1. Cohort Review in Arizona
Ayesha Bashir, M.D., M.P.H.
Arizona Department of Health Services
Tuberculosis Control Program

2. Objectives
Identify cohort review methods used by Arizona Department of Health Services (ADHS)
Data collection & review processes
Lessons learned
Benefits of cohort review

3. 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.

4. Response

5. Arizona Cohort Review 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.

6. Three Regions Northern Region
Apache, Coconino, Mohave, Navajo, Yavapai
Southern Region
Cochise, La Paz, Pima, Santa Cruz, Yuma
Central Region
Gila, Graham, Greenlee, Maricopa, Pinal

7. Northern & Southern 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.

8. 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.

9. 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.

10. Timelines for Cohort Review
Date Of
Cohort review
meeting
January
2011
April
July
October
Quarter in which
Cases were Counted
Thru
June
2010
September
December
March

11. NTIP and State Objectives for Cohort Review
Completion of treatment
Directly Observed Therapy
Sputum culture results reported for pulmonary cases
Recommended 4 drug therapy
HIV status
Treatment initiation within 7 days for smear positive cases
Sputum conversion within 60 days

12. Data Summaries Age at report Country of Origin Month/Year Arrived
Site of Disease
Laboratory results
CXR results
TST/IGRA results
Correctional resident
Contact Investigation
Number identified
Number evaluated
Number of new LTBIs
Number started on treatment
Number completing treatment
Source case identification
Epi-linked case identification

13. Preparation LHDs ADHS 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

14. Preparation: 1 month prior to cohort review
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 14

15. Preparation: 2 weeks prior to cohort review
Order of case presentations determined by ADHS.
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.

16. 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.

17. Arizona Cohort Review Meeting
ADHS TB Nurse reviews cohort review objectives and process.
ADHS Surveillance Epidemiologist
Review of National Objectives.
Provides comparison of cohort review data summaries to National Objectives.
Contact Investigation summaries.
LHD case manager presents case and contact investigation results.

18. Arizona Cohort Review Meeting
ADHS and LHDs discussion follows each case presentation:
Resolution of data conflicts
Review of contact investigation results
Flag items for follow-up after review
Discussion open to all attendees.
Provides educational opportunities 18

19. Follow-up Activities 1 week following the review:
ADHS distributes updated data analysis of cohort:
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. 19

20. Data Collection and Analysis

21. Cohort Review Form Fillable PDF form. ADHS revises form as needed.
No personal identifiers
State case number and initials
ADHS revises form as needed.
Has been revised after each cohort review
Original form was created based on Colorado, Utah, and Washington’s forms.

22. Cohort Review Form

23. Data Collection & Analysis
RVCT data extracted from eRVCT data to EXCEL spreadsheet.
Fields added for national objectives based on NTIP calculations.
Fields added for contact investigation results.
Formulas to evaluate national objectives.

24. Summary Spreadsheet

25. Data Collection and Analysis
Conflicts between cohort review form and RVCT data:
Conflicts are annotated on cohort review form
Discussed during case presentation
Additional verification requested from LHD
eRVCT data updated as needed

26. Data Collection and Analysis
Contact Investigations.
Contact investigation data added to spreadsheet
Results discussed during cohort review.
Appropriateness of contact investigation
Contact investigations expanded when necessary
Discussion of obstacles encountered during investigations and LTBI treatment completion
Ensure ADHS received contact investigation results for ARPE reporting

27. 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

28. Cohort Review vs Case Reviews
Retrospective
Real time
Review of: Case management
Current case management review
Patient outcomes (COT)
Status of patient
Contact investigations results
Status of contact investigation
Identify variances or progress

29. Lessons Learned Ensure case presentations follow the agenda!
Chaos ensues if counties present in “their own order”.
Slows pace of cohort review if you have to fish for forms and case files.

30. Lessons Learned Preparation and follow-up are time consuming.
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.

31. 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
Additional RVCT training provided to new staff at LHDs.

32. Lessons Learned Obtained missing information:
HIV results
TST results
Country of Origin and Month/year arrived
Identification of source cases and epi-linked cases
Several instances of reported cases being ruled out by LHDs after ADHS submitted to CDC.

33. Benefits of Cohort Review
Arizona RVCT data completion has improved and more accurate.
Improved communication between ADHS and LHD staff.
Increases accountability of LHD staff.
Obstacles identified for completion of treatment and contact investigations.

34. 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.

35. ….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.”

36. Questions