Understanding the TB Cohort Review Process: Instruction Guide (2006)
How to Tailor Cohort Review to Local Program Areas
The purpose of this section is to provide practical guidance on implementing the cohort review method in local program areas. As stated previously, many of the forms and processes highlighted in this document reflect the New York City Department of Health and Mental Hygiene cohort review methodology. Because the New York City program has a high case volume in a small, highly concentrated geographic area, the program has developed methods that work well in that setting. Your program profile may be very different. The keys to successful implementation in your program area include two steps:
- Establish political and managerial commitment
- Modify the elements of cohort review to fit your program area’s needs
Staff are often reluctant to accept change, such as a new policy or procedure. Change may make them feel uncomfortable. This may be especially true if they perceive that the new policy or procedure means extra work or scrutiny for them. People have to believe something is important to them before they will accept change. Therefore, management staff in the health department must communicate to staff at all levels that they themselves, the management team, believe in the cohort review method. There is no substitute for leading by example. If it is not important to TB program leadership, why will staff want to do it?
In communicating with staff, think of all the people who will need to know about cohort review, what each person’s role is, and what new tasks they will have to do. Staff may be more likely to accept the implementation of the cohort review process if management staff emphasize how the process builds on what they are already doing well. In addition, staff may be more invested and motivated in the process if they are directly involved in tailoring the review process to the particular strengths and needs of the program area. Staff need to hear why it is important and how assistance will be provided to make sure everyone has the knowledge and skills to do the new tasks.
A sample letter follows, showing what the director of TB control may want to communicate to staff when initiating cohort reviews.
Sample Letter from Director of Local Health Department
Our TB control program has been successful in reducing rates dramatically since the peak of reported cases in the early 1990s; however, the rate of decline has slowed. We have already implemented effective case management and DOT practices, and have improved our contact investigation procedures. You are all to be congratulated on your efforts, which have led us to the point where we are today—at the lowest number of cases since reporting began.
What is the next step? Starting cohort reviews—a system of quality assurance and accountability that can help us improve outcomes using the resources we have available. The cohort review process is used in countries all over the world to help ensure improved case management, greater staff accountability, educational support that meets staff and program needs, and achievement of objectives for treatment completion and contact investigation.
The cohort review process builds upon our current practices, like the monthly case review meetings. However, it adds a quantitative difference to program review and examination of treatment outcomes. This new management approach is challenging. It will require commitment and hard work. But it will guide us in correcting problems we find, and ultimately, improve the services our patients and contacts receive.
The following is a proposed schedule:
Case managers and supervisors will continue to manage cases and contact investigations following our protocols. Case review meetings will continue as usual, but will include preparation of a simple case format for presentation in a cohort review meeting.
Dr. ________________ will provide clinical oversight before cases are presented.
_______________ (data analyst) will generate a list of the cases and contacts and will assist in gathering and analyzing data at the cohort review meeting.
Successful implementation will require time, patience, and understanding—the positive results you expect may not be evident immediately. However, experience shows that programs that regularly conduct cohort reviews continue to improve.
Director of TB Control
Adapting the cohort review method to fit the program area is also essential. At first, it is better to start small and allow staff to become accustomed to the process. For each element, be sure that the plan is consistent with the local situation.
Shared TB program objectives: Consider using only the most basic objectives at first. Select objectives that are familiar to staff. Ensure staff understand the time frame for defining the cohort and conducting the review. Let them know that program management is committed to conducting periodic cohort reviews and that you understand it may take time to improve outcomes.
Comprehensive case management: This may be an area that needs little change in order for your group to conduct a cohort review. Case managers can proceed with their routine activities of ensuring that a) patients with TB disease adhere to treatment, comply with medical visits, and complete treatment; and that b) contacts are identified, evaluated, and complete treatment for latent TB infection (LTBI), if appropriate.
Reliable TB registry: This also may need little change. Continue using a locally developed database to provide the “universe” or cohort of patients to be reviewed. Make sure the data analyst generates the preliminary and final lists of cases, so staff know what presentations to prepare.
Preparation of cases for presentation: Program areas may already conduct periodic case review meetings. Supervisors and case managers should continue their preparations to make sure all the case details are in place, from the initial interview to compliance with and completion of treatment, to the contact investigation. New cohort review forms may be added to guide case presentation. Consider organizing mock cohort review sessions to ensure staff develop their confidence and presentation skills.
Detailed review of each case: This is an element that needs to be specifically tailored to each local situation. There are several approaches to consider for the cohort review session:
The case manager or the presenter should be well prepared to present the details of the cases that he/she is responsible for. The case manager should prepare information on each case, present the information at the cohort review session, and be prepared to follow up on suggestions made by reviewers at the cohort review session.
The reviewer will need practice in learning how to manage time and go over all of the most important points raised in regards to each case. In general, routine cases need less time and attention. It is important to spend more time on the difficult cases, especially those in which the patient is nonadherent, has multidrug-resistant TB, or has numerous contacts in a congregate setting.The reviewer should remember to use “teachable moments” to give feedback to staff and update them on policies, protocols, and guideline revisions.
During the presentation and review of each case, the data analyst must quickly and accurately tally results, update information, and note issues that require follow-up. This can be very exacting work in a fast-paced cohort review session, and it takes some time to get accustomed to the process and how and where to enter results.
Immediate analysis of outcomes: This is the role of the data analyst. If possible, the data analyst should immediately provide a report card of the status of the cohort. The status of patient and contact investigation outcomes should lead to a discussion of programmatic issues, as well as yield direction for follow-up to in order to achieve program objectives.
Timely follow-up of noted problems: No management process is complete until information collected is used to guide improvement. Usually it is the job of the data analyst to compile a summary report of the cohort review outcomes, as well as a list of issues that require follow-up actions. These actions, however, may need follow-up by several different people: program director, medical director, public health nurse, case manager, supervisor, outreach worker—thus, a separate list for each person may be useful.
Also, remember that the outcomes of persons with TB disease who were “likely to complete” treatment and the contacts who are still on treatment for LTBI will be reported and reviewed in 6 months, as part of a future cohort review. Case managers and their supervisors have to keep managing these cases and contact investigations until they are “closed.”
Be patient. With time and practice, the skills of the case managers, reviewers, and data analysts will improve.
“For any program that is considering implementing cohort review, there are four main points you have to keep in mind: first you have to have the commitment of your staff to move towards this process; second, recognize that there is a time factor; third, be flexible and look at the models from New York City but adapt them to your regional area; and fourth, you are going to need buy-in from your higher management or others in your state who are providing the direct care…”
Kim Field, RN, MSN, TB Program Manager, Washington State Department of Health TB Program
Process in Washington State
In 2003, the Washington (WA) State Department of Health (DOH) TB Program adapted the New York City cohort review model and implemented this process. Reasons for implementing the cohort review process in WA State included the desire to: 1) increase accountability for patient outcomes, 2) ensuree completion of therapy for TB patients and contacts, 3) evaluate achievement of program objectives, and 4) provide opportunities for staff education.
The cohort includes all patients whose cases were counted by the WA State TB Program during a particular quarter of the year. Quarterly cohort review sessions are scheduled approximately 7–9 months after cases are counted (Table 21).
Table 21: Washington Cohort Review Timeline for 2005
|January 2005||April 2005||July 2005||October 2005|
Review cases counted April–June 2004 and their contacts
Review cases counted July–Sept 2004 and their contacts
Review cases counted Oct–Dec 2004 and their contacts
Review cases counted Jan–March 2005 and their contacts
The quarterly cohort review session is conducted with the DOH TB Program Coordinator, DOH Nursing Consultants, DOH medical consultant, DOH epidemiologist, and local health jurisdiction (LHJ) staff. Telephone conference calls are used to conduct these sessions. Nursing Consultants work with LHJ staff to prepare for cohort review presentations using a cohort review form (Appendix C).
- Case reports are sent from LHJs to the WA State Department of Health TB Program and entered into the Tuberculosis Information Management System and DOH Contacts Database.
- The DOH TB Program epidemiologist analyzes the DOH databases and certain information from the cohort review forms prior to the cohort review session.
- At the beginning of the cohort review session, the epidemiologist presents final case and contact data summaries for the previous cohort and preliminary summaries for the cohort being reviewed during the session (Table 22: “WA Cohort Review Data Analyses” on the following page).
- Case and contact summaries include outcome measures and timeliness measures developed specifically for WA State. Timeliness measures include lab sputum collection, start of medication, reporting from LHJ to the DOH, reporting from health care provider to LHJ, reporting from lab to LHJ, reporting from lab to LHJ of susceptibility results, and identification of contacts.
Table 22: Washington Cohort Review Data Analyses
|January 2005||April 2005||July 2005||October 2005|
Final analyses of Jan–March 2004 cases and contacts
Preliminary analyses of April–June 2004 cases and contacts
Final analyses of April–June 2004 cases and contacts
Preliminary analyses of July–Sept 2004 cases and contacts
Final analyses of July–Sept 2004 cases and contacts
Preliminary analyses of Oct–Dec 2004 cases and contacts
Final analyses of Oct–Dec 2004 cases and contacts
Preliminary analyses of Jan–March 2005 cases and contacts
Impact of Cohort Review
In 2004, the DOH TB Program conducted an assessment of the impact of implementing cohort review in Washington State. A comparison of the outcome and timeliness measures were analyzed for January–March 2001 patients and their contacts (prior to the introduction of cohort review) and January–March 2003 patients and their contacts (post 1 year of implementing cohort review). The results of the comparison demonstrated that cohort review made a substantial impact on the management of TB cases in Washington State.
Table 23: Outcome measures on TB cases by year, Washington, 2001 and 2003.
Completion of therapy
Died during therapy + reported at death
Lost to follow-up
Treatment not completed within 12 months
HIV test not offered at time of screening
Table 24: Timeliness of reporting measures on TB cases by year, Washington, 2001 and 2003
Timeliness of lab sputum collection
Timelines of reporting from local health to state health department
Timeliness of reporting from the lab to local health department
Timeliness of susceptibility reporting
No patients died during treatment or were reported at death among the 2003 cohort as compared to 2001 (0 in 2003 vs. 8% in 2001) (Table 23).
- No patients were lost during treatment among the 2003 cohort as compared to 2001 (0 in 2003 vs. 6% in 2001), despite being a larger cohort of cases to manage in 2003 (Table 23).
- A smaller proportion of patients did not complete treatment within 12 months among the 2003 cohort as compared to 2001 (8% in 2003 vs. 15% in 2001) (Table 23).
- A smaller proportion of patients among the 2003 cohort were not offered HIV tests at the time of their screening as compared to 2001 (15% in 2003 vs. 27% in 2001) (Table 23).
- It took an average of 0.79 days to collect sputum and have it received at the lab in 2003 vs. 5.49 average days among the 2001 cohort (Table 24).
- Local health jurisdictions improved their timeliness of reporting TB cases to the state health department in 2003 as compared with 2001 (an average of 6.30 days in 2003 vs. 15.50 days in 2001) (Table 24).
- Labs improved the reporting of positive sputum-smear results to local health in 2003 as compared to 2001 (an average of 2.60 days in 2003 vs. 7.00 average days in 2001) (Table 24).
- Labs also improved the reporting of culture + MTB susceptibility results to local health in 2003 as compared to 2001 (an average of 21.23 days in 2003 vs. 71.58 in 2001) (Table 24).
Table 25. Outcome measures on TB contacts by year, Washington, 2001 and 2003
|Refused to continue therapy||33%>||6%|
|Treatment not completed within 12 months||13%||0|
|Timeliness of identifying contacts to smear-positive cases (mean days)||4.3||2.7|
*Note: The large number of contacts (504) was a result of an incarcerated patient.
- A smaller proportion of contacts refused to continue treatment in 2003 as compared to 2001 (6% vs. 33%, respectively) (Table 25).
- A smaller proportion of contacts were lost to follow-up in 2003 as compared to 2001 (1% vs. 7%, respectively) (Table 25).
- All contacts in 2003 completed treatment within 12 months as compared to 2001 (0 vs. 13%, respectively) (Table 25).
- In 2003, contacts of infectious (smear-positive) patients were identified in a shorter period of time as compared to 2001 (an average of 2.66 days in 2003 vs. an average of 4.33 days in 2001) (Table 25).
Since implementation in WA State, cohort review has increased knowledge of TB among staff and has increased staff accountability for the management of their cases. Benefits closer scrutiny of patients and contacts, and an increased understanding of TB morbidity due to the cohort review sessions, have improved patient outcomes and the treatment of patients and contacts in Washington State.