ࡱ> '` bjbjLULU 4J.?.?6)6)6)8n)b*lD*****+++DDDDDDD$EhG7D;++;;7D**LDAAA;**DA;DAAA** Nv6)g=A]CbD0DAH??VHAHAp+F1A47+++7D7DAX+++D;;;;$6)6) Slide 1 Bill Bower: Good afternoon and welcome to our first Web based seminar on Best Practices in TB Control, the Introduction to the TB Cohort Review Process. My name is Bill Bower and I'm the Director of Education and Training at the Charles P. Felton National TB Center, a component of the New Jersey Medical School Global Tuberculosis Institute. I will be moderating today's program. Slide 2 This is the first of its series of three webinars that will look at the cohort review process. Today is the introduction. Slide 3 The objectives of the webinar today are these; you'll be learning the elements of the cohort review process so that you can lead your team in doing that. You will learn the CDC guidance and how you can apply it regarding the cohort review process. You will compare the cohort review experiences of TB programs in New York City, Missouri and Oregon to identify the aspects of those that you can adapt for your own program. And then you'll discuss how to apply principles of continual quality improvement that are sort of the basis of the cohort review process so that you can manage the clinical services, contact investigations and so forth in your program to eliminate tuberculosis. Slide 4 The faculty today are myself; Dawn Tuckey, the Program Consultant from the Field Services and Evaluation Branch in the Division of TB Elimination at CDC; Dr. Chrispin Kambili, Assistant Commissioner of Health and Director of the Bureau of Tuberculosis Control, the New York City Department of Health and Mental Hygiene Slide 5 Harvey L. Marx, Jr., he's the chief of Disease Investigation Unit at the Bureau of Communicable Disease Control and Prevention, the Missouri Department of Health and Senior Services; and Heidi Behm, she's the TB Controller of the State of Oregon, Department of Health and Human Services. Slide 6 The agenda for today is after the introduction I'll provide and overview of the principals and processes of cohort reviews. I'll share with you some of the tools involved, how other programs are doing it, and place this in the context of what we'll be exploring in the future webinars on cohort review. Ms. Tuckey will present the recent CDC guidance regarding the cohort review process and what is expected of programs in 2010. Dr. Kambili will share a historical perspective of cohort reviews in New York City highlighting the key components, benefits and challenges in that work. Mr. Marx will share the experience in implementing cohort reviews in Missouri and Ms. Behm will share that with implementing cohort reviews in Oregon. And finally we will have time for questions and discussions. Slide 7 Now participating in this webinar I know we have a really mixed audience. Some of you may be program managers, medical directors or consultants, epidemiologists, public health nurses, supervisors, case managers, outreach workers or any of a number of health occupations that contribute to the effort to eliminate TB. I would like to get us all on the same page by going over the basic principles and processes of cohort reviews. Slide 8 So if you Google TB cohort review, you only get as far as TB COH and then a link to this resource pops up. This is Understanding the TB Cohort Review Process produced in 2005 by CDC and the video and DVD are still available. The guide is being updated. These are the basic source of what we'll be talking about today. Slide 9 And I want to start with a quote here. What is a cohort review? Well, in essence it is a meeting. And the part of this definition that I wanted to highlight here is this part here. You've got a list of patients, you've got the people with first hand knowledge of each patient and you've got someone supervising and reviewing their work. That's what a cohort review is. This is from Dr. Frieden when he was the Commissioner of Health in New York City in charge of TB control and of course now he's the Director of CDC. Slide 10 So I'll go over some definitions and the timing of cohort reviews here. In a meeting of a cohort review, you do a systematic review of the patient with TB disease and their contacts. And it's important to remember that a cohort in this case is defined a group of TB cases that were identified over a period of time. As we'll talk later, usually that's three months and so it's done quarterly but there are different ways to do it. The cases are reviewed approximately six to nine months after theyre reported. So let me talk to you through this. If cases are reported, say, identified in January, February and March. Then you're going to leave six months, April, May, June, July, August, September. You leave those to do the work on those cases and then you would be doing your cohort review sometime say in October or November. That's the timing that's important to bear in mind. And because many of the patients will have completed or they're nearing treatment completion, you may still have time to be able to take action to make sure that they complete treatment before the time is up. Slide 11 Now when we talk about how the meeting goes, in fact, the cases are reviewed in a group setting. In this group setting, there's information that is presented on each case by the case manager and it falls into these categories: demographic information, the clinical lab and radiology information related to the diagnosis of TB, and then the treatment information, the regimen adherence completion and how that was managed, and lastly the results of contact investigation. So during the meeting you are assessing these individual outcomes. Slide 12 But that sort of adds up to a picture of the program as a whole. And you're able to assess group outcomes during the meeting. Different indicators are used and what's good is that it's a chance for you to track your progress towards national, state and local objectives. Everyone leaves the meeting knowing the results and the meeting can be done in a number of ways. In person is often more common in a city health department or by teleconference in a state program. Slide 13 Now I want to say something about the participants in a cohort review. The people who pretty much are the real key leaders in a cohort review are the program manager, the medical reviewer and the data analyst or epidemiologist. But the largest number of people who will be participating will be these, the case managers, OK. The case managers will be presenting their cases to these people up here. The supervisor, I think I would have drawn this with the supervisor on the side because the supervisor intervenes and supports the case managers but is not really a bypass through whom things are presented. And in fact the case manager will have information from outreach staff, DOT staff, community providers. I've seen that the social workers, shelters, any other place that has been involved in the care and treatment or the contact investigation. That information will be presented by the case manager to the leaders of the program and they'll give feedback. Slide 14 Now I said before that cohort review was a meeting but in fact it's the entire process of preparation for this meeting, presenting and feedback during the meeting and following it up afterwards that makes this management intervention really work to improve programs. So I'm going to go through each of these steps now and remind you that some of these will be explored in more detail in our upcoming webinars. Slide 15 First of all in the preparation phase, the first point is that all staff must know your national and your local objectives. And I know that many programs are also incorporating their NTIP indicators into the cohort review process. That is an innovation which is really exciting to see. The second point is that every case of TB must be assigned to a case manager so that all of your system of case management, case review meetings, supervision, all of that is in place and working to do the work of TB control. The third point is that the TB registry is your basic platform, that's where you get your list of patients and you can send that list out three months before a cohort review meeting so people will know which patients are the ones that they'll expect to report on. Then through the normal case management and review processes your staff will be prepared to successfully present the outcomes of the cases and contact investigations. Some programs do actually include sort of a practice session through practice presentation skills. Slide 16 Now one of the things that makes the presentation of many cases in the meeting possible is to have sort of a standardized, concise form that requires only the most important information and you get the same information on each patient. There's a Wiki that is being set up at the TB program evaluation network tools committee and here's the site, and it will have many examples of the form. The form that I'm showing right here is the sample one that is in that booklet, Understanding the TB Cohort Review Process. In giving the standard presentation some programs find that a good form like this is sort of like an instructive roadmap that nurses in rural counties can follow, sort of a step by step approach to provide complete TB care. The form can detail what's expected in the patient information, diagnosis, treatment, management and contact investigation. And I know that one program was clever in how they introduced the forms and they commented that the nurses liked the way that the form guided their work. I think that must have been some very clever marketing. But it is true. These can be a great tool for keeping your case management on track So if those of you out there who are case managers and are thinking, what's in it for me? In fact, a form like this can really be a good guide step-by-step to getting things done correctly in TB control. Now, using a concise form like this can allow a program to review maybe 40 cases in two and a half hours, just under four minutes a case. I think that you can do an uncomplicated extra-pulmonary case maybe in 30 seconds and a more complicated case may go seven, eight, or ten minutes, but by managing your time it's possible to be very efficient using an approach like this. And definitely programs should remember to continue their practice of using periodic case reviews to make sure that the case and the contact information needed for this is being collected and that everything is being done right before the cohort review. Slide 17 The next step is presentation actually during the day of cohort review and here is where information is presented on each case one by one. Slide 18 A typical location is in an office or a conference room or an auditorium if its a face-to-face meeting but more and more programs these days are also doing this by telephone or a web-based conference call and that can be very effective. You want to keep the meeting to a manageable length so I would recommend that you find way of reviewing 20 to 50 cases at one sitting, so larger programs may need to do break up into regions and do more than one cohort review. For example, in New York City each quarter they do four cohort reviews because they have four regions in the city. During the review, there is a chance to give feedback and actually teach about important points that are learned during the review. And it's important to analyze the outcomes. Nobody likes to think that they give a lot of information and nothing is done with it. And one of the principals of adult education is that the sooner the feedback is to the event the better. And in fact, if you can analyze the outcomes right there during the meeting and it's possible to do that with spreadsheets and PowerPoint presentations, you can give immediate feedback to people. Slide 19 Now this is the sample form that comes from the booklet, Understanding the TB Cohort Review Process instruction guide. And it's a sample where you just one line for each patient and then information about their TB diagnosis, their treatment, the disposition of the case. Was it cured? Still on treatment? Lost, died? Whatever. Contact investigation is then on the right. So in a spreadsheet form like this you can have, if you want on the spreadsheet, an additional tab with all of the formulas to calculate the rates and indices. And this can be linked to a presentation that you can present for everyone to see. Slide 20 Now the types of outcomes that you can get immediate feedback from are was the patient cured? And you will have a measurable result like the completion of treatment or other outcomes that you're looking at and contact investigation. You can have measurable results like the number and percent of contacts who are identified, tested, evaluated, started and completed treatment for LTBI. What's good is that all of this can be done pretty quickly and it's feedback that people appreciate. Slide 21 The last step that really is what brings it full circle is the follow-up in a timely manner on issues that get identified. Slide 22 Now obviously the follow-up is different for different staff. Your supervisors, nurses and case managers will be following up more on the case management suggestions that were made during the cohort review making sure that patients and contacts finish their treatment. The TB program manager will probably be addressing programmatic concerns and concerns about modifying staff training or orientation to better meet the needs for staff to learn what they need to do the job. The data analyst or epidemiologist will be updating the registry, correcting any data errors and preparing a summary report. And the medical reviewer will address the clinical issues that came up and especially provide medical consultation among the medical provider community if any is needed to make sure that treatments are going OK. As a result over time the TB program can improve its outcomes through a continual cycle of implementing, evaluating and refining the procedures and processes. This is really an example of continual quality improvement in action and that's what makes it work. Slide 23 Just to summarize here I'd like to show you how the information flows because some people have had questions about that. The TB registry is where you get the list of patients and that information goes to the cohort spreadsheet with one line for each patient. During the cohort review meeting, the forms that the presenters views contain the information which they present and that goes to complement what is on the spreadsheet. Then this one here is the manual spreadsheet but you probably use a computerized one. And that would allow you to analyze the indicators like the completion rate, death rate, default rate, the contacts who are identified, evaluated, started, completed, et cetera and then your reasons for stopping treatment. And after you've analyzed that right there in the meeting you can compare how you're doing to the national and local objectives and talk about what things are going well, what things aren't going and how you may be able to improve. If you give immediate feedback to people or later feedback then everybody feels that they're involved in the process and of course, reports are generated and you follow up to make sure that you're doing what's needed to correct and improve any of the processes that you are working on. Slide 24 Benefits of the cohort review process are these. At the heart of it, it really can increase staff accountability for patient outcomes. It's a case of the TB program doing something to make sure that each patient gets what they need to be taken care of with TB disease or latent TB infection. You can also improve your case management and identification of contacts and programs that have started doing cohort reviews notice that within the first six months or year or so. As far as motivating staff it's important because a meeting like this can be magnet. It can really draw people together to feel like a team thats working to fight TB. And for the leaders of the program it can reveal your strengths and your weaknesses. And often things that you thought were doing well maybe are weaker, other areas you thought were weak are actually real strengths and you can give praise to a job well done. And it can help you figure out what staff training needs area and education needs are. So that concludes the summary of the process of cohort reviews. Slide 25 And now I'd like to turn the program over to Dawn Tuckey. As a CDC Program Consultant, she's had the good fortune to work with a number of programs that have adopted the cohort review process and she's been a strong advocate for supporting the dissemination of this. Dawn? Dawn Tuckey: Good afternoon I'm briefly going to discuss CDC's cohort review guidance and expectations. Slide 26 OK according to the 2010 TB cooperative agreement it states that all TB programs receiving (inaudible) funds should contact cohort reviews as part of program evaluation activities. The language states that in order to improve TB case management and program accountability and feedback that the grantee should hold quarterly cohort reviews at the state and local levels or both. Cohort reviews are integral to TB control and provide a systematic review of the management of cases and contact investigations. Instructions on the 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 Instructional Guide. And this can be found on the internet. Slide 27 Grantees should report their progress on conducting cohort including the number of cases discussed, key issues identified during the reviews and the recommendations made and this should be included in your progress report and it should be used in order to develop evaluation activities. Slide 28 Our expectations for 2010 are that all programs should conduct at least one cohort review by using one of the following approaches: whether it would be face to face, teleconferencing or the (hybrid) approach. Regardless of whichever method that you choose, all models do consist of an interactive meeting to retrospectively review all TB cases that are registered in the program area in a given timeframe. In addition, each model allows the delivery of concise and standardized presentations from the frontline staff to the program directors and clinicians. This allows for accountability and the immediate feedback and teaching and a systematic follow-up. Slide 29 OK the expectations for 2010 reporting requirements should be included in your interim and annual progress report. The things that you actually should include are as follows. The date the cohort review occurred, the number of cases in each cohort, the type of cohort model that you used whether it was a face-to-face, telemeeting or whether was a hybrid approach. The frequency of the cohorts whether it was semi-annual or quarterly and indication whether the cohort reviews included patients with disease or LTBI, the key issues that were discussed and the recommendations that were provided and the progress on implementing these recommendations. Slide 30 Although the COAG states that each TB program should conduct cohort reviews on a quarterly basis, we acknowledge that certain programs may not need to do it this often. So therefore we are recommending to use the following to determine the frequency. Programs with zero to fifty cases per year should conduct semi-annual cohort reviews. Programs with fifty or more cases quarterly and for those low incidence states with 15 cases or fewer were encouraging you to actually review the management of patients with LTBI or your contacts and their completion of treatment and you can actually do this the exact same way as you would with the cohort review for active TB cases. Slide 31 Some of you may choose that you would actually want to do a regional cohort review and that would be fine and that's certainly acceptable. You can partner up with your neighbors but if you do choose to actually do this, an agreement should be developed among all the partners and should include the process, the location, the model that you're going to use and whatever each program's role and responsibility is in this. Slide 32 As I had stated earlier with regards to understanding the TB cohort review process, the instructional guide published by CDC this is certainly a document that is available for your use and currently it's being revised but that does not preclude you from actually using it to help you develop your process. It's basically going to have the new guidance steps in there and some other things but certainly it's still a good document to use. As well Bill had alluded to in the beginning that there are going to be other webinars coming up with regards to the RTMCCs. The RTMCCs as well will be developing the standardized cohort review training and I would also encourage you to work with your TB program consultant to establish a system that really works for your program. Slide 33 All this information that I actually have gone over here plus additional information can be found in the Dear Colleague letter that was sent out in August 9, 2010. Thank you. Slide 34 Bill Bower: I would like to introduce now Dr. Chrispin Kambili, a graduate of Fisk University who studied medicine at Columbia. He started working in New York City TB Control 10 years ago and now leads the Bureau there. He will share a historical perspective from a program that has been doing cohort reviews for a long time. Chrispin? Chrispin Kambili: Thank you, Bill. My name is Chrispin Kambili, as Bill said I'm the Director of the Bureau of TB Control here in New York City and I'll share with you a historical perspective of cohort reviews here in New York City focusing on components on how we do cohort review and why we like it and the challenges we have met along the way. Slide 35 So many of you may be familiar with this slide. It shows the epi-curve of TB cases in New York City spanning from 1976 to 1991 and I think this is representative of what was going on in many parts of the country at that time when we saw a resurgence of tuberculosis after decades of decline in the number of cases of tuberculosis. A lot of things contributed to the resurgence but one of the most important reasons was what we'd call the breakdown of the public health infrastructure so that includes people, knowledge, and processes on how to control TB. And in New York City in 1991 there was so much TB that essentially everyday you open a newspaper, the front page would be some story about tuberculosis. It was quite scary to be here to read the newspapers because there were twists and turns about how the stories were being told but it was indeed a crisis. Slide 36 So one of the things that we noted at that time is that when we got better at collecting the information about just how much TB there was out there because we couldnt really know the extent of the problem until we did good surveillance. And so one of the first things that was done was to collect adequate information as to how many cases were prevalent and how many cases were incident every year. And one of the telling problems was when one examined treatment completion that is something that one wants to achieve at very high rates in order to have significant control over tuberculosis. We were hovering just under 50 percent, under 50 percent of TB cases in New York City were completing their treatment and that's a shame. And there weren't as good data going back in the mid '80s, but so that going forward we know what happened. And this is the problem that we saw and one of the things that at that point Dr. Thomas Frieden was appointed Director of the TB program here. And one of the things that he was trying to do is how does one go about turning this tide of tuberculosis that we were seeing. And he invited to New York City an expert in tuberculosis in the name of Dr. Styblo. Dr. Styblo has been working at the International Union for a long time and he had tried also to think to the extent that, you know, the concept DOTS that we talk about today in global tuberculosis control. Its based on a lot of the things that he has done in very poor areas of the world. Slide 37 So he knew that one could leverage one's resources, both human and otherwise, to do very good control if one had a way of ensuring accountability and ensuring that one could actually answer the question thats posted in this slide. So when you identify your patients, you have good surveillance, you have all these patients in your log, in your register, what happens to them? That's where New York City found itself in around 1991. We couldnt really answer that question adequately. Fifty percent of the time the answers would say, yes we sort of know what happened to them but the other 50 percent we didnt know what had happened to those patients we had identified or they they had disappeared into the concrete. Slide 38 So that's the picture of Dr. Styblo during his visit who came during a visit to the United States and to New York City. And he stated to Dr. Frieden, every patient you start on treatment, you're responsible for their outcome. And Dr. Frieden showed all these numbers of patients we had identified in New York City and he said, I do see how many patients you diagnosed last year but how many of them did you cure? And Dr. Frieden could only account for about half of them. So at that point Dr. Styblo introduced the concept of doing a cohort review as a way of ensuring accountability at every level, from the top of the organization of the TB program to the case manager that on a daily basis interacts with the individual patients and has information about those patients. Slide 39 So at that point, New York City set out to start cohort reviews and they were in full swing by 1993. And the format in which they were used is the same format that we still use today. With technology weve changed how things are presented but the essence is still the same. The TB program director, I am that person now, I review every case that's been counted and as Bill Bower said, we do our cohort reviews about six months after the cases were counted. And in New York City every case is assigned to a case manager. In some cases the case manager is a nurse and in other cases it's a trained lay person who is trained on TB 101 and other knowledge that is important for them to be able to case manage these cases. And these cases are presented to a group of people that includes the case manager's, supervisors, managers that manage various units of tuberculosis control, clinicians that provide care in the public clinics in New York City, and I also review cases that are being managed by non-public physicians. Now for example we just finished a cycle of cohort reviews. We've divided the city up into four regions and it took us about three to four hours for each cohort review and the number of cases ranged from 26 to 62 for the first quarter of this year. It took us longer this time around because in September of this year, we actually introduced a new TB registry. Its fancy, it has everything we ever wanted to be in our registry. So we were navigating through it. So it took us a little longer but normally it takes us about maybe half that time but we were able to still, using a new system and go through the 62 cases in Queens for example in under four hours. So each case is presented and it's reviewed for all its tenets both from a medical standpoint, social issues associated with it, as well as public health outcomes including contact investigation. Slide 40 What this does is that we assure consistency with the principles of tuberculosis control because tuberculosis control we don't have to re-invent the wheel. Everybody knows what they need to do in order to have good outcomes. So we just make sure that what we're doing is consistent with what everybody else does, everybody else recognizes as what one needs to do in order to have good control of tuberculosis. And it will also set standards for accountability. So presenting cases on a standard form helps everybody have the same kind of pictures. So that when someone says something that seems to not be in line with what's expected, we all know and everybody recognizes that something is amiss. And, you know, we follow up both the patients and their contacts and that to us completes the picture of doing good TB control. And what we have done over the years, is instead of just having global indicators for our cohort we have linked to the national indicators. So our indicators or cohort actually are link and aligned with the national TB indicators (NTIP) that the CDC has developed. So recently we revised our indicator collection process so that as cohorts we see how well we're doing vis a vis NTIP indicators. So at cohort we know for example that at this point in time, we have 80 percent of our patients demonstrate culture conversion, of course exceeding the benchmarks that's been defined in NTIP. So we are trying to do that so that by the time that we report our numbers to the CDC we already know how we're doing by following this through the cohort process. So this is a new addition, in addition to just to identifying for example treatment completion. Slide 41 So with the advent of cohort in 1993 we did make tremendous inroads in terms of treatment completion for TB cases. And as you can see in a graph that's projected now on your screen, we managed to achieve treatment completion rates of close to 90 percent starting from under 50 percent because we demanded accountability at every level. And a lot of the reasons why people were not completing treatment is because there was no coordination between the treating physicians and the health department. And, you know, things that treating physicians lack for the example, to be able to follow patients, to track patients when they are lost. Those are skills that the Health Department in New York City had and when the two of them got together and linked their efforts the outcome was much better. So we have managed to achieve that and we're able to make sure that this continues by doing the cohort review where all these issues that might lead us back in time identify and nipped in the bud if you will. Slide 42 So I touched on a little bit on the evolution of cohort review. Initially, we focused almost entirely on treatment completion because we were so low, 40 percent, 50 percent. So the focus was on that. That was the biggest problem. Later on we expanded and not only looked at the cases but also looked at the identification, evaluation and treatment of contacts for LTBI. And more recently, we've also focused on HIV testing, not only HIV testing of cases but of contact as well. Essentially, with the CDC's recommendation several years back that HIV testing be routinized. We latched on to that very strongly to the extent that we have expanded HIV testing to contacts and we demand that, that will be addressed during cohort as well, for example, how many of your contacts had HIV testing. Anecdotally, we did an evaluation at one point looking at HIV infection rates among contacts who index case is also HIV infected. And we saw a great number of HIV infection among the contacts although they may not have been sexual contacts but I guess because HIV is a family disease as well maybe what we're seeing was this phenomenon in families whereby 79 percent of TB contacts to HIV-infected index cases were also HIV infected compared to about 20 percent of contacts to people that didn't have HIV. So that was quite telling. It was a small group of contacts that we evaluated but, you know, that sort of strengthened our desire to be able to look not only at TB indicators but also things that determine outcomes for TB such as HIV infection. And as I said, you know, this year we aligned our cohort indicators with CDC NTIP indicators to emphasize best practices. Slide 43 So benefits of the cohort for us it's been the main way that we evaluate the things we're doing on a day to day basis. We ensure accountability; everybody knows what they're supposed to be doing. It's improved greatly the quality of the data that we collect. And the forum where issues can be discussed with people that generally on a day-to-day basis dont come in contact with each other and we use the forum also to praise staff for achievements. We try not to denigrate people. We try to chastise in private but we try to praise people in public and the cohort forum is one of those places we like to do that. Also, we highlight to our staff the overall strategic goals and objectives of the program because, you know, maybe the case manager out there in Queens may not be on top of things in terms of knowing what is the organization's strategic goals and we try to bring everything together so that people can see the big picture to why they do the things that we ask to do. Slide 44 So, it has limitation and as I've said we review our cases about six months out. And sometimes it's too late to make an intervention because the case may have already moved out of jurisdiction, or especially moved out of the country. And then I said it's time consuming. We try to limit the depth of certain discussions but sometimes it takes us forever to complete these discussions. So, one has to really learn how to manage their time which I should be doing right about now. Slide 45 In conclusion, the good thing about cohort is its customizable to content. The way we do it in New York it's slightly different than how they're doing it in Missouri and but it achieves the same goals. And it can be applied in various context of TB incidence. And actually it can be applied to diseases beyond TB and it's been used in Malawi when they started treating their HIV/AIDS patients with anti-retrovirus in public hospitals. And it's been used in New York City and other areas including the HIV program here uses it to track potential exposures when doing partner notification activities. And the Bureau of Tobacco Control was also going to adopt it and try to see how many people that have been on dialysis to help them stop smoking, do actually stop smoking over time. So it can be used to areas beyond just TB control. And with that I'll conclude that, you know, cohort has served us really well. You know, a lot of people have come to visit us and the thing that they are quite impressed about is how we do cohort and how we they can adopt the cohort. I was on a visit to the United Kingdom, to London in September and I was able to observe their first cohort that they adopted from what we do here in New York City. So it was quite, for me, very encouraging that, you know, a lot of people find this useful and they have adopted it to their own environment. So thank you very much. Slide 46 Bill Bower: And now we will have Harvey Marx. Harvey Marx: I'm Harvey Marx and I'm going to be discussing Missouri's approach with the cohort review. Slide 47 Certainly reasons for implementation is it's currently in the CDC Cooperative Agreement. However, we had opted to implement this in 2005. We felt that it would be a good mechanism in evaluating our program. We've also seen that it has increased learning. As a low incidence state, there are several jurisdictions that might not see a TB case for a while. We invite our partners to be part of the cohort whether they have cases or not, and again, it's a good learning opportunity. We feel that it improves case management at both the state and the local levels. Again, I mentioned that we use it as a tool to evaluate our program. And we've also found that it improves documentation in our clinic records which certainly overall improves patient outcomes. Slide 48 Missouri's approach is that we look at TB cases that were identified over a three month period and then approximately six months after those cases were identified they are cohorted. We cohort our cases in a group setting; you know, in the state of Missouri we have the state Health Department and then we have 114 autonomous local public health agencies. But we are able to connect to them through our network and we actually have a video conferencing available to those individuals and we have five district offices where they can come in to present the cohort and a couple of our larger metro areas can actually directly connect into this teleconference. Slide 49 Again as I mentioned, every LPHA is invited to attend and again we encourage those agencies that, you know, maybe having a case coming up at the next cohort to kind of sit in, especially if they haven't seen a case in awhile to kind of get a feel of how the cohort runs here in Missouri also the type of questions we are going to be asking and looking at. I've also got feedback from, you know, the local agencies. That was a good review for them to be looking at things as they're working through in managing their case. We have adapted our TV registry where most of the cohort information that we're going to be asking can be obtained through that registry. And again we look at individual outcomes as well as group outcomes. Slide 50 Again, Missouri tracks our progress toward our national and state and local program objectives. And as Bill had mentioned earlier, we have a form or a process that we follow so our presentations are consistent as we work through the process. Slide 51 A little bit on our registry, it has general patient information, medical treatment history, contact information. As I mentioned, the cohort form can actually be printed from WebSurv or our TB registry where somewhere between 85 and 90 percent of the information that would be covering is extractable through that registry. And again, we used the registry to generate our line listing which we get out to our partners about two months before the review is actually scheduled. Slide 52 And again this is an example of our cohort schedule is that the cases that were identified in January and March would be cohorting in the third quarter, July, September, April, June will be October, December and so on. Slide 53 These are some examples of our state objectives that I mentioned earlier that we like to have our cases interviewed within three business days of the case report. We like to see our contact investigations completed within 21 days and all TB and will be offered the opportunity to be screened for HIV. Slide 54 Every TB case in Missouri, even though as I mentioned, you know, the State Health Department and then their partners at the local health agencies, each is assigned a case manager. We have written protocols that should be followed and our department provides routine consultation, case management and as such with extended contact investigations. We also provide, you know, the cohort and, you know, evaluation of the overall TB program in the state. Slide 55 Generally with our cohort review either the TB controller which is my self, our TB program manager, our TB nurse consultant will be asking the questions through the cohort process. We may depending on the length of the cohort which in our state, which we have around 110 cases reported a year. And again about a quarter of those are done at each cohort. We may switch up where give one of the persons listed above a break but again we don't want to be bombarding the person with different questions. So again we try to limit it our TB controller, manager or nurse. Again we're looking at, you know, treatment information, did they begin on the four drugs or was it appropriate, HIV status. Were negative labs obtained? You know. Sometimes, you know, we focus on, you know, positive results but, you know, looking at sputum conversions, culture conversions, where those are documented in the records and of course successful completion of treatment. Slide 56 On the contact investigations as I mentioned earlier we're looking at a number of contacts identified, were appropriate for testing, were they evaluated, started and completion of treatment, not only for LTBI but those who are identified with disease and then we get those individuals within the system. Slide 57 During the cohort review, we also, you know, even though we try to prepare ahead of time, you know due to different reasons there may be missing data as the cohort is progressing but as the cases are presented a lot of our case managers bring their files and they're able to provide us with missing data that we did not have; we may have opportunity to update and correct data. There may have been some information initially that was misrepresented that we could correct. Certainly we're looking at the DOT coverage, the timeliness of our investigations and how we're meeting our objectives. Slide 58 The contacts, we're looking at, you know, for those who started treatment, how many of those, you know. Did they refuse? Were they having adverse reaction, moved, died, etc. So we're also looking at the contacts. Slide 59 And samples of issues that we have had during the cohort is again, I mentioned earlier documentation of culture conversion you know this is one of the things that we had identified early on when we first initiated the cohort in 2005, is again documenting those negative results and making sure that we have those, that were offering HIV status or we have HIV status on all of our TB disease and how well we are doing on our contact investigation and follow-up. Slide 60 You know, we feel here Missouri its an important meeting of our TB program and our partners within our state, you know, it's low-tech and it could be done by hand, but as I say we've integrated it into our TB registry where most of it can be extracted. Our cohort process is closely linked to CDC and our state objectives through our cooperative agreement. It's a group process. You know, everyone leaves the meeting knowing the results or soon afterwards. As with most technical systems, you know, we may have some glitches in our web connection and stuff. And we may have to present our data up on our intranet site with our partners but with if we can't present it at the end of the cohort we get an email out to all of our partners saying that the data is now available and is up there for review. So not only the state but our partners know how well we're reaching and obtaining our objectives in our grant and the objectives that weve set for ourselves. It's a teaching and learning opportunity, and again, we have partners out there that have a vast amount of experience dealing with tuberculosis. And I'm sure as many of you are aware, there can be turnover at the local agencies and even for those that don't have turnover in a low incident state such as Missouri it may have been four or five years since a jurisdiction had a case and the opportunity for them to come to the cohort and set and kind of look at the key components of a case management contact investigation, I think has proven very valuable. And that concludes our presentation. Slide 61 Heidi Behm: OK, hello, I'm Heidi from Oregon and I'm going to talk about our TB cohort here. Slide 62 So just a little bit about TB in Oregon, we are a low incidence state and we have a large geographic area. Our metro Portland area is about 2.5 million but we also have what's called frontier areas where we have very large counties and theres usually about only about a thousand people in those counties. In 2010 we had 89 cases and 72 percent were foreign born. Our state TB control staff consists of just three people, myself as the TB controller. We also have a TB epidemiologist and a TB registrar. So some of our challenges overall are staffing, keeping expertise in TB in our rural counties, cultural competency since we do have a large percent of foreign born patients and DOT especially in our rural areas. Slide 63 So this is just a little timeline of how our cohort review started. We are really fortunate that way back in 2007 our metro area County Multnomah really started having cohort reviews. They called them the end of treatment review but the concept was the same. So they really were the innovators in the state and we're fortunate for that. Then in July of 2007 they invited the other metro counties to join them and they had a face-to-face review with those two other counties. Then in January of 2008 our program the Oregon TB Control started a cohort review for the balance of the state, the non-metro counties and we were doing that by phone. Then finally in April of 2009 we combined the cohort reviews with the metro area and the rural areas. So that has been outstanding and that took a bit of an effort on our part. And then finally in June of 2010 the state wrote a program element which basically requires cohort review participation of all of our counties in order for them to receive funding from us. Slide 64 So just to conclude on that, establishing cohort review takes time and I think that that is OK and just to understand if you get started that it is a process. Slide 65 So this is a little bit about how we prep for the review. We do a quarterly review and we review cases that were counted as six to nine months prior. Our TB epidemiologist pre-fills a form with the case and contact information before the review and she emails that to the TB nurse case manager. Now I have to say this is a lot of work on our TB epis part but it's really worth it because it helps save the nurses time. And it also helps the TB epidemiologist to gather all the data before the review. And I think that helps the TB nurse case manager to feel a little bit more ready for the review and there aren't any surprises for them that occur as the review is going on. Then finally once our TB epidemiologist has that all information gathered, she emails all the counties on our state the completed form so if they want to listen into the review they can follow along with the cases. Slide 66 So this is the little bit about our participation. The TB nurse case manager for the county is required to present. We do allow somebody else to fill in if they can't make it. Sometimes counties will actually do a joint presentation if the patient is transferred and thats kind of fun. Also, I always participate as the TB controller, our TB epi participates, the metro area TB nurse supervisor participates and we always have a TB physician attend. All the other health officers for the state and all the other TB nurse case managers are invited to attend and they can call in at any time if they wish. Other attendees we sometimes have are medical residents and case interns, and sometimes we actually have some TB nurse case managers from Washington State. And the last we had the lab participate as well which was really great. And we allow questions from any participant and actually encourage that. Slide 67 So on the day of the review, our review is about three hours, our TB epidemiologist presents aggregate data on the cases and their contacts for the quarter under review. And she can kind of comment on how the data looks and compare them to the program objectives and the national objectives. The TB nurse case manager attend in person, other areas attend via teleconference. Everybody has those sheets that we emailed out previously so they can follow along with the case details. Slide 68 Some of the initial barriers that we encountered when we first started to do these reviews was really a fear on presenting on the part of nurses. Some people said they didnt have enough time to participate and then as like I alluded to it earlier we had some difficulty combining the reviews and also some problems with sound quality. So I'm going to address these issues as I go on. Slide 69 So one of the things we did to kind of overcome some of these barriers, especially the fear of presenting, is we try to encourage a more casual atmosphere during the review. We have food and it's kind of mellow and casual. We also allow the nurse case managers to put in some individuality when they do the review. Sometimes they'll add pictures, for example, the one you see here, it's some pill that's wrapped in cotton candy that one of the nurses used to get a kid to take some medications or sometimes they'll put in a chest x-ray it's unusual. Slide 70 Also, we pre-fill the forms and that has really saved the nurses time and they appreciate that. We also minimized some of the routine clinical data on the form, so it didnt seem so repetitive. And we added a few subjective questions to create some more discussion. So nurses will discuss what incentives and enablers they used, what unique case management strategies they utilized, any community resources they used, and then most importantly I think is anything you would do differently the next time you got a similar case. Slide 71 So I think this is kind of some of our proof of success. People call in when they don't have to and I think that's great. So we have lots of our counties that call in just because they want to listen and learn so I think that shows how valuable it is to them. We have seen that our HIV testing has improved. We're definitely getting more HIV tests done. I think overall DOT is better managed and a big part of that is during the review nurses will show strategies on how they got DOT done. You know, for example, some of them will use the local pharmacy or weve even had fire departments utilized. And that's really helpful especially for the rural areas. Also, we learn from each other and we gained additional resources. And so, nurses don't always feel like they have to rely on the State for consultations, at times we'll call each that's really great. Slide 72 So we're trying to improve and I think we always will be trying to improve. It still seems a little too long at times and we're trying to narrow it down to really what is essential and most beneficial for our listeners. Sometimes we still have sound quality issues and our remote listeners will report that they're not hearing everything. We did buy a new Polycom that has microphones that can be handed around the room and I think thats helped. Rural counties at times have expressed concern for their rural patients regarding confidentially and that's an interesting issue. If we have a very rural county sometimes, you know, if you are talking about a Hispanic patient who is a male that could easily identify that person in the community. So we have to be very careful especially with our rural patients. We need to work a little bit further on a process of follow-up after the review and we're still tackling that. I was going to spend a couple of seconds talking about evaluation. Right now the cohort review is not part of our formal evaluation process, however, as I mentioned earlier we do compare our quarterly data to national objectives. So we do evaluation that way. And it has really been useful to improve contactt follow-up and also in HIV testing. And it's also helpful as far as evaluation goes in ensuring that everybody is using the same data definitions. For example, what is directly observed therapy versus self administered therapy so that has been very helpful to us as well. Slide 73 So that is my presentation and thank you for your time. Bill Bower: We know have some time for discussion Operator: First question comes from the line of Richard Kohler. Richard Kohler: My question is do you have separate processes in Missouri and New York, and in Missouri for prospectively trouble shooting in addition to the cohort process? Bill Bower: Either member of our panel who presented their programs should answer this question and I do think that the programs continue their prospective work in addition to preparing for cohort. Harvey Marx: Yes, this is Missouri and I would say that, you know, we request certain elements from the record to be returned to the state and our nurse consultant does, you know, review case information through the process. So, you know, we do not just rely on the cohort review process. Heidi Behm: And this is Heidi from Oregon. I think similarly we do require that the counties send in a case report form and then usually, since were small enough, I'll go through the case report form and look at drug dosages and things like that. And if the county is a small lower incidence county, you know, we'll call them and follow up as the case is being treated. Chrispin Kambili: Hi, this is Chrispin from New York. Yes, of course we do. You know, when the case is reported to us and, for example, if the case is potentially very infectious, a smear positive case a case manager is assigned and is supposed to interview that case, you know, in under three days. And from that point on when we have engaged the patient, there's a series of weekly case management meetings in the regions that I described previously. And it is at these weekly case management meeting where the case manager gets guidance from their immediate supervisors on how to address issues that might be identified. Sometimes, you know, a case may fall through the cracks and not undergo that process and these are the cases that eventually bring in issues at the cohort six months later but yes we do have monitoring ongoing weekly management case meeting so that issues can be identified promptly and addressed right away. Richard Kohler: Thank you. Operator: Next question comes from the line of Clayton Weiss Clayton Weiss: I have two questions. The first question is, why review patients who are at the end or near the end of their treatment and rather than reviewing patients in the middle of their treatment? And the second question is, what is a hybrid approach? Thank you. Bill Bower: This is Bill Bower. I'll go ahead and start the answer on this one. Of course during your normal case reviews that you do perhaps at month two or month four during treatment, you do review those cases and that part of your routine case management should continue. The purpose of cohort review is to look at things later and see really what the outcomes have been. The second question was what is a hybrid approach? And a hybrid means that and I'll give you the example of the state of Washington. Most of their cases are in not most, the largest number are in Seattle and King's County. So they do a face-to-face cohort review in the morning with those cases and then in the afternoon they divide the state into two regions and they'll do, say, the northern region by phone for an hour and so, and then the southern region by phone for an hour or so. So it's hybrid in the sense that they're doing a face-to-face meeting followed by two regional telephone based cohort reviews. And that's probably going to be a good approach in many more extensive states where you, you know, have one or two cities where TB is concentrated but a larger area where you can't expect people to come to a meeting front. If anyone else would like to comment from the panel, please do. Harvey Marx: Yes, Bill, this is Harvey. And I would also like to add that, you know, looking closer to the end, looking to see what outcomes were met or not met. In our state, and that we have the autonomous local public health agencies that partner with us, it allows them an opportunity to see as a state how we are meeting those objectives and national goals as well, and how just, you know, one or two cases, you know, can impact since we are a low incidence state, those outcomes that we report nationally. Chrispin Kambili: Hi, this is Chrispin. I guess as Bill did mention it, because we're looking at outcomes and for TB the most important outcome is treatment completion and cure. So, that doesnt take place until much later so it does help to wait a little while in order to give time to the case managers and their supervisors to address the issues that come in day to day and to remember also there are contacts to be identified and to be evaluated and perhaps to be placed on treatment. And if you add all that together those are issues that take a while to come around, to wrap one's head around and so it does makes sense to review, to do these cohort reviews at the time that we do them. So, yes, just to reiterate, they're not supposed to be the only way that one looks at their cases. One is supposed to have an ongoing monitoring process that is much more regular than the cohort. Heidi Behm: This is Heidi from Oregon. I just wanted to mention about that hybrid approach. So we have kind of a combined metro area and rural area review. And I just want to mention that our more rural areas has really seen the value in at least being able to listen in to the metro area review because that they gain a lot of knowledge from that. Operator: Next question comes from the line of Allison Maiuri. Regina Gore: This is Regina Gore, program consultant in Atlanta, and I have a question. I have an area that does not have the luxury of having a medical consultant or a TB epi or data analysis person, and has gone so far as to do cohorts with another area. So my question is, how can they provide analysis back to their area when they don't have a medical consultant or a TB epi? And, you know, what would they provide as follow-up for the review because that the information that they're getting is coming from another doctor in another state who has, you know, consented to being on the call as a medical consultant for another area but because this is a very small area with limited staff this is the best way that they have found to come up with doing cohort review. Bill Bower: Hi, this is Bill. I would suggest that most of the follow-up action needs to be done by that program itself and not be provided to them but the guidance about what needs to be done is what comes from the cohort review. And so, a lot of the follow-up is in correct data collection or follow-up in contact investigation, perhaps in training. And I think that the local program can probably do a lot of that by themselves. I wonder whether a public health student or somebody could be found who can give some help in the epidemiology area in analyzing data for them. That might be another possibility but I'd like to hear from the other presenters too. Heidi Behm: This is Heidi from Oregon. We do have a TB epidemiologist and that's really great but I don't think the analysis needs to be extremely complex. So, you know, maybe somebody else could be trained to do it. Slide 75 Bill Bower: OK, well it's really fun for me to see how programs that have started doing it recently or have been doing it for a decade or more or anywhere in between are using the same principles, and also how they can do it by tele-medicine hook-up or by phone conference call or just old fashioned face-to-face meeting. Either way works. I really want to thank our faculty for sharing their knowledge and experience with us. Thank you very much for your participation. This concludes the webinar today on the Introduction to the TB Cohort Review Process. 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