 55 43 29 26 18
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
a
Includes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
b
National comparison group data from the National Cancer Data Base (Commission on Cancer of the American College of
Surgeons and the American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL,
Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
36 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 36 9/19/17 5:00 PMFive-Year Overall Survival of Patients With Stage IIA, IIB, and IIC Ovarian Cancera (N = 58)
2007 – 2015
Survival (%)
100 Stage IIA CC (N = 15)
Stage IIA AJCCb
Stage IIB CC (N = 21)
Stage IIB AJCCb
80 Stage IIC CC (N = 22)
Stage IIC AJCCb
60
40
20
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIA 14 10 10 6 5
Stage IIB 18 12 7 4 1
Stage IIC 18 14 11 9 5
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bNational comparison group data from the National Cancer Data Base (Commission on Cancer of the American College
of Surgeons and the American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG,
Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
Ob/Gyn & Women’s Health Institute 37
108376_CCFBCH_17OUT415_Rev1_acg.indd 37 9/19/17 5:00 PMGynecologic Oncology
Five-Year Overall Survival of Patients With Stage III and IV Ovarian Cancera (N = 536)
2007 – 2015
Survival (%)
100 Stage IIIA CC (N = 22)
Stage IIIA AJCCb
Stage IIIB CC (N = 25)
Stage IIIB AJCCb
80 Stage IIIC CC (N = 244)
Stage IIIC AJCCb
Stage IV CC (N = 245)
60 Stage IV AJCCb
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIIA 19 16 12 6 3
Stage IIIB 22 14 9 6 5
Stage IIIC 211 153 100 64 38
Stage IV 174 121 79 41 23
AJCC = American Joint Committee on Cancer, CC = Cleveland Clinic
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
bNational comparison group data from the National Cancer Data Base (Commission on Cancer of the American College
of Surgeons and the American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL,
Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
38 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 38 9/19/17 5:00 PMFive-Year Overall Survival of Patients With Stage III and IV Ovarian Cancer by Treatment Modalitya (N = 540)
2007 – 2015
Survival (%)
100 Stage III and IV S+C (N = 424)
Stage III and IV C (N = 116)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage III and IV S+C 371 267 175 102 61
Stage III and IV C 391 284 188 110 64
C = chemotherapy, S = surgery
aIncludes patients treated at main campus and Fairview Hospital, a Cleveland Clinic hospital
Ob/Gyn & Women’s Health Institute 39
108376_CCFBCH_17OUT415_Rev1_acg.indd 39 9/19/17 5:00 PMBreast Disease
Cleveland Clinic’s Breast Center is committed to providing patients with the best possible prevention, detection,
and treatment options for breast disease. A multidisciplinary team comprising surgeons, medical oncologists,
radiation oncologists, nurses, and social workers collaborates with each patient to develop a tailored care plan
at 4 accrediteda breast centers throughout northeast Ohio.
Prevention and Screening
Percentage of Screening Mammograms Resulting in Callback
2012 – 2016
Percent
20
15
10
5
0
2012 2013 2014 2015 2016
N= 62,959 63,355 65,875 66,934 67,842
Cleveland Clinic offers a diagnostic callback program for patients with abnormal screening mammograms.
aAccredition by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons
40 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 40 9/19/17 5:00 PMQuality Measures
Needle Core or Fine Needle Aspirate Biopsy Prior to Surgical Treatment
of Breast Cancer (N = 350)
2015
5.1% Not performed (N = 18)
100% 94.9% Performed (N = 332)
Source: Data from Cleveland Clinic tumor registry for main campus and family health center locations
Cleveland Clinic’s performance was 94.9% (332 of 350 patients) in 2015 for this Commission on Cancer
standard of care quality measure (95% confidence interval [CI], 92.5-97.2). Cleveland Clinic performs
within the acceptable range for biopsy prior to surgical treatment of breast cancer.
Ob/Gyn & Women’s Health Institute 41
108376_CCFBCH_17OUT415_Rev1_acg.indd 41 9/19/17 5:00 PMBreast Disease
Breast Conservation Surgery Rate for Women With Clinical Stagea 0, I, or II Breast Cancer (N = 563)
2015
43% Not performed (N = 242)
100%
57% Performed (N = 321)
Source: Data from Cleveland Clinic tumor registry for main campus and family health center locations
a
American Joint Committee on Cancer (AJCC) stage I–IV breast cancer
Cleveland Clinic’s performance was 57% (321 of 563 patients) in 2015 for this Commission on Cancer
(CoC) standard of care quality surveillance measure (95% CI, 52.9-61.1). The CoC does not define a
benchmark performance rate. The National Accreditation Program for Breast Centers standard is 50%.
The rate at Cleveland Clinic reflects patient choice and referral bias of patients seeking surgery and
reconstruction at Cleveland Clinic.
42 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 42 9/19/17 5:00 PMTreatment
Five-Year Overall Survival of Female Patients With All Stagesa of Breast Cancer (N = 7632)
2007 – 2015
Survival (%)
100
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk 6965 5853 4691 3422 2246
aAJCC stage I–IV breast cancer
Five-Year Overall Survival of Female Patients With Breast Cancer by Racea (N = 7381)
2007 – 2015
Survival (%)
100 White (N = 6263)
Black (N = 1118)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
White 5732 4821 3880 2848 1865
Black 1006 842 659 464 309
aSelf-reported
Ob/Gyn & Women’s Health Institute 43
108376_CCFBCH_17OUT415_Rev1_acg.indd 43 9/19/17 5:00 PMBreast Disease
Five-Year Overall Survival of Female Patients With Breast Cancer by Hormone Receptor Status (N = 6155)
2007 – 2015
Survival (%)
100 ER/PR negative (N = 1321)
ER/PR positive (N = 4834)
80
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
ER/PR negative 1168 957 756 552 351
ER/PR positive 4502 3845 3074 2223 1439
ER = estrogen receptor, PR = progesterone receptor
Five-Year Overall Survival of Female Patients With Breast Cancer by HER2 Status (N = 3881)
2007 – 2015
Survival (%)
100 HER2 negative (N = 3183)
HER2 positive (N = 698)
80
60
40
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
HER2 negative 2794 2114 1461 787 240
HER2 positive 613 486 343 190 64
HER2 = human epidermal growth factor receptor 2 Years After Diagnosis
44 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 44 9/19/17 5:00 PMFive-Year Overall Survival of Female Patients With Breast Cancer by Estrogen Receptor, Progesterone Receptor,
and HER2 Status (N = 6025)
2007 – 2015
Survival (%)
100 ER/PR positive (N = 4834)
HER2 positive (N = 698)
80 Triple-negative (N = 493)
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
ER/PR positive 4502 3845 3074 2223 1439
HER2 positive 613 486 343 190 64
Triple-negative 396 279 188 96 23
ER = estrogen receptor, HER2 = human
epidermal growth factor receptor 2,
PR = progesterone receptor
Ob/Gyn & Women’s Health Institute 45
108376_CCFBCH_17OUT415_Rev1_acg.indd 45 9/19/17 5:00 PMBreast Disease
Five-Year Overall Survival of Female Patients With Stagea 0 and I Breast Cancer (N = 4405)
2007 – 2015
Survival (%)
100 Stage 0 CC (N = 1345)
Stage 0 NCDBb
Stage I CC (N = 3060)
80 Stage I NCDBb
60
40
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage 0 CC 1227 1067 874 629 422
Stage I CC 2806 2360 1891 1396 939
CC = Cleveland Clinic, NCDB = National Cancer Database
a
AJCC stage I–IV breast cancer
b
Reference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the American
Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging
Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
46 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 46 9/19/17 5:00 PMFive-Year Overall Survival of Female Patients With Stagea IIA and IIB Breast Cancer (N = 1947)
2007 – 2015
Survival (%)
100 Stage IIA CC (N = 1339)
Stage IIA NCDBb
80 Stage IIB CC (N = 608)
Stage IIB NCDBb
60
40
20
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIA 1254 1075 868 627 420
Stage IIB 560 478 384 268 152
CC = Cleveland Clinic, NCDB = National Cancer Database
aAJCC stage I–IV breast cancer
bReferencegroup data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the
American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer
Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
Ob/Gyn & Women’s Health Institute 47
108376_CCFBCH_17OUT415_Rev1_acg.indd 47 9/19/17 5:00 PMBreast Disease
Five-Year Overall Survival of Female Patients With Stagea IIIA and IIIB Breast Cancer (N = 552)
2007 – 2015
Survival (%)
100 Stage IIIA CC (N = 429)
Stage IIIA NCDBb
80 Stage IIIB CC (N = 123)
Stage IIIB NCDBb
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIIA 389 318 252 195 131
Stage IIIB 116 86 60 41 31
CC = Cleveland Clinic, NCDB = National Cancer Database
aAJCC stage I–IV breast cancer
bReference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons
and the American Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL,
Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.
48 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 48 9/19/17 5:00 PMFive-Year Overall Survival of Female Patients With Late Stagea Breast Cancer (N = 452)
2007 – 2015
Survival (%)
100 Stage IIIC CC (N = 157)
Stage IIIC NCDBb
80 Stage IV CC (N = 295)
Stage IV NCDBb
60
40
20
0
0 1 2 3 4 5
Years After Diagnosis
Number at Risk
Stage IIIC 142 106 82 59 38
Stage IV 217 155 97 62 37
CC = Cleveland Clinic, NCDB = National Cancer Database
a
AJCC stage I–IV breast cancer
b
Reference group data from the National Cancer Database (Commission on Cancer of the American College of Surgeons and the American
Cancer Society) 2000–2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual.
7th ed. New York, NY: Springer Science & Business Media; 2010.
Ob/Gyn & Women’s Health Institute 49
108376_CCFBCH_17OUT415_Rev1_acg.indd 49 9/19/17 5:00 PMSpecialized Women’s Health
The Center for Specialized Women’s Health comprises an interdisciplinary team that specializes in addressing
health issues specific to women, such as menstrual disorders, menopause, menopausal hormone therapy,
female sexual dysfunction, medical treatment of urinary and fecal incontinence, alternatives to hysterectomy,
hormone therapies, uterine fibroids, and osteoporosis.
Outcomes reported here relate to care by women’s health staff practicing at Cleveland Clinic’s main campus.
Diagnosis of Patients Following Dual-Energy X-Ray Absorptiometry Scan (N = 6976)
2012 – 2016
Number
2000
1500
Osteoporosisa
1000 Osteopeniab
Normal
500
0
2012 2013 2014 2015 2016
N= 1674 1866 1272 1084 1080
aOsteoporosis = T-score ≤ -2.5
bOsteopenia = -2 < T-score < -1.0
Zoledronic Acid Injections Administered for Low Bone Mineral Density (N = 630)a
2012 – 2016
Number
150
100
50
0
2012 2013 2014 2015 2016
N= 139 109 107 140 135
aSome patients received more than one injection.
The center began using zoledronic acid in 2008 to treat women with osteopenia and osteoporosis. In the
majority of patients, this treatment has helped prevent further deterioration of bone mineral density.
50 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 50 9/19/17 5:00 PMChange in Bone Mineral Density by Treatment Duration and Treatment
2007 – 2016
Percent
100
80
60 Improveda
Stable
40 Worseneda
20
0
No Bisphos- Zoledronic No Bisphos- Zoledronic No Bisphos- Zoledronic
Treatment phonates Acid Treatment phonates Acid Treatment phonates Acidb
2 – 3 Years 4 – 5 Years 6 – 7 Years
Treatment Duration
N= 3166 326 287 2243 248 256 1177 138 148
aImprovement or deterioration in bone mineral density is defined as a difference of at least 0.03 g/cm2
between the baseline and follow-up scans.
b
Patients receiving zoledronic acid injections completed a maximum of 6 years of therapy.
Patients included those having a dual-energy x-ray absorptiometry scan between 2007 and 2016
who were diagnosed with osteoporosis or osteopenia at any age. Follow-up scans were used to track
changes in bone mineral density as often as every 2 years, and their progress over time is reflected
in the figure (individual patients may be represented in more than 1 of the 3 time periods).
Ob/Gyn & Women’s Health Institute 51
108376_CCFBCH_17OUT415_Rev1_acg.indd 51 9/19/17 5:00 PMMaternal-Fetal Medicine
Outcomes reported here relate to care by maternal-fetal medicine staff practicing in Cleveland Clinic
facilities in northeast Ohio.
While the acuity of Cleveland Clinic’s obstetrical population has not changed significantly, the
implementation of guidelines for fetal surveillance together with an organization-wide emphasis
on containing costs have likely led to more judicious use of antenatal fetal surveillance methods.
Tests of Fetal Well-Being (N = 142,299)
2012 – 2016
Number
40,000
30,000
Doppler
20,000 Biophysical profiles
Nonstress test
10,000
0
2012 2013 2014 2015 2016
N= 23,814 28,333 32,966 29,025 27,660
With the incorporation of cell-free DNA technology and noninvasive prenatal testing in late 2012, the
institute continues to see a greater uptake of aneuploidy screening in the obstetrical population. Cell-free
DNA technology offers higher detection rates and far fewer false-positive results than traditional screening
tests, leading to a significant decline in the number of invasive diagnostic procedures being performed.
While cell-free DNA technology is reserved for higher risk patients, the institute has also noted
that low-risk patients are more likely to pursue aneuploidy screening. A positive screen with a traditional
test, such as sequential screening, can now be followed up with cell-free DNA testing rather than
an invasive procedure, thus avoiding the main drawback with traditional screening tests and making
screening more palatable for more patients.
52 Outcomes 2016
108376_CCFBCH_17OUT415_Rev1_acg.indd 52 9/19/17 5:00 PMYou can also read
