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Understanding the TB Cohort Review Process: Instruction Guide (2006)

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Essential Element 1:  Preparation for a Cohort Review

This chapter provides information for preparing for a cohort review session.  Each of the four areas of cohort review preparation is explained in detail, and the necessary tools are provided.  For some areas, case studies or exercises are suggested to help individual readers or groups learn necessary skills.

Cohort Review Process: Preparation: 1. Shared Objectives, 2. Case Management, 3. TB Registry, 4. Preparation of Cases for Presentation. Presentation. Follow-up

1.  Shared TB Program Objectives

In order for cohort reviews to be successful, all staff should know the objectives of the TB program.  Staff who have shared in the development or articulation of these objectives may be more vested in their accomplishment.  Working toward the same goals instills accountability within each TB team member for TB cases, contact investigations, and program outcomes.

To guide TB control efforts, several levels of objectives have already been set by other agencies such as CDC, or state and local health departments.  Examples of these objectives were presented in “Table 2: Examples of TB Program Objectives” on page 3.  It is essential that staff members understand how their efforts aid the TB control program in meeting these objectives.

The following exercise assists TB control teams with understanding the importance of developing shared objectives.

Exercise 2:  Developing TB Program Objectives

  1. Read the CDC National TB Program Objectives below.
  1. How do the outcomes in your program area compare to the CDC National Objectives?
  1. Write any specific state-level TB control objectives in the second box.  How do the outcomes in your program area compare with the objectives listed?
  1. Write any specific local-level TB control objectives in the third box.  How do the outcomes in your program area compare with the objectives listed?

Read
CDC National TB Program Objectives

  • At least 90% of confirmed TB patients will complete treatment within 365 days.
  • At least 90% of TB patients with positive AFB sputum-smear results will have contacts identified.
  • At least 95% of contacts to TB patients with positive AFB sputum-smear results will be evaluated.
  • At least 85% of infected contacts who are started on treatment for LTBI will complete treatment within 365 days.

Insert
state-level objectives for TB control

  •  
  •  
  •  

Insert
local-level objectives for TB control

  •  
  •  
  •  

  1. Are there any new objectives your program area would like to set?  If so, what are they?

For a cohort review, the objectives become the standards to which the outcomes of case management and contact investigation efforts are compared.  The objectives also dictate which data elements need to be collected in the TB registry and presented at the cohort review session.  For example, in order to determine what percentage of contacts of smear-positive patients were evaluated, data must be collected on smear results, number of contacts identified, and number of contacts evaluated.

After the cohort review, if some new aspect of the program needs to be strengthened, objectives can be revised or new objectives can be added for the next cohort review.  For example, one TB program believed that the timeliness of conducting the first interview with a newly diagnosed TB patient was an area that needed improvement.  Therefore they set an objective that was SMART, an objective that is specific, measurable, attainable, realistic, and time-framed.  The objective was that “At least 90% of persons identified with TB disease will be interviewed by health department staff within 3 business days of case notification.”  Starting at the next cohort review, the date the case was reported and the date of the initial interview were part of the standard case presentation format.  By adding these data elements, the program was able to track this timeliness variable and measure improvement over time.

2.  Comprehensive Case Management

Comprehensive case management is essential in TB control and elimination efforts.  Cohort review brings together data from many of the components of case management and provides a qualitative assessment of the effectiveness of case management activities.

Case management is a system in which a specific health department employee, typically a case manager, is assigned primary responsibility for managing the patient’s case.  Systematic, regular review of patient progress is conducted, and plans are made to address any barriers to adherence.  All reported cases should be assigned to a case manager, whether they are seen at a health department clinic or in the private sector.  The case manager is responsible for ensuring that patients adhere to treatment, comply with medical visits, and complete treatment.  In addition, case managers are also responsible for making sure that contacts are identified and evaluated, and that they complete treatment for LTBI, if appropriate.

In general, case managers are expected to

  • Follow all policies and protocols for case management to ensure that patients adhere to treatment, comply with medical visits, and complete treatment.
  • Follow all policies and protocols for contact investigation to ensure that contacts are identified and evaluated, and that they complete treatment for LTBI if appropriate.
  • Communicate periodically with clinic and outreach workers to ensure all aspects of patient care are being addressed and troubleshoot any problems that arise.
  • Participate in case review meetings with their supervisor and the TB control team.
  • Prepare information on each case, present the information at the cohort review session, and follow up on suggestions made at the cohort review session.

Exercise 3:  Reviewing Case Management Protocols

Discuss the following questions with your TB control team.

  1. What case management policies and protocols does your program area have?
     
  2. How are existing case management policies and protocols leading to successful outcomes compared to your objectives?
     
  3. How are contact investigations included in the policies and protocols?
     
  4. What modifications of the policies and protocols would be useful to help staff do a better job?
     

For more information on case management protocols and training, see the Resources section at the end of this document.

Improvement.  Therefore they set an objective that was SMART, an objective that is specific, measurable, attainable, realistic, and time-framed.  The objective was that “At least 90% of persons identified with TB disease will be interviewed by health department staff within 3 business days of case notification.”  Starting at the next cohort review, the date the case was reported and the date of the initial interview were part of the standard case presentation format.  By adding these data elements, the program was able to track this timeliness variable and measure improvement over time.

3.  Reliable TB Registry

A reliable TB registry is an essential tool of the cohort review process.  Typically, programs use a registry database to collect TB patient and contact investigation information.  A locally developed database provides the universe of patients from which the cohort is drawn.  The date on which the case is counted determines the cohort in which the case will be reviewed.

A reliable TB registry will include

  1. General patient information: name, address, telephone number, date of birth, sex, race, ethnic origin, date of entry into the United States (if foreign born), and country of origin.
     
  2. Medical history: disease site, laboratory results (smear, culture, susceptibility, conversion), radiology, drug regimen, adherence, if on DOT, evaluation dates, completion of treatment or other disposition, provider name or code, etc.
     
  3. Contacts: name, address, telephone number, sex, date of birth, relationship to patient, TST status, medical evaluation, and information about LTBI treatment (started treatment, regimen, disposition).
     

The data analyst will use the registry to generate the list of TB cases to be reviewed in a given cohort, being certain to include the data elements needed to evaluate program objectives.  He or she will distribute the lists to case managers and supervisors so they can be prepared to present these cases.

The following lists are prepared and distributed ahead of time:

  • Preliminary cohort list.  Distributed 5–6 months before a cohort review.  This list provides diagnostic and preliminary treatment and contact information.  The supervisor and case manager use this list to track the cohort of patients from a quarter and to begin preparation of case presentations for a cohort review.
  • Final cohort list.  Distributed 1–2 months before a cohort review.  This list provides updated treatment information from the registry and the results of the contact investigation.  The supervisor and case managers use this list to hold practice review sessions and complete final preparation of the case presentations.

Typically, a “line listing” is all that is needed—one line for each case.  The information may be more complete for the final cohort list because more time has elapsed.

See:


 
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