Cohort ReviewTuberculosis Control Program
Objectives
Identify cohort review methods used by Arizona Department of Health Services (ADHS)
Data collection & review processes
Benefits of cohort review
Cohort Review in Arizona
Arizona’s cohort review protocol developed by Gayle Schack, R.N., P.H.N., M.S. as an internship project in 2010.
ADHS held Cohort Review Training webinars for local county health departments (LHDs) prior to implementation.
First cohort review: December 2010.
Response
Divided Arizona into three regions.
All LHDs are invited to participate in all three region’s cohort reviews.
Provides educational opportunities for low morbidity counties.
All cohort reviews are conducted by tele-conferencing.
Northern Region
Southern Region
Central Region
Three Regions
Teleconference – Biannual.
Regions combined into one cohort review if small number of cases.
Majority of the LHDs in the Northern and Southern regions are low morbidity areas.
Central Region
Maricopa County reports >50% of TB cases in the state (Metro Phoenix).
Pinal County: Majority of cases are in correctional facilities.
Many are in Federal custody and may not be included in the cohort reviews.
Gila, Greenlee, & Graham LHDs report few (<5 cases) annually.
Arizona Tribal LHDs
Arizona’s tribal cases are excluded from cohort reviews.
ADHS participates in a monthly call with Navajo Nation, IHS, New Mexico, Colorado, and Utah to review all Navajo Nation TB cases.
Other tribal TB cases are reviewed with individual tribal LHDs as needed.
Date Of Cohort review meeting
January 2011
April 2011
July 2011
October 2011
April Thru June 2010
July Thru September 2010
October Thru December 2010
January Thru March 2011
Timelines for Cohort Review
Completion of treatment
Directly Observed Therapy
Recommended 4 drug therapy
Sputum conversion within 60 days
Data Summaries
Complete cohort review from medical chart
Complete cohort review from RVCT data
Case review including contact investigation results
Compare LHD cohort form with ADHS data to identify conflicting data
Cohort review forms are submitted to ADHS 2 weeks prior to review.
Team review of cases and case management
Prepare case presentations for cohort review
Prepare summary of cohort data and PDF’s of cohort forms for LHDs prior to review.
Begins the day a TB case is reported
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ADHS distributes case lists for cohort review to LHDs.
LHD case manager prepares case report.
Cohort review forms submitted to ADHS 2 weeks prior to scheduled review.
ADHS prepares analysis of cases.
TB Nurse reviews case management.
Case manager reviews and familiarizes oneself with the case
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Comparison of data between cohort review form and RVCT.
Assessment of data against National objectives.
ADHS completes summary spreadsheets for entire cohort and individual LHDs.
Preparation: 1 week prior to cohort review
Provided to LHDs:
Agenda with order of case presentations.
Excel files with summary of cohort review and for individual LHDs.
PDF files of completed LHD cohort review forms.
Arizona Cohort Review Meeting
ADHS Surveillance Epidemiologist
Provides comparison of cohort review data summaries to National Objectives.
Contact Investigation summaries.
Arizona Cohort Review Meeting
Resolution of data conflicts
Flag items for follow-up after review
Discussion open to all attendees.
Provides educational opportunities
Summary of cohort review
NTIP indicators and results
ADHS TB Control Section objectives
ADHS and the LHD case managers ensure follow-up case management activities identified are fulfilled.
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Has been revised after each cohort review
Original form was created based on Colorado, Utah, and Washington’s forms.
Cohort Review Form
Data Collection & Analysis
Fields added for contact investigation results.
Formulas to evaluate national objectives.
Summary Spreadsheet
Conflicts are annotated on cohort review form
Discussed during case presentation
Data Collection and Analysis
Results discussed during cohort review.
Appropriateness of contact investigation
Discussion of obstacles encountered during investigations and LTBI treatment completion
Ensure ADHS received contact investigation results for ARPE reporting
Lessons Learned
Resistance or lack of “buy-in” from LHD staff during training and implementation of cohort reviews.
Felt it was just “extra work” because they conducted their own case reviews.
Attitudes changed after understanding of differences between case reviews and cohort reviews.
Occurred after participating in several cohort reviews
Cohort Review vs Case Reviews
Retrospective
Chaos ensues if counties present in “their own order”.
Slows pace of cohort review if you have to fish for forms and case files.
Lessons Learned
Case file review
Data entry for EXCEL file and analysis
ADHS team: Up to 60 hours of staff time not including case follow-up after review.
Fillable PDF form decreased time spent by LHDs preparing case presentation.
Lessons Learned
A substantial number of RVCTs reported incomplete laboratory results or incorrect information.
Private or commercial laboratory results obtained by the LHD and not to ADHS
RVCTs filled out incorrectly
Lessons Learned
Identification of source cases and epi-linked cases
Several instances of reported cases being ruled out by LHDs after ADHS submitted to CDC.
Benefits of Cohort Review
Improved communication between ADHS and LHD staff.
Increases accountability of LHD staff.
Obstacles identified for completion of treatment and contact investigations.
Benefits of Cohort Review
Facilitates discussion and action planning to overcome obstacles in case management, completion of treatment, and contact investigations.
Promotes accountability for LHD progress in achieving 2015 National Objectives.
….and one LHD’s response after 3 cohort reviews completed….
“Cohort reviews are good because they force us to review our case management and identify gaps in case management and missing information.”
Questions
Case Manager State Case Number Case Initials
2. Age at report 3. Country of Birth USA or 4. Month/Year Arrived
5. Resident of Correctional Facility at Diagnosis: No Yes Unknown
6. 1HIV: Negative Positive Refused Results Unknown Not Offered, Why:
7. TST: Positive Negative Not done Unknown
8. IGRA: Positive Negative Indeterminate Not done Unknown
9. 2Chest X-rays and/or CT Scan: Non-Cavitary (TB) Cavitary Miliary Abnormal NOT TB Normal
10. 3Drug Susceptibilities: Pansensitive Resistance: INH Rifampin Streptomycin Other
11. For cases < 6 years of age: Source case identified Yes No If no, why?
12. Laboratory Confirmed Case Clinical Diagnosis Provider Diagnosis
13. Sputum Smear: + Negative Not Done Date of Collection:
14. Sputum Culture: Positive Negative Not Done Date of Collection:
# Contacts Started on LTBI Treatment
Treatment & DOT Initial Treatment: Start Date: RIPE Completed Therapy Date:
Currently on therapy Has completed ____ weeks of treatment
Likely to complete Date _____________ Did not complete treatment and is no longer under care
Refused Lost Deported Died TB related Yes No Dead at diagnosis
Moved In-state, out of jurisdiction Out of state Out of country Interjurisdictional sent to
DOT: Yes No #Weeks on DOT:
If NO DOT, why not? Patient refused Provider refused Staff resources Patient followed by Private Provider Other
4,5Pulmonary Case with Only Sputum Results
Pulmonary
5Pulmonary Cases with Other Respiratory Results
Pulmonary only
Culture collected on:
Culture Conversion on:
Specimen:
CONTACT INVESTIGATIONS Number Infectious Period
# Contacts Identified # Contacts Evaluated # New LTBI Positives
# Continuing LTBI Treatment # Completed LTBI Treatment
GENOTYPING PCR Type
Revised 6/20/11
Cohort Review Form Notes, Definitions, and Special Cases 1. HIV results: Please explain why HIV test results of either positive or negative are not available. 2. CXRs are reported as non-cavitary, cavitary, or normal. Normal includes CXRs that are abnormal but NOT consistent with TB. Do not report dates of CXRs or follow-up CXR results. 3. Drug Susceptibilities: Report as pansensitive if no resistance is detected. 4. Positive Sputum smear pulmonary cases: Report positive sputum smears regardless of the culture’s result. Suspicious smears are considered to be positive. 5. This section is used to present cases with a disease site involving the respiratory system. This includes pulmonary, and specimens from anatomic codes 18 -25, 27 and 28. Respiratory System Anatomic Codes
Code Code 18 Nose 25 Lung 19 Accessory Sinus 27 Upper respiratory fluids or tracheal fluids 20 Nasopharynx 28 Bronchial fluid 21 Epiglottis 22 Trachea 23 Bronchus 24 Bronchiole
6. Highest grade of smear.
ADHS Use Only Objective Objective Met Known HIV Status Known HIV Status (25-44 years of age) Country of Origin Foreign-born Only—Month/Year Arrived Patient Started on the Recommended Initial 4-drug Regimen When Suspected of Having TB Disease Sputum Smear Positive TB Case who Started Treatment Within 7 Days of Sputum Collection Culture Positive Case with Drug Susceptibilities Reported Case with a Pleural or Respiratory Site of Disease (>12 years) with Sputum Culture Results Reported TB Case with Positive Culture Sputum Results with Documented Conversion to Sputum Culture-Negative Within 60 Days of Treatment Initiation
Completion of Treatment Within 12 Months Ongoing Treatment, Likely to Complete Sputum Smear Positive TB Case with Contacts Identified Sputum Smear Positive TB Case with Contacts Evaluated Newly Diagnosed Infected Contacts to Sputum Smear Positive Case Started on LTBI Therapy Newly Diagnosed Infected Contacts to Sputum Smear Positive Case who Complete LTBI Therapy
Revised 6/20/11