Evolution of Cohort Review Chicago

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Richard M. DaleyMayor

Bechara Choucair, MDCommissioner

EVOLUTION OF COHORT REVIEWCHICAGO

Juan Elias, Field Operations Manager

CHICAGO DEPARTMENT OF PUBLIC HEALTHTUBERCULOSIS CONTROL

WebinarNovember 10th, 2010

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DEFINITIONUNDERSTANDING THE TB COHORT REVIEW PROCESS: INSTRUCTION GUIDE

Cohort review is a systematic review of the management of patients with TB

disease and their contacts.

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• 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

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Traditional Cohort Review Approach

Presentation

TB

Cohort Cases

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resent

Cohort Review Roles

Medical Reviewer

s (2)

CISupervisor

TB Program

Mgr

Data Analyst

CDCICase Mgr

DOTWkr

Presenters

Understanding the TB Cohort Review Process: Instruction Guide (2006)

Chicago Cohort Review Roles 2010

Sup CDCI

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TB IN CHICAGO

• 202 Cases in 2009

• 2 city clinics• 3 subcontract

agencies• Monthly case

conferences1993

19951997

19992001

20032005

20072009

0100200300400500600700800900

Num

ber o

f TB

case

s

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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.

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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

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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

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Cohort Review Rotation after 1st Restructuring

Review Panel

PMD

Heartland/Homeless

Stroger/JailUptown

Englewood

West Town

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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

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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

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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

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Run NTIP

queries on

INEDSS data

Research cases

not meeting objectiv

es

Review all documentat

ion 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

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Timeline for Cohort ReviewCurrent 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

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Cohort Review with NTIPResults (NTIP Indicators)

Presentation

Cases

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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

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TB Program NTIP Results 4th Quarter 2009

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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

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Methods• Data sources

– INEDSS (76 confirmed TB cases counted for October, November, and December 2009)

– Contact Investigation Forms• Contact Report Forms (2nd sheets)• Contact Records (3rd sheets)

• Contact Investigation measures were obtained from– 2nd and 3rd sheets – INEDSS– Discussions with nurses, CDCI Supervisors, and CDCIs

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Results

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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%.

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Sputum Culture Conversion: 50.0% (10/20)Individuals who did not meet objective*

Patient Age Site Conversion? Days to convert

Reason

73 ENG Yes 91

61 PMD Yes 142

33 Stroger Yes 72

72 Stroger Yes 79

35 PMD Yes 252

48 Stroger Yes 147

41 PMD Yes 395

57 Stroger Yes 168

56 Stroger Yes 178

51 Stroger Yes 140

.

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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%

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Name Site

Patient 1 STR

Patient 2 ENG

Patient 3 ENG

Patient 4

Patient 5

Patient 6

Recommended Initial Therapy

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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%.

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Sputum Culture Conversion: 50.0% (10/20)Individuals who did not meet objective*

Patient Age Site Conversion? Days to convert

Reason

Patient 1 73 ENG Yes 91

Patient 2 61 PMD Yes 142

Patient 3 33 Stroger Yes 72








*Results were obtained after entries were revised in INEDSS.

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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%.

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Completion of Treatment: 70.6% (24/34)

Patient Age Site Did they complete?

Reason

Patient 1 61 PMD No PMD decisionPatient 2 47 Stroger No Moved: out of countryPatient 3 35 PMD No PMD decisionPatient 4 48 Stroger No Provider decisionPatient 5 49 PMD No PMD decisionPatient 6 52 PMD No PMD decisionPatient 7 37 Stroger Yes Complete, after 12 months

Patient 8 17 StrogerENG No Initially unable to locatePatient 9 56 PMD No PMD decisionPatient 10 32 Stroger No

Individuals who did not meet objective*

*Results were obtained after entries were revised in INEDSS.

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Known HIV Status• National Objective: Increase proportion of TB cases with positive or

negative HIV test results reported to 94.0%.

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Known HIV Status:Individuals who did not meet objective*

Patient Age Site Reason

Patient 1 85 ENG Not offered

Patient 2 1 WTN Not offered

Patient 3 64 PMD/WTN Refused

Patient 4 35 WTN Refused

Patient 5 81 PMD Refused

Patient 6 56 WTN Refused

Patient 7 49 PMD Not offered

Patient 8

*Preliminary results from CDC query.

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Contact Investigation (CI)

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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%

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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%

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CI: Contact Evaluation (Qtr 4 2009)Contacts who did not meet objective

Index Site Contact Age Reason

STR 50

STR 38

ENG 33 UTL

WT 31

WT 34

WT 26

ENG 66

ENG 41

ENG NA

ENG 9

ENG 31

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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%

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CI: Treatment Initiation (Qtr 4 2009)Contacts who did not start treatment

Index Site Contact Age Reason

Index 1 ENG Contact 1 38

Index 2 WT Contact 2 35 Refused

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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%

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CI: completion of treatmentContacts who did not complete treatment

Index Site Contact Age Start Regimin ReasonSTR 7 1/5/2010 Rifampin Still on Tx

STR 52 3/4/2010 Rifampin Contact chose to stop

STR 15 12/31/2009 Isoniazid Contact chose to stop




STR 40 8/19/2010 Rifampin Still on Tx

STR 31 3/10/2010 Rifampin Still on Tx

WT 38 9/16/2009 Isoniazid Contact chose to stop

UPT 50 5/18/2010 Isoniazid admin closure

UPT 27 3/23/2010 Isoniazid Still on Tx


UPT 15 5/12/2010 Rifampin Still on Tx



ENG 28 3/19/2010 Rifampin Still on Tx

ENG 34 6/15/2010 Rifampin Still on Tx

WT 56 1/19/2010 Rifampin Contact chose to stop

WT 53 4/5/2010 Rifampin UTL

WT 58 1/5/2010 Rifampin Still on Tx

WT 48 7/19/2010 Rifampin Still on Tx

WT 64 1/5/2010 Rifampin UTL

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Summary CI Results (for Sputum Smear Positive cases only)

NTIP Measure Qtr 3 2009 (N=13) Qtr 4 2009 (N=19) National Target

Contact Elicitation 100% 100% 100%

Contact Evaluation 88.1% (81/92) 78.8% (89/113) 93%

Treatment Initiation 96.2% (25/26) 95.1% (39/41) 88%

Treatment Completion 60% (15/25) 41% (16/39) 79%

Likely to complete 68% (17/25) 71.8% (28/39)

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Future Directions• INEDSS

– New cohort list (1st 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 2nd and 3rd sheets for accuracy

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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

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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

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Thanks

Questions?

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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

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Acknowledgements• TB program staff

– Especially those who diligently enter all patient information into INEDSS!

• Margarita Reina, Epidemiologist III• Peter Ward (IDPH)

Evolution of Cohort Review Chicago

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