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Evolution of Cohort Review Chicago

Juan Elias, Field Operations Manager CHICAGO DEPARTMENT OF PUBLIC HEALTH TUBERCULOSIS CONTROL Webinar November 10 th , 2010. Evolution of Cohort Review Chicago. Cohort review is a systematic review of the management of patients with TB disease and their contacts. .

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Evolution of Cohort Review Chicago

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  1. Juan Elias, Field Operations Manager CHICAGO DEPARTMENT OF PUBLIC HEALTH TUBERCULOSIS CONTROL Webinar November 10th, 2010 Evolution of Cohort ReviewChicago

  2. Cohort review is a systematic review of the management of patients with TB disease and their contacts.  DefinitionUnderstanding the TB Cohort Review Process: Instruction Guide

  3. Details regarding the management and outcomes of TB Cases Patient’s clinical status Patient’s treatment outcome Adequacy of the medication regimen Treatment adherence or completion Results of contact investigation Percentage of contacts who did, or are likely to, complete treatment.

  4. Traditional Cohort Review Approach

  5. Cohort Review Roles Understanding the TB Cohort Review Process: Instruction Guide (2006) Chicago Cohort Review Roles 2010 Medical Reviewers (2) TB Program Mgr CI Supervisor Data Analyst Presenters resent Case Mgr DOT Wkr Sup CDCI CDCI

  6. 202 Cases in 2009 • 2 city clinics • 3 subcontract agencies • Monthly case conferences TB in Chicago

  7. Each of our sites perform monthly case conferences that are an interactive detailed review of TB cases and contact investigations. Case conferences average 2 to 3 hours per session. Monthly Case Conferences

  8. History of Cohort Review in Chicago • Started June 2005 as quarterly • Originally modeled after New York • Every case for quarter systematically reviewed • Used NY Presentation forms as a template • Forms completed and submitted by presenters prior to cohort day for reviewers • Presenters consist of Case managers, Contact Investigators and DOT Workers • Case reviewed and concerns addressed by TB Medical Director, Program Mgr., Data Analyst and CI Supervisors • Data simultaneously entered into excel spreadsheet

  9. History of Cohort Review in Chicago (2) • Mandatory full day for all staff • Data analyzed and results presented the same day • Feedback from staff • Staff were on board • Long and tiring • Most prep work was being done a few days prior to cohort day

  10. Cohort Review Rotation after 1st Restructuring

  11. First Restructuring of Cohort Review • Simplification of forms • Staff only required to attend only for their cases (Scheduled sites to present cases) • Results emailed few days later • Feedback • Unclear how differed from monthly case conference • Limited utility for staff • Prep work still done few days prior to cohort • Delayed results made CR incomplete

  12. Second Restructuring Cohort Review • Started in March 2010 • NTIP Pilot Site to implement with cohort review • Goals of changes: • Decrease case conference redundancy • More meaningful and useful for staff • Identify areas for program improvement

  13. Second Restructuring Cohort Review • Utilizes NTIP Indicators • Utilized Illinois National Electronic Disease Surveillance System (INEDSS) • Web-based reporting system required by state • Consolidated databases • Mainly focuses only on cases not meeting objectives

  14. Data Flow for Cohort Review Cohort list generated from INEDSS and sent to field staff Field staff update INEDSS CDPH generates final line list of cases not meeting objectives

  15. Timeline for Cohort Review Next cohort Current cohort Data cleaning Month 1 Month 2 Update data in INEDSS Case list for next cohort given to field staff Final data cleaning Generate final NTIP measure results (% and line line of cases not meeting NTIP objectives Generate line list of cases not meeting NTIP objectives

  16. Cohort Review with NTIP

  17. Cohort Day • Mandatory for all staff • First half of day discussions • Cases not meeting NTIP objectives • Challenging cases with good outcomes • How to improve program to meet target for each objective • Second half day : Educational and Staff appreciation

  18. TB Program NTIP Results 4th Quarter 2009

  19. Purpose • Guide to evaluate TB program activities based on CDC’s National TB Program Objectives • Review patients who missed completion of objective • NTIP measures being evaluated • Recommended Initial Therapy • Sputum Culture Conversion • Completion of Treatment • Known HIV Status • Contact Investigation

  20. Methods • Data sources • INEDSS (76 confirmed TB cases counted for October, November, and December 2009) • Contact Investigation Forms • Contact Report Forms (2nd sheets) • Contact Records (3rd sheets) • Contact Investigation measures were obtained from • 2nd and 3rd sheets • INEDSS • Discussions with nurses, CDCI Supervisors, and CDCIs

  21. Results

  22. Sputum Culture Conversion • National Objective: Increase proportion of TB patients with positive sputum culture results who have documented conversion to culture-negative within 60 days of treatment initiation to 61.5%.

  23. Sputum Culture Conversion: 50.0% (10/20) Individuals who did not meet objective* .

  24. Recommended Initial Therapy 100% • National Objective: Increase proportion of patients who are started on the recommended initial 4-drug regimen when suspected of having TB disease to 93.4%.

  25. Recommended Initial Therapy

  26. Sputum Culture Conversion • National Objective: Increase proportion of TB patients with positive sputum culture results who have documented conversion to culture-negative within 60 days of treatment initiation to 61.5%.

  27. Sputum Culture Conversion: 50.0% (10/20) Individuals who did not meet objective* *Results were obtained after entries were revised in INEDSS.

  28. Completion of Treatment • National Objective: For patient with newly diagnosed TB for whom 12 months or less of treatment is indicated, increase the proportion of patients who complete treatment within 12 months to 93.0%.

  29. Completion of Treatment: 70.6% (24/34) Individuals who did not meet objective* *Results were obtained after entries were revised in INEDSS.

  30. Known HIV Status • National Objective: Increase proportion of TB cases with positive or negative HIV test results reported to 94.0%.

  31. Known HIV Status: Individuals who did not meet objective* *Preliminary results from CDC query.

  32. Contact Investigation (CI)

  33. CI: Contact Elicitation 100% 25 = Total number of cases needing contact investigation • Increase the proportion of TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited to 100.0%.

  34. CI: Contact Evaluation • Increase the proportion of contacts to sputum AFB smear-positive TB patients who are evaluated for infection and disease to 93.0%. 88.1% 143 = Total number of contacts elicited. 126 = Total number of contacts evaluated.

  35. CI: Contact Evaluation (Qtr 4 2009) Contacts who did not meet objective

  36. CI: Treatment initiation (Qtr 4 2009) • Increase the proportion of contacts to sputum AFB smear-positive TB newly diagnosed latent TB infection who start treatment to 88.0%. 95.1% 41 = Total number of LTBIs identified. 39= Total number of LTBIs who start treatment .

  37. CI: Treatment Initiation (Qtr 4 2009) Contacts who did not start treatment

  38. CI: Treatment completion (Qtr 4 2009) • For contacts to sputum AFB smear-positive TB patients who have started treatment for the newly diagnosed LTBI, increase the proportion who complete treatment to 79.0%. 39 = Total number of LTBIs who started treatment . 71.8% 16= Number of LTBIs who completed treatment . 41% 12= Number of LTBIs who are still on treatment .

  39. CI: completion of treatment Contacts who did not complete treatment

  40. Summary CI Results (for Sputum Smear Positive cases only)

  41. Future Directions • INEDSS • New cohort list (1st Qtr 2009) available now • Please check the TB program server for updated cohort roster: \\Cdph\cdphshare\TB_Program\Cohort Review Data\1st Quarter 2010 • Check 2nd and 3rd sheets for accuracy

  42. Lessons Learned • Listen to feedback from staff • Be willing to continually modify and adapt your process to meet program needs and changing technology • New cohort model • Allows more focus on cases that need attention • Provides extra time to incorporate other staff requests (ie training and education) • Allows staff to learn from other sites • Good tool for program evaluation • Less time consuming • Allows us to present results same day

  43. Future Plans • Change how contact indicators are calculated • ARPE analysis done through INEDSS • Change in contact cohort form • Challenge our program by creating new target outcomes

  44. Thanks Questions?

  45. ACKNOWLEGDEMENTS • JOSHUA JONES, M.D. CDPH Medical Director • NEHA SHAH, M.D., MPH, CDC, Chicago • BILL BOWER, MPHCharles P. Felton National TB Center at Harlem Hospital • KIM FIELD, R.N. MSN Washington State H.D. • KAI H. YOUNG, MPH, CHES, CDC, • MARGARITA REINA, MPH, Chicago Dept. Public Health • CDPH TB CONTROL PROGRAM • New York City Department of Health and Hygiene

  46. Acknowledgements • TB program staff • Especially those who diligently enter all patient information into INEDSS! • Margarita Reina, Epidemiologist III • Peter Ward (IDPH)

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