Presentation on theme: "Cohort Review in Arizona"— Presentation transcript:
1Cohort Review in Arizona Ayesha Bashir, M.D., M.P.H.Arizona Department of Health ServicesTuberculosis Control Program
2ObjectivesIdentify cohort review methods used by Arizona Department of Health Services (ADHS)Data collection & review processesLessons learnedBenefits of cohort review
3Cohort 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.
5Arizona 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.
6Three Regions Northern Region Apache, Coconino, Mohave, Navajo, YavapaiSouthern RegionCochise, La Paz, Pima, Santa Cruz, YumaCentral RegionGila, Graham, Greenlee, Maricopa, Pinal
7Northern & 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.
8Central RegionMaricopa 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.
9Arizona Tribal LHDsArizona’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.
10Timelines for Cohort Review DateOfCohort reviewmeetingJanuary2011AprilJulyOctoberQuarter in whichCases were CountedThruJune2010SeptemberDecemberMarch
11NTIP and State Objectives for Cohort Review Completion of treatmentDirectly Observed TherapySputum culture results reported for pulmonary casesRecommended 4 drug therapyHIV statusTreatment initiation within 7 days for smear positive casesSputum conversion within 60 days
12Data Summaries Age at report Country of Origin Month/Year Arrived Site of DiseaseLaboratory resultsCXR resultsTST/IGRA resultsCorrectional residentContact InvestigationNumber identifiedNumber evaluatedNumber of new LTBIsNumber started on treatmentNumber completing treatmentSource case identificationEpi-linked case identification
13Preparation LHDs ADHS Complete cohort review from medical chart Complete cohort review from RVCT dataCase review including contact investigation resultsCompare LHD cohort form with ADHS data to identify conflicting dataCohort review forms are submitted to ADHS 2 weeks prior to review.Team review of cases and case managementPrepare case presentations for cohort reviewPrepare summary of cohort data and PDF’s of cohort forms for LHDs prior to review.Begins the day a TB case is reported
14Preparation: 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 case14
15Preparation: 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.
16Preparation: 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.
17Arizona Cohort Review Meeting ADHS TB Nurse reviews cohort review objectives and process.ADHS Surveillance EpidemiologistReview 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.
18Arizona Cohort Review Meeting ADHS and LHDs discussion follows each case presentation:Resolution of data conflictsReview of contact investigation resultsFlag items for follow-up after reviewDiscussion open to all attendees.Provides educational opportunities18
19Follow-up Activities 1 week following the review: ADHS distributes updated data analysis of cohort:Summary of cohort reviewNTIP indicators and resultsADHS TB Control Section objectivesADHS and the LHD case managers ensure follow-up case management activities identified are fulfilled.19
21Cohort Review Form Fillable PDF form. ADHS revises form as needed. No personal identifiersState case number and initialsADHS revises form as needed.Has been revised after each cohort reviewOriginal form was created based on Colorado, Utah, and Washington’s forms.
23Data 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.
25Data Collection and Analysis Conflicts between cohort review form and RVCT data:Conflicts are annotated on cohort review formDiscussed during case presentationAdditional verification requested from LHDeRVCT data updated as needed
26Data Collection and Analysis Contact Investigations.Contact investigation data added to spreadsheetResults discussed during cohort review.Appropriateness of contact investigationContact investigations expanded when necessaryDiscussion of obstacles encountered during investigations and LTBI treatment completionEnsure ADHS received contact investigation results for ARPE reporting
27Lessons LearnedResistance 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
28Cohort Review vs Case Reviews RetrospectiveReal timeReview of: Case managementCurrent case management reviewPatient outcomes (COT)Status of patientContact investigations resultsStatus of contact investigationIdentify variances or progress
29Lessons 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.
30Lessons Learned Preparation and follow-up are time consuming. Case file reviewData entry for EXCEL file and analysisADHS 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.
31Lessons LearnedA substantial number of RVCTs reported incomplete laboratory results or incorrect information.Private or commercial laboratory results obtained by the LHD and not to ADHSRVCTs filled out incorrectlyAdditional RVCT training provided to new staff at LHDs.
32Lessons Learned Obtained missing information: HIV resultsTST resultsCountry of Origin and Month/year arrivedIdentification of source cases and epi-linked casesSeveral instances of reported cases being ruled out by LHDs after ADHS submitted to CDC.
33Benefits 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.
34Benefits 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.”