evolution of cohort review chicago
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Chic
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
EVOLUTION OF COHORT REVIEWCHICAGO
Juan Elias, Field Operations Manager
CHICAGO DEPARTMENT OF PUBLIC HEALTHTUBERCULOSIS CONTROL
WebinarNovember 10th, 2010
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Richard M. DaleyMayor
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DEFINITIONUNDERSTANDING THE TB COHORT REVIEW PROCESS: INSTRUCTION GUIDE
Cohort review is a systematic review of the management of patients with TB
disease and their contacts.
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• 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.
Details regarding the management and outcomes of TB Cases
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Traditional Cohort Review Approach
Presentation
TB
Cohort Cases
4
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resent
Cohort Review Roles
Medical Reviewer
s (2)
CISupervisor
TB Program
Mgr
Data Analyst
CDCICase Mgr
DOTWkr
Presenters
Understanding the TB Cohort Review Process: Instruction Guide (2006)
Chicago Cohort Review Roles 2010
Sup CDCI
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TB IN CHICAGO
• 202 Cases in 2009
• 2 city clinics• 3 subcontract
agencies• Monthly case
conferences1993
19951997
19992001
20032005
20072009
0100200300400500600700800900
Num
ber o
f TB
case
s
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MONTHLY CASE CONFERENCES
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.
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
Cohort Review Rotation after 1st Restructuring
Review Panel
PMD
Heartland/Homeless
Stroger/JailUptown
Englewood
West Town
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
Run NTIP
queries on
INEDSS data
Research cases
not meeting objectiv
es
Review all documentat
ion for cases and contacts
Update data in INEDSS
Data Flow for Cohort Review
14
CDPH generates final line list of
cases not meeting objectives
Cohort list generated from INEDSS and sent
to field staff
Field staff update INEDSS
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Richard M. DaleyMayor
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Timeline for Cohort ReviewCurrent cohort
Next cohort
Case list for next cohort given to field staff
Month 1 Month 2
Generate line list of cases not meeting NTIP objectives
Final data cleaning
Generate final NTIP measure results (% and line line of cases not meeting NTIP objectives
Update data in INEDSS
Data cleaning
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Richard M. DaleyMayor
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Cohort Review with NTIPResults (NTIP Indicators)
Presentation
Cases
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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TB Program NTIP Results 4th Quarter 2009
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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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
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Results
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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%.
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Sputum Culture Conversion: 50.0% (10/20)Individuals who did not meet objective*
Patient Age Site Conversion? Days to convert
Reason
73 ENG Yes 91
61 PMD Yes 142
33 Stroger Yes 72
72 Stroger Yes 79
35 PMD Yes 252
48 Stroger Yes 147
41 PMD Yes 395
57 Stroger Yes 168
56 Stroger Yes 178
51 Stroger Yes 140
.
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Richard M. DaleyMayor
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Recommended Initial Therapy• 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%.
100%
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Name Site
Patient 1 STR
Patient 2 ENG
Patient 3 ENG
Patient 4
Patient 5
Patient 6
Recommended Initial Therapy
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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%.
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
Sputum Culture Conversion: 50.0% (10/20)Individuals who did not meet objective*
Patient Age Site Conversion? Days to convert
Reason
Patient 1 73 ENG Yes 91
Patient 2 61 PMD Yes 142
Patient 3 33 Stroger Yes 72
Patient 4 72 Stroger Yes 79
Patient 5 35 PMD Yes 252
Patient 6 48 Stroger Yes 147
Patient 7 41 PMD Yes 395
Patient 8 57 Stroger Yes 168
Patient 9 56 Stroger Yes 178
Patient 10 51 Stroger Yes 140
*Results were obtained after entries were revised in INEDSS.
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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%.
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
Completion of Treatment: 70.6% (24/34)
Patient Age Site Did they complete?
Reason
Patient 1 61 PMD No PMD decisionPatient 2 47 Stroger No Moved: out of countryPatient 3 35 PMD No PMD decisionPatient 4 48 Stroger No Provider decisionPatient 5 49 PMD No PMD decisionPatient 6 52 PMD No PMD decisionPatient 7 37 Stroger Yes Complete, after 12 months
Patient 8 17 StrogerENG No Initially unable to locatePatient 9 56 PMD No PMD decisionPatient 10 32 Stroger No
Individuals who did not meet objective*
*Results were obtained after entries were revised in INEDSS.
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Known HIV Status• National Objective: Increase proportion of TB cases with positive or
negative HIV test results reported to 94.0%.
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
Known HIV Status:Individuals who did not meet objective*
Patient Age Site Reason
Patient 1 85 ENG Not offered
Patient 2 1 WTN Not offered
Patient 3 64 PMD/WTN Refused
Patient 4 35 WTN Refused
Patient 5 81 PMD Refused
Patient 6 56 WTN Refused
Patient 7 49 PMD Not offered
Patient 8
*Preliminary results from CDC query.
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Contact Investigation (CI)
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Richard M. DaleyMayor
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CI: Contact Elicitation• Increase the proportion of TB patients with positive acid-fast bacillus (AFB)
sputum-smear results who have contacts elicited to 100.0%.
25 = Total number of cases needing contact investigation
100%
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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%.
143 = Total number of contacts elicited.
126 = Total number of contacts evaluated.
88.1%
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Richard M. DaleyMayor
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CI: Contact Evaluation (Qtr 4 2009)Contacts who did not meet objective
Index Site Contact Age Reason
STR 50
STR 38
ENG 33 UTL
WT 31
WT 34
WT 26
ENG 66
ENG 41
ENG NA
ENG 9
ENG 31
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Richard M. DaleyMayor
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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%.
41 = Total number of LTBIs identified.
39= Total number of LTBIs who start treatment .
95.1%
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
CI: Treatment Initiation (Qtr 4 2009)Contacts who did not start treatment
Index Site Contact Age Reason
Index 1 ENG Contact 1 38
Index 2 WT Contact 2 35 Refused
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Richard M. DaleyMayor
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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 .16= Number of LTBIs who completed treatment . 41%
12= Number of LTBIs who are still on treatment .
71.8%
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CI: completion of treatmentContacts who did not complete treatment
Index Site Contact Age Start Regimin ReasonSTR 7 1/5/2010 Rifampin Still on Tx
STR 52 3/4/2010 Rifampin Contact chose to stop
STR 15 12/31/2009 Isoniazid Contact chose to stop
STR 17 12/7/2009 Rifampin Contact chose to stop
STR 19 12/31/2009 Rifampin Contact chose to stop
STR 22 3/10/2010 Rifampin Contact chose to stop
STR 40 8/19/2010 Rifampin Still on Tx
STR 31 3/10/2010 Rifampin Still on Tx
WT 38 9/16/2009 Isoniazid Contact chose to stop
UPT 50 5/18/2010 Isoniazid admin closure
UPT 27 3/23/2010 Isoniazid Still on Tx
UPT 50 2/9/2010 Isoniazid Still on Tx
UPT 15 5/12/2010 Rifampin Still on Tx
UPT 17 7/2/2010 Isoniazid Still on Tx
UPT 42 7/2/2010 Isoniazid Still on Tx
ENG 28 3/19/2010 Rifampin Still on Tx
ENG 34 6/15/2010 Rifampin Still on Tx
WT 56 1/19/2010 Rifampin Contact chose to stop
WT 53 4/5/2010 Rifampin UTL
WT 58 1/5/2010 Rifampin Still on Tx
WT 48 7/19/2010 Rifampin Still on Tx
WT 64 1/5/2010 Rifampin UTL
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Summary CI Results (for Sputum Smear Positive cases only)
NTIP Measure Qtr 3 2009 (N=13) Qtr 4 2009 (N=19) National Target
Contact Elicitation 100% 100% 100%
Contact Evaluation 88.1% (81/92) 78.8% (89/113) 93%
Treatment Initiation 96.2% (25/26) 95.1% (39/41) 88%
Treatment Completion 60% (15/25) 41% (16/39) 79%
Likely to complete 68% (17/25) 71.8% (28/39)
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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
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Bechara Choucair, MDCommissioner
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
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Richard M. DaleyMayor
Bechara Choucair, MDCommissioner
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
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Thanks
Questions?
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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
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Richard M. DaleyMayor
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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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