Surveillance Data in Action: Tuberculosis Indicators Melissa Ehman, MPH Tuberculosis Control Branch (TBCB) Division of Communicable Disease Control Center 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 Liaison Epidemiologist Fiscal Analyst LOCAL TIP TEAM TB Controller Program Manager Epidemiologist Staff

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 Indicators Identification 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 Indicator Report sss

Culture Conversion TIP Indicator Methods

Culture Conversion TIP Indicator Goal, 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 Process 1.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 Therapy1- 3% Recommended Initial Therapy10% Timely Reporting2+ 9% Complete Reporting1+ 12% Timely Completion of Therapy3+ 13% Pediatric TB3+ 14% Contact Evaluation3+ 16% Culture Conversion3+ 23% Inappropriate SAT1+ 68% Appropriate DOT3+ 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 ( –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 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 Indicators for 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 Testing from 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) On-line TIP reports, national TB indicators, objective setting Melissa Ehman, MPH Lead TIP Epidemiologist (510)

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