The Cohort Review Process The Cohort Review Process

Kim Field RN, MSNWA State DOH

Tuberculosis Program

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

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.

 

“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

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

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

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

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

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

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

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.

Implementation of Cohort Review in Washington

34 Local Health Jurisdictions (LHJs) for 39 counties – all counties participated in training

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

Detailed Case Review

Facilitators ask questions to make sure that:

• Details are consistent

• Regimen is appropriate

• Treatment is completed

• Contact investigation is thorough

Timeline1ST QUARTER 

JAN FEB MAR

2ND QUARTER 

APR MAY JUN

3RD QUARTER 

JUL AUG SEP

4TH QUARTER 

OCT NOV DEC

1ST QUARTER 

JAN FEB MAR

2ND 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

1st 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 1st quarter

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

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

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

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 2nd 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

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

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

Modifications:Timeliness Measures for Contacts

Average number of days: Sputum smear + and

cavitary CXR to date contacts identified

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)

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

HIV Test Not Offered, Missing or Unknown TPCHD 1999-2008

0

5

10

15

20

25

30

35

40

1999 2000 2003 2004 2005 2006 2007 2008

Year

Perc

en

tag

e o

f R

VC

T

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

Impact of Cohort Review: DOT

• 2000 - DOT done on 76.9% of all cases • 2007 – DOT done on 92% of all cases (100% smear+)

TB Cases With DOT TPCHD 1999-2007

0

20

40

60

80

100

120

1999 2000 2003 2004 2005 2006 2007

Year

Perc

en

tag

e o

f R

VC

T

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

Timeliness Measure: Reporting - LHJ to DOH

-0.50

0.00

0.50

1.00

1.50

2.00

2.50

2003 2007

Year

Ave

rag

e N

um

ber

of

Day

s (M

ean

)

Impact of Cohort Review: Treatment Completion for Contacts

20032007

Smear +

Smear -/Culture +

0

10

20

30

40

50

60

70

80

Year

Percentage of Infected Contacts Who Completed Treatment TPCHD

Example Cohort Summary: CasesSeattle & 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

Example Cohort Summary: CasesSeattle & 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

Example Cohort Summary: ContactsSeattle & 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 cases123 contacts total

Example Cohort Summary: ContactsSeattle & 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

Impact of Cohort Review

• Washington State

Impact of Cohort Review in WA State:

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

Impact of Cohort Review in WA State:Contacts Identification

NTIP Process

• Goals and Objectives• Importance and rationale for objective• Local level implication• Program performance• Challenges and Successes

NTIP: 4-drug regimen

NTIP: 12-month completion

Selected National TB Program Objectives

Objective Categories Objectives 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 reporting Increase the proportion of culture-positive TB cases with initial drug-susceptibility results reported

>95% 100% 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/A 61.5% 73.7 Y

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/A 93.4% 97.4% Y

Known HIV status Increase 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/A 95.7% 96.0% Y

Selected National TB Program Objectives

Objective Categories Objectives and Performance Targets

WA State 2010 Target

NTIP Performance

Target

PHSKC(4th qtr 2008)

NTIP Target Met?

Contact Elicitation Increase the proportion of TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited

84% 100% 100% Y

Contact Evaluation Increase 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

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

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

Summary Measurable improvement in meeting local,

state and national TB objectives through the use of the cohort process

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!

• 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/

CohortPresentation.pdf• http://www.doh.wa.gov/cfh/TB/Manual/Forms/

CohortDictionary.pdf• http://www.cdc.gov/tb/pubs/cohort/default.htm• http://www.cdc.gov/tb/pubs/tbfactsheets/NTIP.htm