ࡱ>  bbjbjVV 4N<<B81 $8h$j$j$j$j$j$j$%(\j$j$$!!!~h$!h$!!!Lj&!T$$0$!( (!(!d!$j$j$ $( : Slide 1 Bill Bower: Good afternoon and welcome to our third web-based seminar on the TB cohort review process, TB Cohort Review in Action: Putting it All Together. My name is Bill Bower and Im the Director of Education and Training at the Charles P. Felton National TB Center, a component of the New Jersey Medical School Global TB Institute. I will be moderating todays program. Slide 2 This is the last in a series of three best practices webinars that highlight the TB cohort review process. Slide 3 The specific objectives are these. By the end of the seminar, youll be able to describe the flow of activities in a cohort review. Youll be to analyze the comments and feedback that come from the program manager and the medical reviewer and other staff who pitch in, in the discussion. Youll be able to examine critically the sort of clinical and programmatic teaching points that are used to highlight the lessons that are learned in the cohort review. Youll be able to identify issues that need follow-up by different staff members who are present. And youll be able to identify benefits of the cohort review process and the program improvements that you can expect if you start doing this as part of your program. Slide 4 Our faculty today; they are myself, Kim Field, Section Manager, TB Services at Washington State Department of Health, Shu Wang, Medical Director at the Ben Franklin TB Clinic, TB consultant for the Ohio Department of Health and Assistant Professor of Infectious Diseases at the Ohio State University. Slide 5 Christina Dogbey, Epidemiologist, Philadelphia Department of Public Health Tuberculosis Control Program, Mary Katie Sisk, the Supervisory Nurse Coordinator at the District of Columbia Department of Health, Bureau of Tuberculosis Control. And joining today, we have also Anthony Lloyd, Disease Intervention Specialist at the Philadelphia Department of Public Health Tuberculosis Control Program. Slide 6 Now I know that participating today in the Webinar, we have a mixed audience. Some of you may be program managers, medical directors, consultants, epidemiologists, public health nurses, supervisors, case managers, outreach workers, or any of a number of other health occupations that are contributing in the effort to eliminate TB. I think that each of you will see a part that you can play in a cohort review portrayed today. Slide 7 Now I want to take a look at some of the background resources. I want to remind everyone that most of the information in this series of webinars comes from our experience, as well as these resources here, the instruction guide and the video DVD that are both entitled Understanding the TB Cohort Review Process. The guide itself is undergoing revision and an updated version will be available soon. Slide 8 Ive put up here a constellation of the TB control staff who are going to be involved in our simulated cohort review today. You met most of them on our last Webinar, and Ill go around clockwise from the top. Kim Field from Washington is the program manager. Christina Dogbey is the data analyst or epidemiologist. Katie Sisk is a case manager and, likewise, Anthony Lloyd is a case manager. On the left, Dr. Shu-Hua Wang is the medical reviewer and this comprises the team of five people who are going to be conducting and theyll actually show you how theyre doing the cohort review. The last webinar, you learned about the activities that they do and the roles that they play in preparing for it and following it up, but right now, youll see them, or hear them actually doing it. I want you to think of our presenters today sort of as actors playing their roles. Theyre not to be considered flawless TB experts. If anyone makes any inadvertent mistakes in following TB guidelines or procedures, this is intended to reflect real work situations. People may in their during the cohort review today, give evidence of priorities or policies or practices that are different from what your program does. Thats OK. I want you to focus on the process and the teamwork that makes a cohort review happen, rather than on any particular case detail. In addition, you may notice that the two case managers; that would be Anthony and Katie. You may notice that theyre using slightly different forms when they make their case presentations. Thats because they come from programs in Philadelphia and in Washington D.C. I want you to take this as an example of how you can customize the form and the approach to meet your own programs needs. Whats really of important is that the order of the information presented from the forms be the same as the order in which it is collected on a spreadsheet. Now I also wanted to point out that Christina, the epidemiologist, will be working in the background and shes going to be checking on her spreadsheet to make sure that it reflects all of the key data that the case managers present. So thats all the opening words I have now. Slide 9 I will turn the program over to Kim Field, who, as the program manager, will be leading the cohort review meeting. Kim? Kim Field: Thank you, Bill, and welcome to our cohort review today. We will have our group of presenters and reviewers. We have Dr. Shu Wang and Christina, Katie and Anthony, as you heard introduced by Bill. Id like to go over a few ground rules before we begin the cohort review, which will assist in a seamless presentation and consideration of the presenters. So if you brought cell phones into the meeting today, please put them on vibrate. And if you do have to take a call and go outside the room, be respectful if theres other offices or other individuals that you might be interrupting. And when participating via conference call, please do not place your phone on hold, so that we might be hearing music or whatever is on that phone when its on hold. And it is just really important to allow the presenters of the case to go through their case presentation and then we wait to the end and then well review the cases and then the contacts are reviewed and well review and we hold our questions to the end to be respectful of each presenter. Slide 10 So if theres no questions on our ground rules, Id like to have Christina now present a summary of the demographic characteristics of our cohort today. Christina? Christina Dogbey: Thank you, Kim. Good afternoon, everybody, and welcome to the cohort review. I will be going over the medical and demographic characteristics of the cases that were counted during this quarter, which is the second quarter of 2010. Slide 11 So this quarter we counted 25 cases. We counted 12 in the month of April, 8 in the month of May, 5 in the month of June, for a total of 25 cases. Slide 12 This is our cases by age group. As you can see, we had two cases under the age of five. We had four in the age 5 to 17 bracket, two in the age of 18 to 24, six cases that were age 25 to 44, eight cases that were 45 to 65 years of age, and three cases that were older than the age of 65. Slide 13 This is our cases by birth country. As you can see, the majority of our cases, 14, were non-U.S. born compared to 11 U.S.-born cases. Of the 14 cases born outside of the United States, 6 have been in the United States less than five years and 8 have been in the United States five years or longer. The countries represented by our foreign-born patients include the Philippines, Laos, Puerto Rico, Indonesia, Haiti, Cambodia, China, the Dominican Republic, Brazil, Guinea and Vietnam. Slide 14 This is our cases by special therapy status, which is their HIV status. We had 17 cases that were HIV-negative, 4 cases that were confirmed to be HIV-positive, and 4 cases, which at this time of cohort, their HIV status is unknown. Slide 15 Heres a presentation of the clinical characteristics for the TB cases counted this quarter. We had 22 culture-positive pulmonary cases, of which 12 were sputum-smear positive. We had two extrapulmonary-only cases, no cases of both pulmonary and extrapulmonary disease, one clinically confirmed case, one multidrug-resistant case, and two cases that showed other drug resistance, which included one case resistant to INH and once case that was resistant to streptomycin. Slide 16 For this quarter, we had one large, extended contact investigation in a local nursing home. And now Im going to turn it over to our case presenters. Kim Field: Thank you, Christina. I noticed in your data there that, as is a national trend, the foreign-born and then living here over five years, so often what were seeing is that the longer someone lives here with latent TB infection, they have other risk factors that they develop disease, so thank you for that summary. Slide 17 Our first presenter today, if theres no other question, is going to be Anthony and he will start out with case number one. Anthony? Tony Lloyd: Yes. Case ID number 102345, 49-year-old U.S. male, homeless male born in the USA, special therapy-positive and on ART. This is a pulmonary case, sputum-smear positive 4-plus, culture-positive. Source of culture, sputum. Date treatment initiated was 5/28/2010; date assigned was 4/20/2010. Date interviewed was 4/21/2010, in the hospital. Persons currently on rifabutin, INH, pyrazinamide, EMB; that was actually administered in a hospital. Sputum conversion within 60 days, yes. Chest x-ray result is abnormal, non-cavitary. Person completed a total of six months on DOT and completion date was 10/21/2010. Kim Field: Thank you, Tony. I have a question, again, related to the start date for the directly observed therapy. Could you kind of review from this case why there was a delay in the directly observed therapy? Tony Lloyd: Well the patient was actually discharged on 5/27/2010 and started on DOT on 5/28. Kim Field: And so there was no DOT in the hospital? Tony Lloyd: The DOT was actually started in the hospital. Kim Field: OK, excellent. Dr. Wang, you had some questions related to this case, I believe. Dr. Wang: Thank you, Kim. Tony, once again going back to the DOT question, if he had a compliance rate of about 85 percent, can you tell me what some of the barriers were in getting a higher compliance rate and how you may have overcome some of these barriers? Tony Lloyd: Yes, original arrangements were made to DOT the patient early in the morning, by 8:00. At the time, I was also aware that there was a 10:00pm curfew at the shelter, which clearly stated that no one would be admitted after that time. And at times the patient would miss the curfew; therefore, it would make it difficult to track him down the next day. After a conversation I had with the patient regarding the missed doses, as well as issue a health department order, he then agreed to go to the DOT center in the morning for his meds if we couldnt make it in the morning. Other than that, there were no major barriers. The patients major concern was applying for Social Security benefits and other services, but those issues were referred to our program social worker, who ultimately was able to spend time helping him overcome some of those issues. Dr. Wang: Great, thank you. I also had one additional question with regard to the duration of therapy. Some physicians may want to extend treatment in a HIV-TB co-infected patient to longer than six months. Can you tell me how that decision was made? Tony Lloyd: Yes, I reviewed the chart and treatment regimen, along with our medical reviewer, who thought that the duration of treatment on the patient was sufficient enough. Dr. Wang: Great, thank you. Kim Field: Any other questions? OK, Tony you want to go on with the contact investigation for this case? Tony Lloyd: Yes, there were 15 contacts identified. There were 15 appropriate for evaluation. There were seven evaluated. There were five negative, two LTBI with new TST, no disease. There were two appropriate for treatment of latent TB infection. There two were started on treatment, one current to care and one lost to follow-up. Kim Field: On the one case lost to follow-up, Tony, were you able to send an inter-jurisdictional follow-up or locate where this person might have gone? Tony Lloyd: Yes, I did a number of things. I conducted what they call the jail track system search. I also did a Department of Welfare check. He actually gave one of his names and I actually put it on Facebook and to see if we can locate the patient through Facebook and that person didnt friend me. Im still waiting for an acceptance. I also provided names to the state shelter administration, just in case they show up at one of the shelters as well. Kim Field: Dr. Wang, you had some questions on some of the contacts here. Dr. Wang: Yes. Tony, you stated that there were 15 contacts identified, but only seven were evaluated. Can you tell me what the reasons why the others were not evaluated? Tony Lloyd: Well I did manage to test all 15 contacts in the first round. Although I stressed the importance of retesting in three months, some were very apprehensive about providing definite locating information to me or the shelter. Neither of them left any forwarding addresses. Dr. Wang: OK, thank you. Kim Field: Tony, I have a question regarding your contacts. Are they offered HIV testing at the time of the investigation? Tony Lloyd: Yes. They were all offered to our I tested them for HIV with the rapid test during the first round of skin testing and all were negative. Kim Field: And so this is real important. Thats wonderful youve done that, because they may have you know a false negative result on the skin test if were not aware of that HIV status. Any other questions for Tony on the contacts? OK, Tony, I think you have case number two. Tony Lloyd: Case number two, 102347, 32-year-old male born in Mexico. Special therapy is negative, pulmonary case, sputum smear-positive 4-plus. Culture-positive, source was sputum. Date initiated was 4/20/2010. Date interview was on the same day, 4/20/2010, which is also the date assigned. Recommended initial therapy, yes. Sputum conversion within 60 days, no; person didnt convert within 60 days. Pansensitive and cavitary. Currently hes taking TB medication, has completed nine months of TB medication on DOT and is likely to complete treatment within 12 months. Kim Field: Dr. Wang, you had some questions related to this case. Dr. Wang: Yes. So one of my questions is regarding the DOT therapy, which was not done initially. Given patients at high risk for noncompliance, was there any consideration for ordering DOT on this patient? Tony Lloyd: Yes. During initial assessment, the patient stated that he is a construction day laborer, who works at 6:00 who started work at 6:00 a.m. and he also asked if he could self-administer the TB medication. But before a decision was made to allow the patient to self-administer, I offered other options, such as being DOTed at one of our 10 district health centers during work hours. The patient claimed that most of the employers were not willing to allow him to leave the site, so I brought the issue back to the team nurse, who decided to conduct a two-week trial to allow the patient to self-administer. At that time, I gave the patient the office number along with my phone number to contact me just in case anything changes. Once I got a chance to speak to the patient in the hospital again, myself along with a Spanish-speaking outreach worker, we educated the patient regarding the seriousness of his illness. The outreach worker also agreed to adjust his schedule to start at 6:00 a.m. to DOT the patient. I then followed up with a health department order and that seemed to do the trick. Dr. Wang: Great, thank you. Seems like you guys overcame a lot of challenges to get him DOTed, which is a great job. And I also want to commend the team for extending the treatment, since the patient was culture positive at two months, to extend it beyond the six-month to nine-month treatment. And then will you be getting a final chest X-ray or did you get one before the closing date? Tony Lloyd: Not yet. Since he is due to complete next month, at that time well obtain a final chest X-ray. Dr. Wang: Great, thank you. Kim Field: Tony, that was excellent. This is a very challenging case, as a lot of our cases are, so Im anxious to hear how the contact investigation went. Tony Lloyd: Yes. There were 16 contacts identified. There were 16 appropriate for evaluation. There were 12 evaluated; four refused. There eight negative; there were four LTBI, new TST, no disease. There were four appropriate for treatment for a latent TB infection. Four started on treatment for LTB and four are current to care. Kim Field: Dr. Wang, you had a question? Dr. Wang: Yes. With regards to the contacts, were there any children that were under the age of five that were identified? And if so, was window prophylaxis offered to these children? Tony Lloyd: Yes. There were two kids, five and seven; they were actually current to care. They started on LTBI treatment and theyre, right now, current to care. During that time, we actually conducted another re-interview and there were no other contacts identified outside of the house as well that could benefit from a skin test or anybody who was HIV positive. Dr. Wang: Great, thanks. Kim Field: So you were able to do the directly observed therapy with those children then, at the same time as the case, right, Tony? Tony Lloyd: Yes. Kim Field: With those that had refused, what type of education or work did you do with those individuals to stress the importance of being exposed to TB? Tony Lloyd: There were numerous attempts to stress the importance of follow-up testing. I did get a chance to do the first round of testing and they were negative. The contacts; they just remained adamant about not getting tested. They never actually gave a good reason, but for their convenience, what I did do is I gave them a list of some of the local district health centers, just in case they wanted to follow up on their own. Kim Field: Besides the family, you really certainly identified that you worked very well with this family. Were there any other social activities outside of the work sites that you identified that you may need to expand the contact investigation? Tony Lloyd: The patient claimed that there were no social activities, such as bars, sports, or churches, but there were four contacts that I did identify who were also bricklayers, just as he was. And at times, they would work with him on larger jobs. They all tested negative in the first round and were informed that a three-month follow-up was needed in order to be considered evaluated. All four made a refused follow-up testing. They for some reason, they felt that they were evaluated the first round and they were OK. But I also gave them some information regarding additional testing at any one of our health centers. Kim Field: Well these are challenging cases, Tony. And I think you and your case managers did a excellent job. If theres no further questions, thank you, Tony, and well move onto case number three and Katies going to present that case. Katie Sisk: Case number 102348, 43-year-old female born in Vietnam. Arrived in the U.S. 2008. Special therapy-negative. OraQuick done on 5/8/10. On no medications, no coexisting medical conditions. Risk factors, she was born in an endemic country and TB control was notified on 4/28/10. Its a sputum smear-negative case, culture-positive. Collection date of the smear was 4/28/10. The culture-positive collection date, 4/28/10. The conversion date of the culture was 5/28/10. The case was assigned on 4/29/10 and the patient was interviewed on 4/31/10. The patient is pansensitive, has an abnormal, non-cavitary chest X-ray. The patient initially was started on INH and rifampin only on 5/4 by a private provider, who we had consulted with when we realized this on 5/8 and he agreed to co-manage the patient. We picked the patient up for DOT on 5/8/10 and began RIPE. The patient has completed medicine, completed within 12 months, and the completion date was 11/31/10. The patient finished six months of DOT therapy, with a compliance greater than 80 percent. Kim Field: Thank you, Katie. Challenging when we work with our private providers. Dr. Wang, you had a few questions? Dr. Wang: Yes. Katie, I heard OraQuick, but I didnt quite hear was what was the HIV status of the patient? Katie Sisk: When the patient was initially reported to us, the private provider had not tested the patient, so we did a OraQuick in the field with the first DOT visit and the patient was negative. Dr. Wang: Great, thank you. And then can you review, again, the initial medication regimen that the patient was started on? Katie Sisk: Yes. Unfortunately, on 5/4, the provider had put the patient on INH and rifampin only. And in having conversations with the patient and the provider, we were able to have one of our clinic physicians call this provider, consult with them, agree to the co-management, and to have the medication adjusted, which was done on 5/8, and that is what we take to be her start date of therapy, when she was placed on RIPE. Dr. Wang: Right. Thank you, it once again, it shows how working with a private physician can be challenging, but great job on the team for getting the medication adjusted quickly and then having the appropriate completion date with the new regimen. Good job. Kim Field: Yes, I agree. Thank you, Katie. Do you want to present the contact investigation for this case now? Katie Sisk: Yes, the patient we identified three contacts. None were inappropriate for evaluation. Three were appropriate for evaluation, three were evaluated, and all three first and second tests negative. Kim Field: And with your contact investigation, were there any other social settings or any other at-risk contacts that you were concerned about? Katie Sisk: In doing this investigation, we tested the spouse and two friends, close friends that she identified. And since all three were negative and we felt they had spent the most time with the patient, the only other activity she identified was going to morning mass. She was not in the choir and since the immediate family and friends were negative, we decided not to; that no other these lesser areas of contact, we felt we didnt need to do an investigation there. Kim Field: Very good. Youre going to present case number four. Katie Sisk: Yes. Case number 102436, a 36-year-old female, USA-born, special therapy-positive. Date of testing 6/1/10. Patient currently refusing antiretrovirals, has a risk factor of IV drug abuse, cocaine. TB Control was notified on 6/10/10. The patient was sputum smear-negative, culture positive. The collection date for the smear was 6/1/10. Culture-positive collection date 6/1/10. Date assigned, 6/10/10. The conversion date was 1/5/11. The date of interview was 8/5/10. And the delay in interview was a delay between the hospital reporting the patient to us and at which such time the patient had already left AMA and then it took us over a month to locate the patient. The patient was initially pansensitive on 6/1/10, but however, on 10/1/10, the patient felt bad, went to the emergency room, got admitted. The chest X-ray was worse; the smear was now positive. The culture was again positive. We suspected MDR and her medications were changed at that time. So on 10/1/10, she was listed as a MDR case, now resistant to INH and rifampin. Her chest X-ray was abnormal, non-cavitary. The patient started treatment again. Her initial start date for RIPE was 8/5/10, when we located her. For some reason, on 9/7/10, the provider seeing her took her off of rifampin, secondary to a drug reaction and did not initially allow us to do DOT; felt that the patient was dealing with enough just finding out that they had immune system issues and was having a lot of problems, so did not agree initially to DOT. But on 10/1, with that new admission, we got a court order for DOT and, due to the previous refusal and now her suspected MDR status and began DOT on the 10/1/10 on the MDR regimen and that became her new therapy treatment start date. The patient has not completed therapy, will not complete in 12 months, and is currently on meds and has taken four months of the MDR regimen. We expect the completion of her therapy to be somewhere, 18 to 24 months or around October 2012. The patient has completed four months of DOT and thats from the 10/1 date, with about a 95 percent compliance and thats was really initially due to the court order. Kim Field: Well this is a very complex case, Katie. And your summary just demonstrates, with the cohort review process and the resources and the time that it really takes to work with these high-risk individuals. I had one question about the delay in the interview. Could you I see that the case was assigned and then there was a almost two-month delay in the interview. Could you explain that? Katie Sisk: Yes. Unfortunately, like I had previously stated, the patient was admitted to the hospital, went AMA on the same day that the hospital reported her to us, so we missed that face-to-face meeting. We did go to the home that she had an apartment. We go the emergency contact numbers that the hospital had. None of those panned out. She never opened the door or even acknowledged that she was home when we were there. We sent her name out through our lost-to-follow-up list to all the area hospitals, the jail and the morgue and were finally able to locate her on 8/5 and that was the day we did the interview and got her started again on treatment. Kim Field: Thank you. Again, many resources, much time for this case. I believe Dr. Wang had some questions. Dr. Wang: Yes. Just a couple questions. One is I know that she had refused DOT initially and then I commend the team for getting a court order later on, when it was just a little bit too late. But initially, were you able to really talk with the private care provider or work with her HIV case manager to try to get the patient DOTed? Katie Sisk: Initially the patient did not accept that she was HIV positive and we were working with the private provider. However, due to her initial negative smear and the provider feeling that they had a good relationship with the patient and the patient would comply, we actually lost in court because of the negative smear. But when we were able to show then that she was noncompliant and by that time the provider had no objections to us doing DOT, we went back to court and picked her back up. She had you know refused initially acknowledging her HIV status. The last CD4 count we had on her was January 10th-11th and she had a CD4 of 209. But however, since the court order and shes met with our staff and realized that you know were only trying to help her and we are accessing some of the incentives that come along through the HIV program, such as housing and helping with rent and food, she is now considering going on treatment and working with an HIV provider. Dr. Wang: OK, good. And then the other question that I had was regarding the rifampin that was discontinued. There was some question whether it was an allergic reaction. Rifampin is such an important part of our initial regimen, even though the patient later became resistant; was there any documentation of this as a true drug reaction? Katie Sisk: No. What was listed in the medical record was really skin rash and of course, you know we would have evaluated that more closely if we had been totally managing the patient, but unfortunately, working with the providers, they had taken them off the meds and then, of course, till we found out and she was already we found her back in the hospital. Dr. Wang: Very difficult case. And then just a last question, after you guys suspected multidrug resistance, what was the regimen again that you started this patient on? Katie Sisk: On 10/1, the regimen began. Amikacin intramuscular, and that was a patient choice; PZA, ofloxacin, ethionamide and Pasur. We did have to add B6, 100-miligram dose and synthroid, because within a month she was had labs that were showing some hypothyroidism. Dr. Wang: OK. Im glad you guys used that the injectable is really important when youre suspecting MDR and once the MDR was confirmed, so that was good, by adding that plus additional agents at that time. Thank you. Kim Field: Katie, I had a few remaining questions here on the case. You had mentioned the commissioners order and that is so important in this high-risk individual and including acquired drug resistance, so is that process difficult or do you have already established policy, procedure, protocol? Katie Sisk: Yes. There is a protocol within the department that, through our legal branch at the department of health and we are able to move forward, once we have all the documentation together, within 24 hours to get a hearing. However, we have to show that each step of the way, what we have done through documentation to help bring this patient into compliance; meeting them, possibly offering off-hour DOT, providing incentives. You have to really have clear, good documentation that weve gone above and beyond to try to help this patient and the patient is not accepting it. Kim Field: Excellent. Good work; good policy in place. And what was her housing situation? Katie Sisk: She was actually able to maintain an apartment and that was the address that the hospital had given us. She does get a disability check, but we were never able to locate her there. So what we had to do is start looking in the known drug areas that we knew of and that is eventually how you know we were able to locate her and find her. Kim Field: Great. And as was mentioned in your excellent presentation and then discovering that we had acquired drug resistance, then you readjusted the treatment regimen and the completion date was adjusted to how many months? Mary Kate Sisk: The completion date; shes going to be 18 to 24 months, minimum 18 and at least you know somewhere between 18 and 24, so that puts her at a completion date of 2 October of 2012. Kim Field: Very good. If there are no other questions then, Katie, do you want to go on with the contact investigation for this case? Katie Sisk: During the investigation, we identified five close contacts. Five were appropriate for evaluation, three were evaluated, and of those three, three were negative. Two were adults and one was a two-year-old child. Kim Field: And, Dr. Wang, I think you had a question here on the contacts. Dr. Wang: Yes. I noticed that the contact investigation was not started until October. Given that the patient was high risk, even though she was smear-negative, was there any concerns or policy to maybe do the contact investigation initially, when she was first diagnosed back in June? Katie Sisk: Yes. We actually did attempt to do one through the initial reporting, but however, the only information that the hospital had was basically her name, her address and, like I said, going there, we were never able to get her. In our lost-to-follow-up list that we send out to the other facilities, we do ask if even if the patient is not in-house, do you have any emergency contact information, but most of the numbers were nonworking numbers and it was just a persons name or number. And it wasnt until we when we located her on 8/5, she was pretty angry and hostile and not giving up much information other than these five people. Dr. Wang: Thank you. Kim Field: Katie, we know the substance-abusing culture makes it very difficult for barriers to a contact investigation. Either people arent aware who their contacts are or they dont want to name people. And so we have to use you know other means or alternatives. What type of strategies do you have in trying to work with the substance-abusing culture in trying to identify these contacts who are at risk? Katie Sisk: Well once we were able to work with her a little bit and when she went back in the hospital on 10/1, she really was scared. And in going back several times to speak with her, bring her some small incentives while she was in the hospital, we were able to get these few names and she did identify an area where she normally did her drugs and it was an open-air market; open drug area in one of the local parks. And we did identify two other contacts, but in talking to them, the field worker talked with them first; they refused. One of the case managers went out and spoke to them, still refused, and then we did try to locate once again, when we found out that it was MDR; have not been able to find them again and were actually have not given up on those two. Were still going to try to find them. But it was mainly gaining her confidence and trying to work through that you know were not going to work with the police. We just need to get these people tested. Kim Field: Very good example of the difficulty, but the strategies that you applied were excellent. Again, this substance-abusing culture, high risk for HIV; do you screen your contacts? Katie Sisk: Yes. The two contacts got OraQuick; the two adults. There was a two-year-old and unfortunately the two adults were her drug partners that she usually used with and the two-year-olds mother actually refused to have the child evaluated or tested. So what we had to do was go through protective services. They brought the child in for the evaluation. The child was negative and, but Mom refused the window prophy, even after speaking with the nurse and our physician. Protective services did mandate the evaluation, but was not willing to override the moms refusal of medication. The mom cited the side effects of the medicine; that she didnt want to hurt her child. We again explained that this could be much more damaging if the child actually came down with MDR, but we were not able to persuade her. We reached out to the childs pediatrician, hoping that maybe they had a better relationship and would be able to convince her. The pediatrician was not, but it did put the pediatrician on notice to when they see this child to be able to follow them a little bit more closely, in addition to us. The mandate from protective services is well be following this child for two years. Kim Field: Very complete follow-up. Again, as we know, children are certainly at very high risk and this was important the follow-up that you have explained with this investigation. And, Dr. Wang, I believe you had some questions. Dr. Wang: Yes, thank you, Kim. And, Katie, another very challenging case and you guys really; working with the child protective services and the private physicians and really trying to educate the family and the mom on the importance of following the child and window prophylaxis, even though shes refusing. What is the plan, in terms of following these MDR TB contacts and the child? Katie Sisk: Everyone will be followed every three months for two years and I know you can go three to six, but because of the drug history, were afraid that if we let it go any longer than three months, we may not be able to locate them. So we really want to keep close tabs on them so that we are able to follow them closely. Dr. Wang: Good; good job and good job getting the contacts retested of those that initially refused, so good. Kim Field: Well, Katie, that was excellent; very challenging cases. We unfortunately see more challenging cases than not today, but excellent presentation and your team did a great job. Slide 18 So if theres no further questions, we will move onto Christina, who is now going to give us a summary of the outcomes of our cohort review today. Bill Bower: This is Bill. I just wanted to have everyone imagine that were going through a fast-forward. Youve just heard four cases presented, but this cohort had a total of 25 cases, so imagine that 21 more cases were presented and now Christinas summary will be based upon the outcomes of the review of all 25 cases. Christina Dogbey: Thank you, everybody, for great presentations. Im going to present the results of this cohort. This is the second quarter of 2010 and todays date is February 10th, 2011. All indices presented will be as of todays cohort. Slide 19 So our index of completion as of today is 54.5 percent. Slide 20 Our index of completion, including those who are likely to complete, is 90.9 percent; the national goal being 90 percent and our program goal being 70 percent, so we are meeting both goals. Good job, everybody. Slide 21 Our death rate, which includes those cases that were reported at death and those cases that died during treatment, was eight percent. Slide 22 Our default rate, which includes those patients that were lost during their course of treatment and those who refused to initiate treatment, was 4.2 percent. Slide 23 Our total cohort failure rate, which doesnt mean that we failed in doing our job; what it does mean is that these include the cases that were lost, the cases that refused treatment and those that were cohort failures or theyre not going to be able to complete their therapy within 365 days of treatment initiation; that was 8.3 percent. Slide 24 The percentage of eligible patients ever on DOT was 78 percent and the mean months of DOT per patient was six months. Slide 25 We counted 12 sputum smear-positive cases and from time to interview, our mean number of days was one day per case and 92 percent of our cases were interviewed within three days and we have a goal of 90 percent, so weve exceeded that goal; good job. Slide 26 This chart shows the sputum smear-positive interview trend and, as you can see, over the last several cohorts, we have been steadily improving our rates, so well done. Slide 27 Our time to interview, other interviews, this includes cases that were sputum smear-negative, culture-positive, extrapulmonary and clinical cases; we had a mean of 11 days per case for getting cases interviewed, but we did a percentage of 85 percent, which means we probably have a couple of outliers who skewed our numbers. Slide 28 Addressing the contacts, we had 22 pulmonary cases, which are cases that are eligible for contact investigation. When we interviewed them, we got 175 cases, for a contact index of eight contacts per case. Of those 175 cases, 174 or 99.4 percent were eligible for evaluation and, of those; we evaluated 140 or 80.5 percent. The national goal is that 90 percent of contacts with sputum smear-positive cases will be identified and evaluated. Slide 29 Of those contacts that were evaluated, we tested 172 or 67.2 percent. Twenty-seven of those were infected, for an infection rate of 23.1 percent. We had one case that had disease, no suspects. For those cases that were appropriate for treatment of LTBI, we had 26 cases and all 26 were eligible and have started treatment. We have four that completed Slide 30 We have 18 that are still on treatment at this time, we had one that refused to continue treatment, no adverse reactions, two that were lost to follow-up and one that moved out of jurisdiction. Slide 31 The last possible cohort that had a chance to complete a full course of therapy would be the fourth quarter of 2009. Our best possible completion rate for that cohort was 100 percent. Slide 32 And our finalized result was 81.8 percent. There were a couple of cases that were not able to complete due to drug challenges. Slide 33 This is our trend over the last few months of cases who were likely to complete versus cases that actually completed therapy. As you can see, we are having some gaps between those cases we think will actually complete therapy within one year and those who actually do complete and so were working to close those gaps and were getting better. The goal is 90 percent, so we still have a little bit of work to do. Slide 34 For LTBI completion, the blue bar is our average over the last several cohorts of every contact that was evaluated and the white bar is the most recent cohort that would have had a chance to complete a course of therapy for latent TB infection. As you can see, we are doing pretty well. We average are evaluating about 80 percent of our contacts. We have an average infection rate of 35.6 percent, which is a little bit above the national average, but we do well at starting all of our contacts on therapy and getting them to complete. Slide 35 The last cohort we did was first quarter 2010. In that cohort, we counted 37 cases. There were 10 case issues identified and nine of those issues were resolved or addressed. Slide 36 An example of those issues included: following the CDC guidelines for HIV testing for all patients between the ages of 15 and 70, following the new CDC guidelines to treat all HIV-infected patients who have been recently exposed to TB regardless of previous treatment, noting that INH resistance is something that we are watching closely, investigating systemic ways to alert hospitals in other jurisdictions about infectious patients who may be lost, and then some database issues, including closing cases in the TB registry, updating contact information and expanding contact investigations when necessary. Slide 37 At this time, if there are any questions, Im open to hearing them. Kim Field: Thank you Christina. Its interesting that our issues that we identify, are we going to really see, with reduced resources that were all experiencing, if were going to be able to work on these issues or will they be continuing as ongoing with short staff and time to address these issues? And that is really one of the benefits of cohort is to document what has occurred over time or what were not able to do, so thank you. Those were excellent. Our cohort today has concluded and we will come back together in May at the same time for our next cohort review. Thank you to all the presenters today. Slide 38 Bill Bower: OK, this is Bill again. That ends our simulated cohort review and now well talk a bit about the benefits and the challenges of cohort review and well take your questions. I would like to invite each of the presenters to actually tell us what does cohort review mean in your program and what sort of benefits have you seen it bring? Kim Field: So one of the challenges I see often in some of these cases; this is Kim again. When the case is being presented by the individual, it may not be the case that theyve cared for. That may be, as often is happening today, with a private provider, so the cohort review really provides that opportunity to identify interventions of really working with the private providers and the challenges of being successful doing that. Dr. Wang: This is Shu Wang. I think for us, its really brought our program together in the sense that were able to really see the data. Weve always been doing case management and contact investigations, but with the cohort review process weve been able to really present the data in a formatted fashion and see the results of the data presented and compare our results to that of the national average and to our previous average. So I think and then all of our TB team is allowed to come this, so that they can actually see what were doing. So I think in that sense, its really brought the program a lot closer together and people know what the beginning and the endpoints are. And some of the challenges were just getting the program started, but I think now that weve gotten it started, weve definitely seen the benefits of the program and will continue with it. Katie Sisk: And this is Katie. For us its meant increased accountability. It allows you to take another in depth second look at your case. The data drives the changes that we make and in many cases it becomes a good teaching moment. Christina Dogbey: This is Philadelphia and I just echo all the sentiments of the other presenters that we kind of use the phrase around here, what gets measured gets done and so it helps us to know what it is that we are doing really well in and what we need to maybe focus on in terms of maybe adjusting policy or creating policies or you know creating teachable moments for training for our staff. And for me, from an epidemiologic standpoint, its a little bit self-serving, because it helps me to kind of get reports and data together a lot faster, because the datas already clean, its already ready to go, and its already in a pretty usable format. Bill Bower: Tony, Id like to ask you, as someone whos out there investigating outbreaks of TB, working with patients in that firsthand, how do you see cohort review? Anthony Lloyd: Well one of the challenges, as always, we started off with the old case reviews, which would take two and three days, sometimes, just to oversee maybe 10 cases. One thing that has worked for me is that, while we implemented it, at the time that the case gets assigned, we actually start the cohort process. We enter all our data information, anything that we can obtain during the initial report, we obtain that information and put it on the sheet, so that kind of helps me do what I need to do as a supervisor. So far we havent had any complaints. No one wants to go back to the old case reviews. The cohort; we can actually go through maybe 20 cases within maybe an hour, so that kind of frees up time for other workers to do what they need to do in the field. So its a great benefit for me as a supervisor and Im sure its a great benefit to my staff; the outreach workers. Bill Bower: Yes, actually I was tracking the amount of time it took us to review the four cases today and case number one took six minutes, case number two seven minutes, case number three four minutes, and then the really complex case; we took 18 minutes to go into that very complex MDR case. So I see that it can be done quickly, but you can really manage it so that where youve got the most to learn, the most work to do; that you one you can you know put more time into. I think that was a good use of time. I think many programs can do this sort of like averaging maybe about five or six minutes per case. Slide 39 Id like to move onto the issue of challenges of doing this. You know some people have the impression that, oh my God; its overwhelming. Its really hard to do. Others see its not too much harder than what you did today. Its just something that you buckle down and do. Id like to ask each of the presenters you know tells us what sort of challenges do you have and you think that others would have if theyre getting started. Kim Field: Well this is Kim again and the way that we started and we continue today in Washington State is that we have the large city of Seattle, which is King County, and they have half of our cases in a year at any one year and then we have the rest of the state; a lot of rural areas. Maybe those some of those counties dont see a case in 5 or 10 years. But we were able to combine with all of our staff going to Seattle, spending half a day with Seattle and then the remainder of the day with the counties calling in on a conference call, because they would not be able to travel you know even quarterly. That maybe sound like a challenge, but you know since 2003 there hasnt been one area that has not wanted to participate and I think of a challenge is that right now we have staff turning over and people coming into programs that dont have the necessary knowledge really or the access to have training and education, so this provides that opportunity. Katie Sisk: And this Katie from D.C. I really think a lot of the challenges are more of a perceived challenge than they really are. We were able to put the process in place fairly quickly, because we borrowed everything from all the other places that were doing it and then just adapted it to meet our needs. Probably the most to overcome is the initial reluctance, but once you actually get past that cohort, to a person here, I dont know of anybody that doesnt believe in cohort and has been able to see immediately what it does for us. Dr. Wang: And this is Shu Wang from Franklin County, Columbus, Ohio. So for us, I just wanted to mention about what Bill had said about the time. We had 66 cases of TB in our county last year, so each cohort session is about 15 and because Im the medical director; I review the cases prior and we have case management sessions and we also have contact investigation sessions, so the cohort actually goes pretty quick. Its maybe an hour to two hours at the most and our epidemiologist has all the data ahead of time, so we can crunch out the numbers. So it can go quicker if youre more familiar with the case. For the presentation today, it was kind of like an outside reviewer who didnt really know the case, so a lot of questions were asked in more detail. In terms of our challenges, and I think I agree with Katie; it was just once we got buy-in and we got it started, it went you know very well and we did borrow the format and stuff from other programs that are established and then once we got it going, we kind of revised it according to our own needs. So I think once you do it, I think itll youll see the benefits. Christina Dogbey: This is Christina from Philadelphia and I agree with all the presenters again. I think a lot of the challenges were perceived challenges as well. Its a matter of getting buy-in. When I actually started working with the TB Control program, they were already doing cohort and one of my first jobs was to get cohort ready and I was able to kind of slide right in as a brand new staff member and get it done, so its very easy to really adapt yourself to it. And as much as there are things that people find that could be problematic with it in their minds; those are the things that actually make it a really good process, because it allows for discussion, it allows for you know teaching, and it allows for people to walk away, including our division director, who doesnt know on the day-to-day, what we actually do. But she can come to the cohort meeting, listen to our presentations, and she walks out knowing exactly what the TB program has being doing, from start to finish, for each and every case that we take care of. Bill Bower: Well thanks very much. Well I guess you know what Im seeing is that, in fact, each cohort review process in each one of your programs sort of has its own personality. Sometimes its like its maybe a real free-flowing discussion, in which youve got social workers or pediatricians or community doctors or outreach workers involved. In other cases, it may be something a little bit more formal, reviewing a lot of work thats already been done that youre already familiar with and it can be used to still highlight important teaching points. In some programs its done over the phone or over live Web communication and its got sort of a distance education approach. In other places, its you know like a group meeting with a breakfast or a lunch or something served there that makes it a real kind of a gathering way. Either way you do it, I think it you know really can be effective. So I really want to thank all of you for sharing what youve been explaining about how youre doing it and sort of for acting out a cohort review. That went really well. Slide 40 By now Im sure that the listening public may have questions. I do have one question that came in and so Ill go ahead and throw this out. I know earlier I said that if any of your programs has a different policy than what you see shown by the people doing the review today on the webinar, thats because your policies are different; its not because you know one way is right or one way is wrong. But a question came in saying why is it that you are measuring the months of DOT in months rather than actually measuring the number of doses that were taken? So Im curious; any of the presenters, can you tell us you know why does your program do it, because its more convenient or its hard to track all the information, dosage-wise? Why is that? Dr. Wang: This is Shu Wang. We actually count the number of doses, so for Gail who asked the question. We do count the DOT doses, but the months just kind of gives us a ballpark idea. Kim Field: This is Kim, on that question, whats happening in Washington State and Ive been getting input from other states, that as, again, the resources are dwindling, people are really, unfortunately approaching that lets cut DOT, of all things, but it is happening in real time. And I think its just very important to speak to the amount of time, also, that the individuals on DOT. If were going to have these you know changes, hopefully well be able to maintain the first part of therapy. But it gives the picture of the whole case management. Christina Dogbey: This is Christina from Philadelphia. I think we do months for the same reason. It just makes it a little bit easier for people to understand, especially if we do have outside people who come in. It just keeps things going a little bit smoother and also we know that the numbers change based on the actual clinical characteristics of the case and so we dont want people getting confused. Katie Sisk: And this is Katie from D.C. We use dose count to get towards completion, but in presentation, we just do it by month. Bill Bower: OK, another written question came in, saying that on the cohort form, looking on the notes and definitions on the backside of it there; theyre saying why are you asking if adherence has been below 80 percent? Is this used to determine if treatment has been completed? And if so, do you consider completion of 80 percent of recommended doses as adequately treatment completion? I know its important to make sure that youve got your definitions understandable for everyone in your program, so this, again, is a question looking at someone elses policies rather than the process. Does anyone want to comment on how their program looks at that? We just did hear that in D.C. and Ohio, theyre actually counting doses, so I would assume then you know on their forms, they could specify the number of doses. But, Christina, I guess you know you guys and some other programs are going mostly by month of completion. Christina Dogbey: We do count the doses and then we convert those into months. That just makes our lives a little bit easier. Bill Bower: OK. So I think, Jill, you asked that question. You can see that most of these programs, I guess just to throw up a rudimentary number are throwing up whole months in which adherence was 80 percent or better, but they are counting doses on the side; they admit. Are there any questions? Ann: Hello? I have a question about definitions. I have a question about the definition of compliance rate; how do you define compliance to get a rate? And then theres number of eligibles for DOT. What is appropriate for evaluation and what is appropriate for LTBI? Bill Bower: Ill jump in and give you a really quick definition. For your program, those definitions should be whatever your program has set them to be. You dont have to follow the definitions used by any of the programs presenting here. But now Id like to invite the programs who just presented to go ahead and give you their rationale for these. Katie Sisk: Hi, this is Katie. To figure out compliance rate, you take the number of DOT days that you would be able to do in a month and you divide that into the actual number of days that the patient did DOT and that should give you your compliance rate. So for January, to count the number of available DOT days, we would not have taken the holiday. We would have taken that out. So again, you count your number of actual DOTs and then divide into that the number of days you could have actually DOTed the patient. We actually have that tabulation on the bottom of our DOT calendar, so that every month it includes the dose and the compliance rate for the physician. Ann: Thank you. Kim Field: And then did you have a question about evaluated; what that meant for contacts? Ann: Yes. There were things on the spreadsheet, like the number of contacts who were appropriate for evaluation, number of contacts appropriate for LTBI treatment. Bill Bower: This is Bill. Ill break in here. Some programs I work with consider that all contacts that were named should be evaluated unless they have died before it was possible to evaluate them. So death is the only excuse for not being able to be evaluated. Your program could do it the way you wanted to because the situation in New York City or Philadelphia or Ohio may be different where their program is. And you should follow the policies and protocols of your state, your city, your countys health. Kim Field: Well I agree. The definitions that were developed here in Washington State were done by a whole panel that included county case managers, physicians and you know everyone thats involved with cohort. Thats one of the processes of setting up your cohort, for sure. Bill Bower: We have another question. How does the epidemiologist practice filling in the spreadsheet in real time, because it seems like a real challenge to do this while the information is coming in rapidly? Christina, can you take that one? Christina Dogbey: Yes I can. The way I practice really is partially, I try to make sure that I get as much of the data entered into the spreadsheet before cohort even happens. So Im constantly talking with staff and were having meetings. We do practice sessions where the staff will come in and start going through their case presentations and anything that I can definitely say OK, this is a definite data point; let me get this in the spreadsheet, it goes in and it stays and then during cohort, I actually update information. And as far as practicing, you just have to get very familiar with it, learning how to quickly navigate across the spreadsheet, because it is a large spreadsheet. Its just a matter of practicing and it took me a few tries to really get it down. But also, during cohort, I really just try to focus in on the voice that Im hearing presenting and the words that are coming out of their mouths. Im listening for key words to say OK, this is where that data point goes. So I really tend to block out everything until its time for me to start talking again. Bill Bower: OK, well this is actually is all the time that we have allotted for the seminar today. Slide 41 Im including right here the contact information for all of the presenters who have been part of this series of Webinars and at this time I want to extend our sincere thanks to all the faculty for sharing their knowledge and experience with us. For me, its been a real pleasure working with this series and I hope you found it useful. Please count on us to keep helping you to get cohort reviews going. Slide 42 Lastly, I want to thank all of you for your participation, participants and presenters alike. This concludes the conference.     Page  PAGE 29 =mn. 4  ! 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