1. Elements of the Cohort Review Approach Harvey L. Marx, Jr. Lisa Schutzenhofer TB Program Controller TB Program Manager

2. Reasons for Implementation 2005 CDC Cooperative Agreement Increase learning Improve case management at the state and local levels Use cohort review as a tool to conduct program evaluation Improve documentation in clinic records

3. What is Cohort Review (1) Cohort review is a systematic review of patients with tuberculosis (TB) disease and their contacts. A “cohort” is a group of TB cases identified over a specific period of time, usually 3 months. The cases are reviewed approximately 6 months after they are reported, so that many of the patients have completed or are nearing the end of treatment.

4. What is Cohort Review (2) 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.

5. What is Cohort Review (3) Group outcomes are also assessed. Indicators track progress toward national, state, and local program objectives. Everyone leaves the meeting knowing the results.

6. Cohort Review Process DHSS Public Health Sernior Nurses (PHSNs) continually work with local health agencies (LHAs) to prepare for cohort review sessions LHA staff or CHNs will present cases During session, TB Controller and Program Manager ask questions and provide input

7. Cohort Review Process Health Program Rep uses TIMS (or other databases) and cohort review forms Health Program Rep presents final analyses of previous cohort of cases and contacts at beginning of session Health Program Rep presents preliminary analyses of cases being reviewed

8. Roles

9. Timeline 1 ST QUARTER JAN FEB MAR 2 ND QUARTER APR MAY JUN 3 RD QUARTER JUL AUG SEP 4 TH QUARTER OCT NOV DEC 1 ST QUARTER JAN FEB MAR 2 ND QUARTER APR MAY JUN TB cases identified Treatment started Contact investigation initiated Ongoing treatment of patients with TB disease Contacts evaluated and started on treatment, as necessary TB disease treatment completed Infected contacts continue on treatment for LTBI 1 st quarter contacts complete treatment COHORT REVIEW SESSION Begin follow up on issues identified Continue follow up on issues identified during cohort review session Treatment completion rate presented for contacts of cases from previous 1 st quarter

10. Timeline Example of a Cohort Review Schedule Quarter Case IdentifiedQuarter Case Reviewed 1 st (Jan-Mar 07) 3rd (Jul-Sep 07) 2 nd (Apr-Jun 07) 4th (Oct-Dec 07) 3 rd (Jul-Sep 07) 1st (Jan-Mar 08) 4 th (Oct-Dec 07) 2nd (Apr-Jun 08)

11. Essential Elements Cohort Review Process PreparationPresentationFollow up

12. Essential Elements Cohort Review Process Preparation 1.Shared objectives 2.Case management 3.TB registry 4.Preparation of cases for presentation PresentationFollow up

13. CDC National Objectives At least 90% of confirmed TB cases will complete treatment within 365 days At least 90% of sputum AFB-smear positive TB cases will have contacts identified At least 95% of contacts to sputum AFB- smear positive TB cases will be evaluated At least 85% of infected contacts who are started on treatment for latent TB infection will complete treatment within 365 days

14. Example of State Objectives Persons with TB disease will be interviewed within 3 business days of case notification. Contact investigations will be completed within 21 days.

15. Case Management Every TB disease case and contact in Missouri has an assigned case manager Staff follow written protocols for case management and contact investigation Supervisors communicate periodically with staff to make sure everything is proceeding OK All participate in case review meetings to make sure a complete job is done

16. TB Registry National (TIMS) or locally developed (.NET)database containing: –General patient information –Medical and treatment history –Contacts info and status Used to generate line listing: –Preliminary cohort list (5 mos. before) –Final cohort list (2 mos. before review)

17. Preparation of Cases for Presentation Starts when case is identified Improved by –“N visits/consultation” –case management meetings Use standard formats

18. Essential Elements Cohort Review Process Preparation Presentation 1.Detailed case review 2.Immediate analysis of outcomes Follow up

19. Detailed Case Review Program Manager asks questions to make sure that: Details are consistent Regimen is appropriate Treatment is completed Contact investigation is thorough

20. Collect Information Data analysts in this cohort review! Analyze data on outcomes Obtain missing or update incorrect data

21. Immediate Analysis of Outcomes Patient is cured –Measurable result is completion of Tx –Other outcomes Contact investigation –Measurable results are # of contacts identified, tested, evaluated, started, and completed Tx for LTBI

22. Cohort Review Indicators Completion index at time of review Completion index without MDRTB cases Completion index including those “Likely to Complete”

23. Cohort Review Indicators (2) DOT coverage Default rate Death rate Timeliness of interview

24. Cohort Review Indicators (3) Contact index for pulmonary cases Contact evaluation index % contacts starting treatment Treatment completion index for infected contacts

25. Of those who had treatment discontinued: Refused to continue treatment Adverse reaction to treatment Lost Moved Died Contacts

26. Index of Completion If you exclude those who could not complete by today (MDRTB cases) Formula: ____________Completed______________________ # Counted - (# Reported @ death + # MDR + # Died)

27. Index of Completion without MDRTB cases Formula: _______Completed_+_Likely to Complete________ # Counted - (# Reported @ death + # MDR + # Died)

28. Index of Completion including those who are likely to complete Formula: _____Completed_+_Likely to Complete___ # Counted - (# Reported @ death + # Died)

29. Death Rate: (# Died + # Reported @ Death) # Counted Default Rate: _______________ # Lost_______________ (# Counted - # Died - # Reported @ Death) Total Cohort Failure Rate ______(# Lost + # Cohort Failures)_______ (# Counted - # Died - # Reported @ Death)

30. Essential Elements Cohort Review Process PreparationPresentation Follow up 1. Timely follow up of identified problems

31. Timely Follow Up of Identified Problems Different items need follow up by: Supervisors, nurses and case managers TB Program Manager Data Analyst

32. Six Case Presentations Typical Case Likely to Complete Died Completion after 365 Days Source Case Investigation The Global Village

33. “A Typical Case”

34. Key Points Contacts with documented history of prior positive TST are evaluated but not re-tested. Use twice weekly DOT when possible

35. “Likely to Complete”

36. Key Points Patients likely to complete treatment within 365 days have actual outcomes reviewed at a future presentation Contacts of extra-pulmonary cases not obtained

37. “Died”

38. Key Point Despite death of patient, contact investigation still conducted

39. “Completion after 365 Days”

40. Key Points Treatment must be completed  365 days of start on  2 anti-TB meds Still responsible for case despite patient moving to another jurisdiction Importance of interstate follow-up

41. “Source Case Investigation”

42. Key Point All children have source case/contact investigations conducted

43. “The Global Village”

44. Key Points More foreign-born TB patients coming to Missouri to receive treatment Notification of airlines and expanded contact tracing needed sometimes Cases with MDRTB removed from the calculations, as they cannot complete treatment  365 days

45. Cohort Review Approach Most important meeting of TB program Low tech, can be done by hand Closely linked to CDC objectives Group process Every one leaves meeting knowing results (or soon afterwards) Teaching opportunity Gives TB Program a sense of current issues