1. The Cohort Review Process The Cohort Review Process Kim Field RN, MSN WA State DOH Tuberculosis Program

2. Objectives Define the cohort review process Outline the roles key TB control staff play Identify how to adapt and implement the cohort review method in your program area

3. What is Cohort Review Cohort review is a systematic review of patients with tuberculosis (TB) disease and their contacts. A “cohort” is a group of TB cases and contacts identified over a specific period of time, usually 3 months. The cases are reviewed approximately 12-15 months after they are reported, so that many of the cases and contacts have completed or are nearing the end of treatment.

4. “The fundamental concept of a cohort review is accountability. Staff are accountable to supervisors and to the program for how well they are caring for patients... and the program is accountable to patients and to the public for controlling TB.” Thomas Frieden, MD, MPH Director of CDC Former New York City Commissioner of Health Photo by David Lubarsky http://www.governing.com/poy/thomas-frieden.html

5. Cohort Review Process Group process, using staff from every level of the organization Individual and group accountability Proactive process Closely tied to state and national TB goals and indicators

6. During cohort review presentations Listen carefully to all case presentations Review available support documents –TB registry, case management forms, medical records. Ensure that all aspects of case management adhere to department of health policies and procedures. Presenter Medical Reviewer

7. Purpose Improves case management at the local level Uses cohort review as a tool to conduct program evaluation Connects case discussions with performance summary report Helps program reflect on performance - think about the big picture Engages a wider audience (e.g., disease investigators) in discussions surrounding program- wide issues

8. During cohort review presentations Review case, diagnosis and treatment: –Pulmonary or Extrapulmonary –Culture confirmed or Clinical case –AFB smear/culture result –Drug regimen is appropriate –Drug Susceptibility results are obtained –Drug regimens are adjusted if necessary –Sputum conversions are documented –Treatment completions are documented

9. Cohort Review Process Goals Evaluate process of public health intervention to: -ensure appropriate drug regimen used -ensure timely treatment completion -improve timeliness of interventions -shorten time of contact identification and screening -improve management of infected contacts -analyze outcome to develop appropriate interventions

10. Cohort Review Process Strengths MD reviews every case Public accountability for case management and follow-up of contacts National objectives are tracked Can be modified to add/delete measurable items Consistent with global principles of TB control

11. During cohort review presentations Assess outcomes Use teachable moments to illustrate important lessons in effective TB control –use specific cases as examples of how certain problems should be handled. –give feedback to staff and –update staff on policies, protocols, and scientific changes.

12. Implementation of Cohort Review in Washington 34 Local Health Jurisdictions (LHJs) for 39 counties – all counties participated in training

13. Why Implement Cohort Review? Increase learning for staff Improve case management at state, local levels Improve documentation in clinic records Use cohort review as a tool for program evaluation Create systematic platform for case mangement and data analyis Decrease TB morbidity

14. Detailed Case Review Facilitators ask questions to make sure that: Details are consistent Regimen is appropriate Treatment is completed Contact investigation is thorough

15. Timeline 1 ST QUARTER JAN FEB MAR 2 ND QUARTER APR MAY JUN 3 RD QUARTER JUL AUG SEP 4 TH QUARTER OCT NOV DEC 1 ST QUARTER JAN FEB MAR 2 ND QUARTER APR MAY JUN TB cases identified Treatment started Contact investigation initiated Ongoing treatment of patients with TB disease Contacts evaluated and started on treatment, as necessary TB disease treatment completed Infected contacts continue on treatment for LTBI 1 st quarter contacts complete treatment Begin follow up on issues identified Cohort prep COHORT REVIEW SESSION Continue follow up on issues identified during cohort review session Treatment completion rate presented for contacts of cases from previous 1 st quarter

16. How do we go from raw data to the summary analyses? TB Morbidity data sources -Cases: TIMS and as of January 2009 PHIMS (Public Health Information Management System) -Contacts: WA State contact Database Cohort review forms adapted to collect additional measures (e.g. timeliness) stored in an excel file SAS software used to analyze all data Enter the output into summary spreadsheets

17. Preparation of Cohort Sheets TB programs basically collect the same information; our processes might be different but the information needed should be available. Begin form completion as you begin working the case, it saves time Most of the case information will be complete or near completion at time of the review It allows for a final review of case It should take approximately 10 minutes to complete a review sheet

18. Analysis of Outcomes Analyze data on outcomes of interest Obtain missing or update incorrect data Discover challenges and opportunities as a program Focus on big picture: – Could we have done things differently? – How can program better support the staff Record and summarize meeting

19. Cohort Practice: Mock Cohort Cases are called in the order listed in notification Supervisors act as medical reviewers Staff are given 1 week to make changes and return corrected sheets to supervisors A 2 nd practice session is held 2 weeks prior to actual cohort (if needed) 1 week prior to cohort review the sheets are forwarded for data entry

20. Modifications: Timeliness Measures for Cases (1) Average number of days:  Sputum collected and received at lab  Sputum smear + and cavitary CXR to TB medications started  For cases with MTD testing, sputum collection to TB medications started

21. Modifications: Timeliness Measures for Cases (2) Average number of days:  Sputum smear + to case reporting from private provider to LHJ  Sputum smear + to reporting from lab to LHJ  Sputum smear + to case reporting from LHJ to DOH  MTB culture + to reporting drug susceptibility from lab to LHJ

22. Modifications: Timeliness Measures for Contacts Average number of days:  Sputum smear + and cavitary CXR to date contacts identified

23. Of the 124 TB cases counted in Pierce County from 2003-2007: 71% were foreign-born from countries with high endemic rates of TB 73% had infectious pulmonary TB 15.7% of the cases that had drug sensitivity testing done were INH resistant Cohort Review: A Local Health Department Perspective (2)

24. The TPCHD staff report that since participating in the the cohort review process they have: established the need to set priorities for program funding and activities improved program evaluation with documentation of meeting local and state objectives increased case management accountability for both patients and contacts identified gaps and barriers to care Cohort Review: A Local Health Department Perspective – Program and Practice Changes

25. Impact of Cohort Review: HIV Testing 2000 - 36% of all TB cases did not have an HIV test 2008 – 11% of TB cases did not have an HIV test

26. Impact of Cohort Review: DOT 2000 - DOT done on 76.9% of all cases 2007 – DOT done on 92% of all cases (100% smear+)

27. Impact of Cohort Review: Timeliness Measure – LHJ Reporting to DOH

28. Impact of Cohort Review: Treatment Completion for Contacts

29. Example Cohort Summary: Cases Seattle & King County October - December 2008 DOT usage –100% for pulmonary cases –93% for extra-pulmonary cases –97% for both pulmonary & extra- pulmonary Treatment not initiated or stopped –1 Dead at diagnosis –2 died during treatment –1 moved during treatment 14 Asian (35%), 15 Black (38%), 10 Caucasian (25%), 1 Unknown (3%) 5 Hispanic (13%) 33 foreign born (83%) –3 in US <1 year at report (9%) –11 in US 1-5 years at report (33%) –18 in US >5 years at report (55%) 1 homeless (3%) 4 < 5 years of age at report (10%) 40 cases counted

30. Example Cohort Summary: Cases Seattle & King County October - December 2008 Culture (all cases) –Time between date culture was received at the lab and date result was reported to LHJ Median: 17 days LHJ to DOH (smear+ cases only) –Time from receipt of smear+ result to report to DOH Median: 14 days Meds starting (smear+ cases only) –Time between date of smear+ result to date TB meds started Median: 0.5 day (meds started w/in half a day of smear+ result received) Susceptibility (all cases) –Time between date of the first positive culture result to date susceptibility results reported to LHJ Median: 13.5 days Timeliness Measures—State Indicators

31. Example Cohort Summary: Contacts Seattle & King County October - December 2008 Contacts identified per pulmonary case –Mean: 4.8 –Median: 4.0 Contacts identified per smear+ case –Mean: 6.5 –Median: 5.0 100% of smear+ cases had at least one contact identified 76% of contacts to pulmonary cases were initially identified and followed up 110 contacts to 23 pulmonary cases 123 contacts total

32. Example Cohort Summary: Contacts Seattle & King County October - December 2008 113 contacts 1 or 2 rounds of testing (92%) – 108 (96%) fully evaluated – 25 (22%) of tested had LTBI 11 contacts 1 round of testing only (9%) 17 LTBI started treatment (68% of contacts infected) –29% have completed treatment –29% currently on treatment –35% lost to follow-up –6% refusal 5 active TB disease to date

33. Impact of Cohort Review Washington State

34. Impact of Cohort Review in WA State:

35. Impact of Cohort Review in WA State: Timeliness Measure – MTD Test

36. Impact of Cohort Review in WA State: Contacts Identification

37. NTIP Process Goals and Objectives Importance and rationale for objective Local level implication Program performance Challenges and Successes

38. NTIP: 4-drug regimen

39. NTIP: 12-month completion

40. Selected National TB Program Objectives Objective CategoriesObjectives and Performance Targets WA State 2010 Target NTIP Performance Target PHSKC (4th qtr 2008) NTIP Target Met? Completion of treatment For patients 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 85%93%70.3%N Laboratory reportingIncrease the proportion of culture- positive TB cases with initial drug- susceptibility results reported >95%100% Y Sputum culture conversion Increase the proportion of TB patients with positive sputum culture results who have documented conversion to sputum culture-negative within 60 days of treatment N/A61.5%73.7Y Recommended initial therapy Increase the proportion of patients who are started on the recommended initial 4- drug regimen when suspected of having TB disease N/A93.4%97.4%Y Known HIV statusIncrease the proportion of TB cases with positive or negative HIV test result reported 95%88.7%82.5%N Sputum culture reported Increase the proportion of TB cases with a pleural or respiratory site of disease in patients ages 12 years or older that have a sputum culture result reported N/A95.7%96.0%Y

41. Selected National TB Program Objectives Objective CategoriesObjectives and Performance Targets WA State 2010 Target NTIP Performance Target PHSKC (4th qtr 2008) NTIP Target Met? Contact ElicitationIncrease the proportion of TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited 84%100% Y Contact EvaluationIncrease the proportion of contacts to sputum AFB smear-positive TB patients who are evaluated for infection and disease 59%93%85%N Contact Treatment Initiation Increase the proportion of contacts to sputum AFB smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who start treatment 53%88%67%N Contact Treatment Completion For contacts to sputum AFB smear- positive TB patients who have started treatment for newly diagnosed LTBI, increase the proportion who complete treatment 80%79%36%N

42. 2009 Pilot Project: Enhancing the Cohort Review Process with NTIP Objectives

43. Aftermath of Cohort Post your data Select indicators that need improvement Select actions to initiate and plan implementation of actions – what process will you use, how will you evaluate results? Document results of implementation – did you get the desired results? Begin again

44. Summary Measurable improvement in meeting local, state and national TB objectives through the use of the cohort process

45. Successful cohort review Successful cohort review The medical reviewer assist in… Improving patient care Improving TB control program Improving Public Health …first steps toward TB elimination Double Rainbow!

46. Kim.Field@doh.wa.gov 360-236-3447 http://www.doh.wa.gov/cfh/TB/07TBManual.htm http://www.doh.wa.gov/cfh/TB/Manual/Forms/Cohort Presentation.pdf http://www.doh.wa.gov/cfh/TB/Manual/Forms/Cohort Dictionary.pdf http://www.cdc.gov/tb/pubs/cohort/default.htm http://www.cdc.gov/tb/pubs/tbfactsheets/NTIP.htm