1. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner EVOLUTION OF COHORT REVIEW CHICAGO Juan Elias, Field Operations Manager CHICAGO DEPARTMENT OF PUBLIC HEALTH TUBERCULOSIS CONTROL Webinar November 10 th, 2010

2. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner DEFINITION UNDERSTANDING THE TB COHORT REVIEW PROCESS: INSTRUCTION GUIDE Cohort review is a systematic review of the management of patients with TB disease and their contacts.

3. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Patient’s clinical status Patient’s treatment outcome Adequacy of the medication regimen Treatment adherence or completion Results of contact investigation Percentage of contacts who did, or are likely to, complete treatment. Details regarding the management and outcomes of TB Cases

4. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Traditional Cohort Review Approach Results Presentation TB Cohort Cases 4

5. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner resent Cohort Review Roles Medical Reviewer s (2) CI Supervisor CI Supervisor TB Program Mgr Data Analyst CDCI Case Mgr DOT Wkr DOT Wkr Presenters Understanding the TB Cohort Review Process: Instruction Guide (2006) Chicago Cohort Review Roles 2010 Sup CDCI

6. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner TB IN CHICAGO 202 Cases in 2009 2 city clinics 3 subcontract agencies Monthly case conferences

7. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner MONTHLY CASE CONFERENCES Each of our sites perform monthly case conferences that are an interactive detailed review of TB cases and contact investigations. Case conferences average 2 to 3 hours per session.

8. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner History of Cohort Review in Chicago Started June 2005 as quarterly Originally modeled after New York – Every case for quarter systematically reviewed – Used NY Presentation forms as a template – Forms completed and submitted by presenters prior to cohort day for reviewers – Presenters consist of Case managers, Contact Investigators and DOT Workers – Case reviewed and concerns addressed by TB Medical Director, Program Mgr., Data Analyst and CI Supervisors – Data simultaneously entered into excel spreadsheet 8

9. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner History of Cohort Review in Chicago (2) Mandatory full day for all staff Data analyzed and results presented the same day Feedback from staff – Staff were on board – Long and tiring – Most prep work was being done a few days prior to cohort day

10. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Cohort Review Rotation after 1 st Restructuring Review PanelPMDHeartland/HomelessStroger/JailUptownEnglewoodWest Town

11. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner First Restructuring of Cohort Review Simplification of forms Staff only required to attend only for their cases (Scheduled sites to present cases) Results emailed few days later Feedback – Unclear how differed from monthly case conference – Limited utility for staff – Prep work still done few days prior to cohort – Delayed results made CR incomplete

12. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Second Restructuring Cohort Review Started in March 2010 NTIP Pilot Site to implement with cohort review Goals of changes: – Decrease case conference redundancy – More meaningful and useful for staff – Identify areas for program improvement

13. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Second Restructuring Cohort Review Utilizes NTIP Indicators Utilized Illinois National Electronic Disease Surveillance System (INEDSS) – Web-based reporting system required by state – Consolidated databases Mainly focuses only on cases not meeting objectives

14. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Run NTIP queries on INEDSS data Research cases not meeting objectives Review all documentation for cases and contacts Update data in INEDSS Data Flow for Cohort Review 14 CDPH generates final line list of cases not meeting objectives Cohort list generated from INEDSS and sent to field staff Field staff update INEDSS

15. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Timeline for Cohort Review Current cohort Next cohort Case list for next cohort given to field staff Month 1 Month 2 Generate line list of cases not meeting NTIP objectives Final data cleaning Generate final NTIP measure results (% and line line of cases not meeting NTIP objectives Update data in INEDSS Data cleaning

16. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Cohort Review with NTIP Results (NTIP Indicators) Presentation Cases 16

17. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Cohort Day Mandatory for all staff First half of day discussions – Cases not meeting NTIP objectives – Challenging cases with good outcomes – How to improve program to meet target for each objective Second half day : Educational and Staff appreciation

18. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner TB Program NTIP Results 4th Quarter 2009

19. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Purpose Guide to evaluate TB program activities based on CDC’s National TB Program Objectives – Review patients who missed completion of objective NTIP measures being evaluated – Recommended Initial Therapy – Sputum Culture Conversion – Completion of Treatment – Known HIV Status – Contact Investigation

20. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Methods Data sources – INEDSS (76 confirmed TB cases counted for October, November, and December 2009) – Contact Investigation Forms Contact Report Forms (2 nd sheets) Contact Records (3 rd sheets) Contact Investigation measures were obtained from – 2 nd and 3 rd sheets – INEDSS – Discussions with nurses, CDCI Supervisors, and CDCIs

21. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Results

22. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Sputum Culture Conversion National Objective: Increase proportion of TB patients with positive sputum culture results who have documented conversion to culture- negative within 60 days of treatment initiation to 61.5%.

23. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Sputum Culture Conversion: 50.0% (10/20) Individuals who did not meet objective* PatientAgeSiteConversion?Days to convert Reason 73ENGYes91 61PMDYes142 33StrogerYes72 StrogerYes79 35PMDYes252 48StrogerYes147 41PMDYes395 57StrogerYes168 56StrogerYes178 51StrogerYes140.

24. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Recommended Initial Therapy National Objective: Increase proportion of patients who are started on the recommended initial 4-drug regimen when suspected of having TB disease to 93.4%. 100%

25. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner NameSite Patient 1STR Patient 2ENG Patient 3ENG Patient 4 Patient 5 Patient 6 Recommended Initial Therapy

26. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Sputum Culture Conversion National Objective: Increase proportion of TB patients with positive sputum culture results who have documented conversion to culture- negative within 60 days of treatment initiation to 61.5%.

27. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Sputum Culture Conversion: 50.0% (10/20) Individuals who did not meet objective* PatientAgeSiteConversion?Days to convert Reason Patient 173ENGYes91 Patient 261PMDYes142 Patient 333StrogerYes72 Patient 472StrogerYes79 Patient 535PMDYes252 Patient 648StrogerYes147 Patient 741PMDYes395 Patient 857StrogerYes168 Patient 956StrogerYes178 Patient 1051StrogerYes140 *Results were obtained after entries were revised in INEDSS.

28. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Completion of Treatment National Objective: For patient with newly diagnosed TB for whom 12 months or less of treatment is indicated, increase the proportion of patients who complete treatment within 12 months to 93.0%.

29. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Completion of Treatment: 70.6% (24/34) PatientAgeSiteDid they complete? Reason Patient 161PMDNoPMD decision Patient 247StrogerNoMoved: out of country Patient 335PMDNoPMD decision Patient 448StrogerNoProvider decision Patient 549PMDNoPMD decision Patient 652PMDNoPMD decision Patient 737StrogerYesComplete, after 12 months Patient 817 Stroger  ENG NoInitially unable to locate Patient 956PMDNoPMD decision Patient 1032StrogerNo Individuals who did not meet objective* *Results were obtained after entries were revised in INEDSS.

30. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Known HIV Status National Objective: Increase proportion of TB cases with positive or negative HIV test results reported to 94.0%.

31. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Known HIV Status: Individuals who did not meet objective* PatientAgeSiteReason Patient 185ENGNot offered Patient 21WTNNot offered Patient 364PMD/WTNRefused Patient 435WTNRefused Patient 581PMDRefused Patient 656WTNRefused Patient 749PMDNot offered Patient 8 *Preliminary results from CDC query.

32. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Contact Investigation (CI)

33. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: Contact Elicitation Increase the proportion of TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited to 100.0%. 25 = Total number of cases needing contact investigation 100%

34. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: Contact Evaluation Increase the proportion of contacts to sputum AFB smear-positive TB patients who are evaluated for infection and disease to 93.0%. 143 = Total number of contacts elicited. 126 = Total number of contacts evaluated. 88.1%

35. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: Contact Evaluation (Qtr 4 2009) Contacts who did not meet objective IndexSiteContactAgeReason STR50 STR38 ENG33UTL WT31 WT34 WT26 ENG66 ENG41 ENGNA ENG9 31

36. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: Treatment initiation (Qtr 4 2009) Increase the proportion of contacts to sputum AFB smear-positive TB newly diagnosed latent TB infection who start treatment to 88.0%. 41 = Total number of LTBIs identified. 39= Total number of LTBIs who start treatment. 95.1%

37. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: Treatment Initiation (Qtr 4 2009) Contacts who did not start treatment IndexSiteContactAgeReason Index 1ENGContact 138 Index 2WTContact 235Refused

38. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: Treatment completion (Qtr 4 2009) For contacts to sputum AFB smear-positive TB patients who have started treatment for the newly diagnosed LTBI, increase the proportion who complete treatment to 79.0%. 39 = Total number of LTBIs who started treatment. 16= Number of LTBIs who completed treatment. 41% 12= Number of LTBIs who are still on treatment. 71.8%

39. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner CI: completion of treatment Contacts who did not complete treatment IndexSiteContactAgeStartRegiminReason STR71/5/2010RifampinStill on Tx STR523/4/2010RifampinContact chose to stop STR1512/31/2009IsoniazidContact chose to stop STR1712/7/2009RifampinContact chose to stop STR1912/31/2009RifampinContact chose to stop STR223/10/2010RifampinContact chose to stop STR408/19/2010RifampinStill on Tx STR313/10/2010RifampinStill on Tx WT389/16/2009IsoniazidContact chose to stop UPT505/18/2010Isoniazidadmin closure UPT273/23/2010IsoniazidStill on Tx UPT502/9/2010IsoniazidStill on Tx UPT155/12/2010RifampinStill on Tx UPT177/2/2010IsoniazidStill on Tx UPT427/2/2010IsoniazidStill on Tx ENG283/19/2010RifampinStill on Tx ENG346/15/2010RifampinStill on Tx WT561/19/2010RifampinContact chose to stop WT534/5/2010RifampinUTL WT581/5/2010RifampinStill on Tx WT487/19/2010RifampinStill on Tx WT641/5/2010RifampinUTL

40. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Summary CI Results (for Sputum Smear Positive cases only) NTIP MeasureQtr 3 2009 (N=13)Qtr 4 2009 (N=19)National Target Contact Elicitation100% Contact Evaluation88.1% (81/92)78.8% (89/113)93% Treatment Initiation96.2% (25/26)95.1% (39/41)88% Treatment Completion60% (15/25)41% (16/39)79% Likely to complete68% (17/25)71.8% (28/39)

41. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Future Directions INEDSS – New cohort list (1 st Qtr 2009) available now – Please check the TB program server for updated cohort roster: \\Cdph\cdphshare\TB_Program\Cohort Review Data\1st Quarter 2010 Check 2 nd and 3 rd sheets for accuracy

42. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Lessons Learned Listen to feedback from staff Be willing to continually modify and adapt your process to meet program needs and changing technology New cohort model – Allows more focus on cases that need attention – Provides extra time to incorporate other staff requests (ie training and education) – Allows staff to learn from other sites – Good tool for program evaluation – Less time consuming – Allows us to present results same day

43. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Future Plans Change how contact indicators are calculated ARPE analysis done through INEDSS Change in contact cohort form Challenge our program by creating new target outcomes

44. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Thanks Questions? 44

45. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner ACKNOWLEGDEMENTS JOSHUA JONES, M.D. CDPH Medical Director NEHA SHAH, M.D., MPH, CDC, Chicago BILL BOWER, MPHCharles P. Felton National TB Center at Harlem Hospital KIM FIELD, R.N. MSN Washington State H.D. KAI H. YOUNG, MPH, CHES, CDC, MARGARITA REINA, MPH, Chicago Dept. Public Health CDPH TB CONTROL PROGRAM New York City Department of Health and Hygiene 45

46. Chicago Department of Public Health Richard M. Daley Mayor Bechara Choucair, MD Commissioner Acknowledgements TB program staff – Especially those who diligently enter all patient information into INEDSS! Margarita Reina, Epidemiologist III Peter Ward (IDPH)