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

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Essential Element 2: Cohort Review Presentation

This chapter will focus on the presentation of cases and analysis of aggregate data at the cohort review session. Section one, Detailed Review of Each Case, explains how the final cohort review process works and highlights how the TB control team examines the case details. Section two describes the on-the-spot feedback to staff, aggregate reporting, and troubleshooting of the cohort cases. Details on preparing the analysis of data on the treatment and contact investigation outcomes for the cohort are provided.

1. Detailed Review of Each Case

Cohort review sessions are adaptable to any setting. They consist of a team reviewing a listing of the TB cases in the cohort. The team consists of the case managers and others with knowledge of the cases, senior staff (usually a medical reviewer and TB program manager) to evaluate the adequacy of treatment and the thoroughness of the contact investigation, and a data analyst to compile data from the session and provide immediate feedback to the group.

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“Cohort reviews aren’t fancy. They are not expensive. In fact, at heart, they are incredibly simple…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 is what cohort review is… it doesn’t take a lot of money, doesn’t take high tech; just takes knowledge of the patients and systematic tracking of how each one is doing…”

Thomas Frieden, MD, MPH, New York City Commissioner of Health

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The TB program manager typically chairs the cohort review meeting. The manager has the list of TB cases and calls them to be reviewed. Because a cohort session can be rather lengthy and clinical staff may have other commitments for patient care, the program manager may group the cases to allow some essential staff to leave before the end of the session.

The following is a sample agenda for a cohort review presentation.

Table 12: Sample Cohort Agenda

Cohort Review Session Agenda 1st Quarter Cases
9:00	Summary of current cohort	Data Analyst
9:15	Case by case review of patient outcomes	TB Program Manager Medical Reviewer Case Managers
	10 presentations by South Street clinic case managers 32 presentations by other case managers Questions from the Medical Director about diagnosis, bacteriology, radiology, treatment regimens, adherence, and contact investigation, as needed Decisions about disposition of each case
11:30	Calculation and presentation of outcomes for this cohort	Data Analyst
11:40	Summary of treatment outcomes for patients who were “likely to complete” from previous cohort review	Data Analyst
11:50	Summary of treatment outcomes for contacts of patients treated from previous cohort review	Data Analyst
12:00	Summary of issues noted, suggestions for follow-up	Medical Reviewer
Reminder: Next cohort review session scheduled for February 15th

As the cases are called, the staff member responsible for managing each TB case presents patient case data to the rest of the TB program staff. The presenter clearly and concisely presents information on his or her cases and responds to questions from the program manager and other staff.

The TB program manager and the medical reviewer listen to the case presentations, ask questions for clarification about each case, prompt for details of staff efforts to solve problems (e.g., trace patients who are lost), and provide feedback and suggestions on how to follow up on the patients and their contacts. It can be expected that more time will be spent on difficult cases, especially those in which the patient is nonadherent, has MDR TB, or has numerous contacts in a congregate setting.

The people involved in the cases, such as outreach staff, laboratory staff, clinic staff, and supervisors, are there to provide additional information as needed. As each case manager describes the details of the cases, the data analyst updates the registry information. At the end of the cohort review, the data analyst tallies the data elements needed to evaluate the objectives, and prepares a summary in aggregate form to present to the meeting participants.

While a primary function of the cohort review is to provide medical oversight of cases and examine outcomes, another very important function is the addressing of programmatic issues. The medical reviewer or TB program manager can use “teachable moments” to give feedback to staff and update them on policies, protocols, and scientific changes. Lapses in following protocols, missing information, or incorrect information can be pointed out and actions taken to prevent their occurrence in future reviews. The medical reviewer may use specific cases as examples of how certain problems should be handled. Finally, staff training and professional education needs may be identified.

Exercise 5: Practice Presentation and Review of Cases

This exercise requires at least two people: a presenter and a reviewer.

1. The presenter will make a brief case presentation to the reviewer, using one of the forms prepared from the case studies in Exercise 4 on page 28.
2. The reviewer will ask questions to ensure that all aspects of case management adhere to department of health policies and procedures.  Questions should address the consistency of details presented, treatment completion (or if no completion why not), and thoroughness of the contact investigation.  Ask all of the questions that you think a reviewer would ask in a real cohort review.

Switch roles in order to experience both perspectives. Thinking like the reviewer may help you develop better case presentations.

For the case studies presented in Exercise 4, the reviewer will likely have the following questions or comments:

Case # 1 – Mr. Parks Why was there no mention of culture conversion? Why were fewer than 50% of contacts evaluated? Need to coordinate TB and HIV care and treatments Need to explain how the one contact started on treatment for LTBI was lost and what efforts have been made to return the individual to treatment Case # 2 – Mr. Morales Because his 4 household contacts were TST positive, need to test the 4 who initially refused testing Patient needed to be on DOT from the start of treatment; failure to do so caused his treatment to be extended Case # 3 – Mrs. Nguyen Why was HIV status not reported? Home visit rather than telephone interview would have been more appropriate to find additional household contacts Need to reach out to private providers with TB education and encourage interaction with health department staff Who were the three TST-negative contacts? Were they members of the household?

 

2. Immediate Analysis of Outcomes

The data analyst or epidemiologist is responsible for providing an analysis of cohort review outcomes, preferably by the end of the cohort review session. Immediate feedback lets the team know how they are doing in relation to program objectives and allows for discussion of case management or programmatic improvements that might enhance treatment and contact investigation outcomes. In order to accomplish this, the data analyst should update information in the registry on treatment outcomes, contact investigations, programmatic indicators, and other information obtained during the case presentations. This recording and analysis may be accomplished using a manual tally sheet or a computerized spreadsheet or database.

At the end of the session, the data analyst

• Tallies the totals of each category of information.
• Calculates the indices and rates.
• Presents these to the group as a “report card” on the group’s progress toward meeting TB program objectives.

On the following page is a sample tally sheet that can be used manually for a small cohort of cases. It may be used to create a spreadsheet that will do the calculations automatically. The sample tally sheet is based upon the cohort presentation forms provided earlier.

The “TB Information” section of the tally sheet pertains to the diagnostic information about the case (site, smear/culture results, sensitivity, CXR results).

The “DOT” section of the tally sheet provides information on the number of months the patient has been on DOT.

The “Disposition” section documents the disposition of the TB case: is treatment completed and, if not, why not.

The “Contacts” section documents information on the contact investigation—how many were identified; how many were evaluated; how many were infected; do any have disease; how many started on treatment for LTBI. A legend to the tally sheet follows.

The information collected on the tally sheet can be modified to fit specific program needs and data reporting requirements.

 

Table 13: Sample Tally Sheet

(See Table 14: Sample Legend for Tally Sheet on next page)

Tally Sheet

Date:____________ Quarter:_____________ Cases Counted: __ January 1 – March 31

		TB Information				DOT	Disposition												Contacts
Name	Registry #	A-D	Sm+	Cult+	Cav CXR	Mos. DOT	a	b	c	d	e	f	g	h	i	j	k		#ID	App test	#Eval	# Inf	# Trt LTBI	# Comp	# Curr
Parks	10123	A	Y	Y	N	6	Y												15	7	7	2	2		1
Morales	10119	A	Y	Y	Y	5.5		Y											16	16	12	4	4		4
Nguyen	10216	B	N	Y	N	6	Y												3	3	3	0	0

Table 14: Sample Legend for Tally Sheet

TB Information
A-D	A = positive sputum smear result B = negative sputum smear result, positive sputum culture results C = negative sputum smear result, negative sputum culture results, but has other clinical characteristics relevant to contact investigation such as cavitary CXR, positive respiratory culture, or is a pediatric case. D = extrapulmonary or clinically confirmed case
SM+	Smear positive
Cult+	Culture positive
Cav CXR	Cavitary CXR
DOT
Mos. DOT	Months on directly observed therapy
Disposition
a	Completed treatment
b	Likely to complete treatment within 365 days
c	Noncount—not a true case of TB
d	Reported at death—case was reported after the patient’s death
e	Counted by other—another program is counting this case
f	MDR—patient organism is resistant to at least isoniazid and rifampin
g	RIF resistant—patient organism is resistant to rifampin
h	Died during treatment
i	Moved—moved to another program area and records were transferred
j	Cohort failure—patients unable to complete within 365 days regardless of reason
k	Lost—lost to follow-up
Contacts
# ID	Number of contacts identified
App test	Number of contacts appropriate for testing
# Eval	Number of contacts evaluated
# Inf	Number of contacts infected
# trt LTBI	Number of contacts started on treatment for latent TB infection (LTBI)
# Comp	Number of contacts who completed treatment for LTBI
# Curr	Number of contacts who are still on treatment for LTBI

The data analyst uses the information from the tally sheet to calculate certain indices, rates, and indicators. These data are presented to the group as a summary or “report card” for that quarter’s TB control efforts. For the purposes of learning the basics of cohort review, we will only examine a few basic indicators, particularly focusing on those that evaluate progress toward meeting the national TB objectives. For further details, Appendix B contains more complex calculation forms from programs already conducting cohort reviews.

The indices and rates include

• Index of treatment completion at time of cohort review—reflects percentage of patients who have completed treatment at the time of review, excluding those not appropriate for treatment (noncount, reported at death, and counted by another program)
• Index of possible treatment completion at time of cohort review—reflects percentage of patients who have completed treatment at the time of review, excluding those not appropriate for treatment AND excluding those who could not possibly complete (died during treatment, multidrug resistant, and RIF resistant)
• Index of completion—including those likely to complete by the end of the cohort year; reflects percentage of patients who have completed treatment or are likely to complete within 365 days
• Death rate
• Default rate
• Total cohort failure rate

Variables collected in order to calculate the rates and indices appear in Table 15.

Table 15: Cohort Review Variables

Sample Variables Form

Date:__________ _____Quarter of __________

Instructions: Insert the numbers within each category from your tally sheet (or generate it automatically if you are using an electronic spreadsheet).

a	Patients completing recommended therapy
b	Likely to complete treatment within 365 days
c	Noncount
d	Reported at death
e	Counted by “other”
f	MDR and still on treatment
g	RIF resistant/intolerant and still on treatment
h	Died during treatment
i	Moved
j	Cohort failure
k	Lost

Use the formulas below to calculate the indices and rates.

Table 16: Indices/Rates for Treatment of TB Disease

Index Calculations for Treatment of TB Disease
Name of Index	Formula
Index of treatment completion at time of cohort review, excludes cases reported at death, counted by another program, or not a true case of TB	a                           100 Total cases – (c + d + e)
Index of possible treatment completion at time of cohort review, excludes patients who cannot complete by the time of the review (multidrug or RIF resistant) or died during treatment	a                           100 Total cases – (c + d + e + f + g + h)
Index of likely to complete treatment, including those likely to complete within 365 days; same exclusions as above	a + b                       100 Total cases – (c + d + e + f + g + h)
Death rate	d + h            100 Total cases – (c + e)
Default rate	k               100 Total cases – (c + e)
Total cohort failure rate	j+ k              100 Total cases – (c + e)

The data analyst also calculates another set of indices and indicators for the outcomes of contact investigations, including

• Contact index (number of contacts identified per pulmonary case)
• Percent of smear-positive patients with contacts identified
• Percent of contacts of smear-positive patients evaluated
• Percent of contacts of smear-positive patients started on treatment for LTBI
• Percent of contacts of smear-positive patients completing treatment for LTBI

The data analyst uses the totals from the tally sheet to calculate the indices and indicators according to the formulas below (or generates the data automatically in an electronic spreadsheet).

Table 17: Contact Investigation Indices

Index Calculations for Contact Investigations
Overall contact index	# of contacts identified # of cases appropriate for contact investigation
Percent of smear positive cases with contacts identified	# smear positive cases with # identified >0 100 # smear positive cases
Percent of contacts of smear positive cases evaluated	# contacts of smear positive cases evaluated 100 # contacts of smear positive cases
Percent of contacts of smear positive cases started on treatment for LTBI	# contacts of smear positive cases started trtmt for LTBI 100 # contacts of smear positive cases
Percent of contacts of smear positive cases completing treatment for LTBI	# contacts of smear positive cases comp. trtmt for LTBI 100 # contacts of smear positive cases started trtmt for LTBI

Exercise 6: Calculation of Indices/Rates for Treatment of TB Disease

Given the information below, calculate the indices and rates for outcomes of treatment of TB disease. Show your work by putting the actual numbers into the formulas (answer sheet is located in Appendix A).

Sample TB Disease Treatment Outcome Data from Cohort Review

43	Cases of TB disease
26	Completed treatment
8	Likely to complete treatment in < 365 days
1	Noncount
2	Reported at death
1	Cases of MDR TB and still on treatment
2	Died
0	Moved
1	Cohort failure
1	Lost to follow-up
0	RIF resistant and still on treatment

Index of treatment completion Answer: ________ Index of possible treatment completion Answer: ________ Percent of cases who are likely to complete treatment within 365 days
Answer: ________ Death rate Answer: _________ Default rate Answer: _________ Cohort failure rate Answer: _________	Index of treatment completion	a              100 Total cases – (c + d + e)
	Index of possible treatment completion	a               100 Total cases – (c + d + e + f + g + h)
	Index of likely to complete treatment	a + b 100 Total cases – (c + d + e + f + g + h)
	Death rate	d + h            100 Total cases – (c + e)
	Default rate	k               100 Total cases – (c + e)
	Total cohort failure rate	j + k               X 100 Total cases – (c + e)

Exercise 7: Calculation of Indices for Contact Investigation

Given the following information, calculate the indices and indicators for outcomes of contact investigations. Show your work by putting the actual numbers into the formulas (answer sheet is located in Appendix A).

Sample Contact Investigation Data from Cohort Review

294	Contacts of cases of pulmonary TB identified
42	Pulmonary TB cases
20	Smear positive cases
202	Contacts of smear positive cases identified
19	Smear positive cases with >0 contacts identified
182	Contacts of smear positive cases evaluated
46	Contacts of smear positive cases started on treatment for LTBI
10	Contacts of smear positive cases completed treatment for LTBI
26	Contacts of smear positive cases still taking meds for LTBI
6	Moved
2	Died
10	Lost to follow up

1

Contact index:

# of contacts identified # of pulmonary cases

= ____

2

Percent smear positive cases with >0 contacts identified:

# smear positive cases with # identified >0 100 # smear positive cases

= ____

3

Percent contacts of smear positive cases evaluated:

# contacts of smear positive cases evaluated 100 # contacts of smear positive cases

= ____

4

Percent contacts of smear positive cases completing treatment for LTBI:

# contacts of smear positive cases comp. trtmt for LTBI 100 # contacts of smear positive cases started trtmt for LTBI

= ____

 

The following is a sample “Group Report Card” that could be presented at the end of the cohort review session.

This information can be presented in a slide presentation, on a flipchart, or by verbal summary.

Table 18: Sample Report Card—Summary of Variables

First Quarter Cohort Review
Summary of Variables

TB Cases Counted 1/1 – 3/31
Total cases counted	42
Completed treatment	26
Likely to complete treatment	8
Noncount	1
Reported at death	2
MDR TB	1
Died	2
Moved	0
Cohort failure	1
Lost	1

Table 19: Sample Report Card—Indices/Rates for TB Cases

First Quarter Cohort Review
Indices/Rates for TB Cases

TB Cases Counted 1/1 – 3/31
Index of completion	65%
Index of possible completion	70.3%
Index of likely to complete treatment	91.9%
Death rate	9.5%
Default rate	2.4%
Cohort failure rate	4.8%

Table 20: Sample Report Card—Indices for Contact Investigation

First Quarter Cohort Review
Indices for Contact Investigation

TB Cases Counted 1/1 – 3/31
		National Objective
Pulmonary cases	42
Contacts identified	294
Smear positive cases	20
Contacts of smear positive cases identified	202
Smear positive cases with >0 contacts identified	19    (95%)	90%
Contacts of smear positive cases evaluated	182  (90.1%)	95%
Contacts of smear positive cases started LTBI treatment	46
Contacts of smear positive cases completed LTBI treatment	10   (21.7%)	85%
Contacts of smear positive cases still taking meds for LTBI	26

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 “The fundamental question is ‘What percentage of patients do you cure?’ and too many programs can’t answer that question. The cohort review not only allows you to answer, but to improve your answer to get an accurate, higher number…”

Thomas Frieden, MD, MPH, New York City Commissioner of Health