Post on 11-Feb-2016
description
Elements of theCohort Review Approach
Harvey L. Marx, Jr. Lisa SchutzenhoferTB Program Controller TB Program Manager
Reasons for Implementation
• 2005 CDC Cooperative Agreement• Increase learning• Improve case management at the
state and local levels• Use cohort review as a tool to
conduct program evaluation• Improve documentation in clinic
records
What is Cohort Review (1)• Cohort review is a systematic review of
patients with tuberculosis (TB) disease and their contacts.
• A “cohort” is a group of TB cases identified over a specific period of time, usually 3 months.
• The cases are reviewed approximately 6 months after they are reported, so that many of the patients have completed or are nearing the end of treatment.
What is Cohort Review (2)
TB cases are reviewed in a group setting with the following information presented on each case by the case manager:
• Patient's demographic information• Patient’s status: clinical, lab, radiology• Drug regimen, adherence, completion• Results of contact investigation
Individual outcomes are assessed.
What is Cohort Review (3)
Group outcomes are also assessed.
Indicators track progress toward national, state, and local program objectives.
Everyone leaves the meeting knowing the results.
Cohort Review Process• DHSS Public Health Sernior Nurses
(PHSNs) continually work with local health agencies (LHAs) to prepare for cohort review sessions
• LHA staff or CHNs will present cases• During session, TB Controller and
Program Manager ask questions and provide input
Cohort Review Process• Health Program Rep uses TIMS (or other
databases) and cohort review forms• Health Program Rep presents final
analyses of previous cohort of cases and contacts at beginning of session
• Health Program Rep presents preliminary analyses of cases being reviewed
RolesTB Program
Controller
DHSS PHSN Case Manager
TB Program Manager
LPHA Case Manager
Data Analyst
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
COHORT REVIEW SESSION
• Begin follow up on issues identified
• Continue follow up on issues identified during cohort review session
• Treatment completion rate presented for contacts of cases from previous 1st quarter
Timeline
Example of a Cohort Review Schedule
Quarter Case Identified Quarter Case Reviewed
1st (Jan-Mar 07) 3rd (Jul-Sep 07)
2nd (Apr-Jun 07) 4th (Oct-Dec 07)
3rd (Jul-Sep 07) 1st (Jan-Mar 08)
4th (Oct-Dec 07) 2nd (Apr-Jun 08)
Essential Elements
Cohort Review ProcessPreparation Presentatio
nFollow up
Essential Elements
Cohort Review ProcessPreparation1. Shared
objectives2. Case
management3. TB registry4. Preparation
of cases for presentation
Presentation Follow up
CDC National Objectives• At least 90% of confirmed TB cases will
complete treatment within 365 days• At least 90% of sputum AFB-smear positive
TB cases will have contacts identified• At least 95% of contacts to sputum AFB-
smear positive TB cases will be evaluated • At least 85% of infected contacts who are
started on treatment for latent TB infection will complete treatment within 365 days
Example of State Objectives
• Persons with TB disease will be interviewed within 3 business days of case notification.
• Contact investigations will be completed within 21 days.
Case Management
• Every TB disease case and contact in Missouri has an assigned case manager
• Staff follow written protocols for case management and contact investigation
• Supervisors communicate periodically with staff to make sure everything is proceeding OK
• All participate in case review meetings to make sure a complete job is done
TB Registry• National (TIMS) or locally developed
(.NET)database containing:– General patient information– Medical and treatment history– Contacts info and status
• Used to generate line listing:– Preliminary cohort list (5 mos. before)– Final cohort list (2 mos. before review)
Preparation of Cases for Presentation
• Starts when case is identified• Improved by
– “N visits/consultation”– case management meetings
• Use standard formats
Essential Elements
Cohort Review ProcessPreparation Presentation
1. Detailed case review
2. Immediate analysis of outcomes
Follow up
Detailed Case Review
Program Manager asks questions to make sure that:
• Details are consistent• Regimen is appropriate• Treatment is completed• Contact investigation is thorough
Collect Information
Data analysts in this cohort review!
• Analyze data on outcomes• Obtain missing or update incorrect
data
Immediate Analysis of Outcomes
• Patient is cured– Measurable result is completion of Tx– Other outcomes
• Contact investigation– Measurable results are # of contacts
identified, tested, evaluated, started, and completed Tx for LTBI
Cohort Review Indicators
• Completion index at time of review
• Completion index without MDRTB cases
• Completion index including those “Likely to Complete”
Cohort Review Indicators (2)
• DOT coverage
• Default rate
• Death rate
• Timeliness of interview
Cohort Review Indicators (3)• Contact index for pulmonary cases
• Contact evaluation index
• % contacts starting treatment
• Treatment completion index for infected contacts
Of those who had treatment discontinued:
Refused to continue treatment
Adverse reaction to treatment
Lost
Moved
Died
Contacts
Index of CompletionIf you exclude those who could not complete by today (MDRTB cases)
Formula:
____________Completed______________________# Counted - (# Reported @ death + # MDR + # Died)
Index of Completionwithout MDRTB cases
Formula: _______Completed_+_Likely to Complete________# Counted - (# Reported @ death + # MDR + # Died)
Index of Completionincluding those who are likely to complete
Formula: _____Completed_+_Likely to Complete___# Counted - (# Reported @ death + # Died)
Death Rate:(# Died + # Reported @ Death)
# Counted
Default Rate:_______________ # Lost_______________
(# Counted - # Died - # Reported @ Death)
Total Cohort Failure Rate______(# Lost + # Cohort Failures)_______ (# Counted - # Died - # Reported @ Death)
Essential Elements
Cohort Review ProcessPreparation Presentatio
nFollow up1. Timely follow up of identified problems
Timely Follow Up of Identified Problems
Different items need follow up by:• Supervisors, nurses and case
managers• TB Program Manager• Data Analyst
Six Case Presentations
• Typical Case• Likely to Complete• Died• Completion after 365 Days• Source Case Investigation• The Global Village
“A Typical Case”
Key Points
• Contacts with documented history of prior positive TST are evaluated but not re-tested.
• Use twice weekly DOT when possible
“Likely to Complete”
Key Points
• Patients likely to complete treatment within 365 days have actual outcomes reviewed at a future presentation
• Contacts of extra-pulmonary cases not obtained
“Died”
Key Point
• Despite death of patient, contact investigation still conducted
“Completion after 365 Days”
Key Points
• Treatment must be completed 365 days of start on 2 anti-TB meds
• Still responsible for case despite patient moving to another jurisdiction
• Importance of interstate follow-up
“Source Case Investigation”
Key Point
• All children have source case/contact investigations conducted
“The Global Village”
Key Points
• More foreign-born TB patients coming to Missouri to receive treatment
• Notification of airlines and expanded contact tracing needed sometimes
• Cases with MDRTB removed from the calculations, as they cannot complete treatment 365 days
Cohort Review Approach
• Most important meeting of TB program• Low tech, can be done by hand• Closely linked to CDC objectives• Group process• Every one leaves meeting knowing results
(or soon afterwards)• Teaching opportunity• Gives TB Program a sense of current
issues