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

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

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.

Response

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.

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

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.

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.

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.

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

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

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

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

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

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.

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.

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.

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

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

Data Collection and Analysis

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.

Cohort Review Form

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.

Summary Spreadsheet

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

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

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

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

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.

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.

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.

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.

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.

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.

….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.”

Questions