COHORT REVIEW: Principles and Models The TB Cohort Review Process Manchester, NH June 16, 2010

Cooperative Agreement Activities for Program Evaluation: To improve TB case management and program accountability and feedback, the grantees should hold quarterly cohort reviews at the state or local levels or both. Cohort reviews are integral to TB control and they provide a systematic review of the management of cases and contact investigations.

Instruction Guide Instructions on cohort reviews, definitions, roles of staff, timelines, core elements, and guidance on tailoring the process to your program are published in the CDC document, "Understanding the TB Cohort Review Process: Instruction Guide.“ lkits/cohort/Cohort.pdf

Cooperative Agreement Also refer to International Journal of Tuberculosis and Lung Disease, 2006 October, 10(10) ; Title “Ensuring accountability: the contribution of the cohort review method to TB control in NYC”, New York City Department of Health and Mental Hygiene, New York, New York, USA. Grantees should report the progress on conducting cohort reviews, including number of cases discussed, key issues identified during these cohort reviews and recommendations provided. Additionally progress on implementing these recommendations should also be included in the progress reports

Definitions Cohort Review: A systematic review of the management of patients with TB disease and their contacts. A “cohort” is a group of TB cases counted over a specific period of time, usually 3 months. TB cases are reviewed for the patient’s clinical status, the adequacy of the medication regimen, treatment adherence or completion, and the results of contact investigation Case Review: A part of case management. Systematic regular review of patient progress presented by the health department employee primarily responsible for managing that case. Plans are made to address any barriers to adherence.

Principles and Process Systematic review of outcomes Patients with disease and their contacts Confirmed cases counted over a period of time Review clinical status, adequacy of medication regimen, treatment adherence or completion, results of contact investigation – and timeliness measures if so desired Immediate analysis and feedback to group Compare to national and local objectives

What is reviewed? (1) TB cases are reviewed in a group setting with the following information presented on each case by the case manager: Patient's demographic information Patient’s status: clinical, lab, radiology Drug regimen, adherence, completion Results of contact investigation Individual outcomes are assessed.

What is reviewed? (2) Group outcomes are also assessed. Indicators track progress toward national, state, and local program objectives. Everyone leaves the meeting knowing the results.

Roles Roles of staff are detailed in the CDC Instruction Guide: TB Program Manager Medical Director Epidemiologist/Data Analyst Supervisor Case Managers

Timeline Example of a Cohort Review Schedule Quarter Case IdentifiedQuarter Case Reviewed 1 st (Jan-Mar 09)4 th (Oct-Dec 09) 2 nd (Apr-Jun 09)1 st (Jan-Mar 10) 3 rd (Jul-Sep 09)2 nd (Apr-Jun 10) 4 th (Oct-Dec 09)3 rd (Jul-Sep 10)

Three Steps PREPARATION PRESENTATION FOLLOW-UP

Cookie cutter or a set of principles? Cohort Review is NOT a cookie cutter approach!

Every program area is different, but the principles remain the same.

Current Models of the TB Cohort Review Process Face-to-face More feasible in higher incidence areas (e.g. Chicago, Columbus, New York, Philadelphia, Washington, and certain counties) Face-to-face interactive meeting to review all TB cases reported in city or county in a given quarter. Concise standardized presentations by front line staff to program directors and clinicians. Immediate feedback, teaching, and analysis of outcomes. Systematic follow up. Requires a large enough meeting room. Remote More feasible in lower incidence program areas (e.g. Missouri) Real-time interactive meeting to review all TB cases reported in program area in a given quarter. Concise standardized presentations by front line staff to program directors and clinicians. Immediate feedback, teaching, and analysis of outcomes. Systematic follow up. Requires good internet, telephone or telemedicine connections. Hybrid Appropriate for lower- or medium-incidence state with a higher incidence area (e.g. Washington State) Series of meetings to review all TB cases reported in state in a given quarter: 1) Face-to-face interactive meeting in the higher incidence city/county. 2) Real-time interactive conference call presentations by nurse case managers to program directors. Immediate feedback. Outcomes analyzed later. Systematic follow up. Requires good internet, telephone or telemedicine connections. Paper-based (e.g. Boston, States of Massachusetts and New York) State/City TB Program officials review records of all TB cases reported in a give quarter. Front line staff do not participate directly. Outcomes analyzed later. Systematic follow up. May be done in city or state capital, or state officials may visit regional sites. Case reviews (many programs) TB Program officials call case review meeting to discuss all relevant aspects of current cases. These are not cohort reviews.

One size does not fit all! Approach must be tailored to account for urban areas and program size.

Who is doing it? CountyCityState

CITIESCOUNTIESSTATES Boston, MABucks, PAColorado (conf call) Chicago, ILFulton, GA (disc) Kansas (conf call) Columbus, OHNassau, NY (2x/yr) Massachusetts New York, NYRockland, NY (disc) Missouri (telemed) Philadelphia, PASan Francisco, CANew York (6 regions) Washington, DCSanta Clara, CAOregon (conf call) Utah (2x/yr) Quarterly face-to-face Washington (hybrid)

Niagara Monroe Suffolk Nassau Rockland New York City Chautauqua Cattaraugus Allegany Wyoming Genesee Orleans Livingston Wayne Ontario Yates Schuyler Steuben Chemung Seneca Tompkins Broome Cortland Cayuga Onondaga Oswego Lewis Madison Chenango Otsego Delaware Herkimer Fulton Montgomery Schoharie Greene Columbia Albany Rensselaer Schenectady Saratoga Warren Hamilton Sullivan Ulster Dutchess Jefferson St Lawrence Franklin Clinton Essex Orange Putnam Oneida Erie Tioga Westchester Queens New York Washington       Rev. 4/8/05 Bronx Richmond  Kings  Bureau of Tuberculosis Control County and Regional Assignments by TB Representative Syracuse Rochester Buffalo New York City Troy New Rochelle Hauppauge

Is this in our future?