Surveillance Data in Action:Tuberculosis Indicators

Melissa Ehman, MPHTuberculosis Control Branch (TBCB)

Division of Communicable Disease ControlCenter for Infectious Diseases

California Department of Public Health

October 15, 2008

Objectives

• Review California TB indicators

• Consider indicators relevant to HIV/TB

• Discuss possible next steps in developing cross-cutting indicators

TB Indicators Project (TIP)• Partnership between TBCB and TB programs of

the 16 local health departments (LHDs) with the highest TB morbidity

• Formal process for using indicators to evaluate and improve program performance

• Implemented beginning in 2000

STATE TIP TEAM

Program LiaisonEpidemiologistFiscal Analyst

LOCAL TIP TEAM

TB ControllerProgram Manager

EpidemiologistStaff

How Did We Create Indicators? • Defined goal areas• Reviewed standards• Identified available data sources• Developed indicators• Assessed indicators according to set criteria:

– Ethical– Useful– Representative– Understandable– Data Accessible– Robust (Valid)– Reliable

• Set objectives

TIP IndicatorsIdentification and Reporting• TB Case Rate• Timely Reporting• Complete Reporting• Culture Identification

Completion of Therapy• Recommended Initial Therapy• Timely Treatment• Culture Conversion• Appropriate DOT• Inappropriate SAT• Timely Completion of Therapy• Not Defaulting from Treatment

Contact Investigation• Contact Identification• Contact Evaluation• Contact LTBI Treatment

Initiation• Contact LTBI Treatment

Completion

Sentinel Events• Pediatric TB Cases• TB Deaths

Infrastructure• Program Capacity (self-

assessment)

Culture Conversion TIP IndicatorReport

sss

Culture Conversion TIP Indicator Methods

Culture Conversion TIP IndicatorGoal, Indicator, Objective

• Goal C: Ensure timely completion of appropriate therapy for all persons with tuberculosis

• Indicator C3: Proportion of sputum culture-positive TB cases with documented conversion to sputum culture-negative within 90 days of initiation of treatment

• Objective: At least 70% of sputum culture-positive TB cases will have documented conversion to sputum culture-negative within 90 days of initiation of treatment, for cases counted in 2006

TIP Process1. Complete Infrastructure Self-Assessment

2. Review indicator data

3. Analyze and plan• Verify problem• Determine reasons for problem

4. Develop interventions

5. Implement interventions

6. Evaluate and reassess

TIP Benefits and Challenges• Improvements in many key areas

• Program performance• Staff capacity and communication• Data quality• TB patient care processes

• Challenges– Limitations with using TIP indicator data– Competing priorities for LHD and TBCB staff

Outcomes Summary

Indicator# of LHDs Targeting Indicator

Average Performance

Change

Contacts Completing TB Therapy 1 - 3%

Recommended Initial Therapy 1 0%

Timely Reporting 2 + 9%

Complete Reporting 1 + 12%

Timely Completion of Therapy 3 + 13%

Pediatric TB 3 + 14%

Contact Evaluation 3 + 16%

Culture Conversion 3 + 23%

Inappropriate SAT 1 + 68%

Appropriate DOT 3 + 128%

LHD Assessment of TIP

Methods

In 10 jurisdictions where long-term TIP outcome data are available, structured interviews were conducted by TBCB staff with LHD key informants.

Results

On a scale of 1 (low) to 5 (high), TIP participants reported:• Average satisfaction with results : 4.2• Average contribution of TIP to results: 3.4

Web-Based Indicator Reports

• Secure system access (www.tbdata.ca.gov)– Access to California-wide TIP reports for all users– For TIP participants, access to individual county

reports

• System always available

• Tailored reports– By year– By indicator

• Data updated several times per year

CDC’s Proposed TB Indicators

• A set of indicators will be included in the TB Cooperative Agreements for new funding period 2010-2014

• Several prioritized indicators will be visualized in a web-based system modeled on the TIP online reports, starting 2009

• One new TB indicator intersects with HIV:Increase the proportion of TB cases with

positive or negative HIV test result reported to 88.7% by 2015

Possible HIV/TB Indicatorsfor Discussion

HIV Testing of Persons with TB

• TB cases alive at diagnosis with positive or negative HIV test result reported

TB Testing of Persons with HIV

• HIV cases alive at diagnosis with positive or negative TB test result reported

Rationale for Testingfrom white paper by the National TB Controllers Association

• HIV testing of TB patients, suspects and contacts: – Detect new HIV infections– Improved outcomes for TB patients with HIV– Make referrals to HIV care and support services– Initiate and coordinate TB and HIV treatment– Prioritize contacts for TB investigation– Educate patients about TB/HIV

• TB testing of known HIV-infected patients, and treatment of TB and LTBI:– Prevent transmission among a highly vulnerable population and

prevent future TB disease– Educate patients about risks and consequences of TB

Next Steps

• Do we agree on the need for indicators?

• Discuss possible indicators

• What are the next steps to being able to measure them?

Want More Information?

General questions about TIP and TIP implementation

Anne Cass, MPH

TIP Coordinator

(619) 692-8642

Anne.cass@cdph.ca.gov

On-line TIP reports, national TB indicators, objective setting

Melissa Ehman, MPH

Lead TIP Epidemiologist

(510) 620-3039

Melissa.ehman@cdph.ca.gov

Acknowledgements

• Local health department staff participating in TIP

• TB Control TIP staff: David Beers, Anne Cass, Bryan Faulstich, Jennifer Flood, Michael Joseph, Lisa Pascopella, Gayle Schack, Stephanie Spencer, Joan Sprinson, Lisa True, Jan Young

• Division of TB Elimination Evaluation Workgroup, CDC