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U.S. Department of Health and Human Services

Understanding the TB Cohort Review Process: Instruction Guide 2006

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Essential Element 1: Preparation for a Cohort Review

4. Preparation of Cases for Presentation

Careful preparation for a cohort review begins the day a TB case is reported. Cohort review facilitates quality assessment of case management activities, which may motivate staff to be accountable for every aspect of every TB case and subsequent contact investigation. The case manager is ultimately responsible for presenting the treatment and contact investigation outcomes for each case to the TB control team.

In preparing cases for presentation, using a standardized form is an effective way to ensure that consistent information is presented on each case. The detailed information on the form provides the necessary clinical data that allow the data analyst to compile the overall statistics. It also provides a guide for case presentation so that essential information is covered in a concise and consistent manner. In general, each presentation should include

Demographic information
Site of disease, bacteriology, radiology
Treatment regimen, adherence, DOT
Unusual events in monitoring treatment (if any)
Status of treatment completion
Contact investigation results

Sample forms for reporting both pulmonary and extrapulmonary cases appear on the following pages. Some TB programs may find it useful to use different forms for pulmonary and extrapulmonary cases, since the latter typically do not require a contact investigation.

The sample forms are very basic forms that collect and report information required for monitoring compliance with the CDC national objectives. As your program becomes accustomed to conducting cohort reviews, you can insert additional data elements that will allow you to evaluate other objectives. Appendix B contains sample forms from the New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control (BTBC). Appendix C contains forms used by the Washington State Department of Health Tuberculosis Program. Both sets of forms are used to collect information that allows the programs to monitor other indicators, such as timeliness of initial interview and DOT status.

Sample Cohort Review Presentation Form I Pulmonary or Laryngeal TB
1. Patient Information: Registry number __________ Date case reported __________ ______ year-old ________ (male/female) born in _______________ (country) HIV status (+ / - / refused / unknown) Protease inhibitor or NNRTI (name)¹: _________
2. TB Information: TST ___ mm, read on _____ (date) Sputum smear results: (+ / –) if + ______plus² Culture _____ (+, -, or not done) Pansusceptible, or MDR or rifampin-resistant or other resistance (_______________) Cavitary, or abnormal (noncavitary), or normal CXR³ Culture conversion? Y/N Date: ________________
3. Treatment Information: Completed therapy ______ Taking TB medications_____ Has completed _____ months of treatment Likely to complete by ___________ (date) Drug regimen ____________________ Check other disposition below: ___Refused ____Lost ____Died ____Moved⁴ ____Reported at death On DOT? ___Yes No If no, why not? ____________________________ On DOT ______ months of which ________ months were > 80% adherent If patient is a child 18 years old or younger: Source identified? Y/N Name/Registry number ___________⁵
4. Contacts
#		#
	Identified		Started treatment for LTBI⁸
	Appropriate for evaluation⁶		Completed treatment for LTBI
	Evaluated⁷		Current to care⁹
	Infected (TST+) without disease (confirmed by CXR)		Discontinued treatment for LTBI (adverse reaction/ died/ moved/ refused/ lost to follow-up)
	Infected, with disease

Reverse Side of Sample Cohort Review Presentation Form

Notes, Definitions, and Special Cases

If patient is taking a protease inhibitor or nonnucleoside reverse transcriptase inhibitors (NNRTIs), specify the name of the medication.
Highest grade of smear, if known.
CXRs are reported as cavitary, noncavitary, or normal. Do not report CXR dates or the results of follow-up CXRs.
A patient can only be classified as “moved” if a new address is documented and a transfer form has been completed.
Be prepared to present the source case and associated contact investigation, including whether this child was listed as a contact in the contact investigation for the source case.
Contacts appropriate for evaluation include all contacts identified who were not counted as “died prior to testing.”
Evaluation of TB contacts should be done in an orderly manner, starting with the highest-priority group of contacts. Contacts should be evaluated for LTBI and TB disease. This evaluation includes at least
- A medical history and
- A Mantoux tuberculin skin test (unless there is a previous documented positive reaction)
For immunosuppressed contacts or contacts who are under 4 years of age, the evaluation should also include a CXR, regardless of skin test result, because of the possibility of a false-negative reaction to the tuberculin skin test and risk of early progression to TB disease if infected.
In addition, any contact who has TB symptoms should be given both a CXR and a sputum examination.Report the number of people who started treatment for LTBI. Do not report the number of people who did not start treatment for LTBI; however, be prepared to explain. Do not report people who received window-period prophylactic treatment and were found not to have had latent TB infection. Provide updated information on those contacts who started treatment for LTBI.
Report the number of people who remain on treatment and are currently up-to-date with their follow-up appointments. People who are delinquent with their follow-up appointments are not counted.

Sample Cohort Review Presentation Form II Clinically Confirmed or Extrapulmonary TB
1. Patient Information: Registry number __________ Date case identified __________ ______ year-old ________ (male/female) born in _______________ (country) HIV status (+ / -/ refused / unknown)
2. TB Information: Clinically confirmed _______ Extrapulmonary _______ Site of disease ______________________ Pansusceptible, or MDR or rifampin-resistant or other resistance (____________)
2. Treatment Information: Completed therapy ______ Taking TB medications _____ Has completed _____ months of treatment Likely to complete by ___________ (date) Drug regimen _______________________ Check other disposition below: ____Refused ____Lost Died ____Moved Reported at death On DOT? ____Yes No If no, why not? _____________________________ On DOT ________ months of which __________ months were >80% adherent
4. Skip Contacts: If patient is a child 18 years old or under, the Cohort Presentation Form I is to be used.
5. Discussion

These forms outline the essential TB case and contact investigation data that need to be presented to the TB control team at the cohort review session. It is important that case managers begin completing cohort review presentation forms from the day a case is reported.

Periodic reviews offer a spot-check system before TB cases and contact investigations are presented at the cohort review session. These reviews can take various forms:

Ongoing case management meetings with the supervisor and other case managers to review case details and detect and resolve any difficult case management issues. This is the time to make sure no details are omitted, all follow-up actions are taken, and all case information is accurate and complete.
Case reviews or consultations with an experienced TB physician to get feedback on the adequacy of treatment regimens for TB patients and contacts on treatment for LTBI.

In addition to these ongoing reviews, a practice cohort review meeting or “mock” cohort review can serve as a dress rehearsal for the final session. The practice presentation is more informal than the actual cohort review. If your area chooses to conduct practice presentations, they should be conducted approximately 2 months before the real cohort review session so that any missing information or needed follow-up can be addressed before the final cohort review. During a practice cohort review presentation, each element of case management is reviewed, with special attention paid to case details, including patient information, TB information, treatment regimen, DOT adherence, and contact investigation.

Practice sessions often point out weak areas in the patient’s case management that need to be strengthened prior to the final cohort review. TB team members can help to brainstorm ideas and develop suggestions for solving difficult case management situations. In addition to the main goal of making sure problems are addressed in the patient’s care and follow-up, an additional goal of the practice cohort review presentation is to help the case presenters be well prepared for the actual cohort review session.

TB Team members

Exercise 4: Completing Forms for Cohort Review

Step One: Description of Exercise

Complete a blank presentation form, using all the information provided for each of the following sample cases. Keep in mind that the information provided on these cases may not be comprehensive. Each case will have flaws that should be picked up by the reviewer(s) in “Exercise 5: Practice Presentation and Review of Cases.”

Glossary of Abbreviations

CXR: chest radiograph

DOT: directly observed therapy

HIV: human immunodeficiency virus

INH: isoniazid

IRZE: isoniazid, rifampin, pyrazinamide, ethambutol

M.tb: Mycobacterium tuberculosis

RIF: rifampin

TST: tuberculin skin test

Case # 1

Image of a homeless man on the street with a garbage bag.

Mr. Parks
49-year-old homeless male born in the United States

1/20	TST + (9mm); sputum smear 4+; culture M.tb, pansusceptible; CXR abnormal, noncavitary; HIV infected
1/21	Started on rifabutin, IZE; DOT started while in hospital
2/28	Continues on DOT at homeless shelter after discharge from the hospital
5/2	Continues on DOT at homeless shelter
7/2	Due to complete treatment at the end of this month
Contacts	15 contacts identified, 7 evaluated, 2 TST positive (7 mm, 12 mm), 2 started on treatment for LTBI but one is lost to follow-up

Case # 2

Image of a patient and doctor

Mr. Morales 32-year-old male born in Mexico, in United States for 2 years

1/20	TST + (11 mm); HIV negative; sputum smear 4+; culture M.tb, pansusceptible; CXR abnormal, cavitary; IRZE started; refused DOT because of irregular work schedule as construction day laborer
2/25	Missed clinic appointment
2/26	Home visit; family had moved; no forwarding address with post office
3/10	Admitted to hospital with cough, fever, night sweats; smear positive/ culture positive, still pansusceptible; patient admitted to stopping medications; started on DOT while in the hospital
4/28	Culture conversion
5/18	Compliant with worksite DOT
8/25	Continues on DOT
9/30	Continues on DOT
Contacts	16 contacts identified, 4 refused evaluation, 12 evaluated, 8 TST negative, 4 TST positive, 2 of the positives are his wife and brother; both on treatment for LTBI; 2 other positives are his children ages 5 and 7; they had negative CXR and are on treatment for LTBI

Case # 3

Mrs. Nguyen 43-year-old Vietnamese female in the United States for 3 years

1/28	Went to private provider with complaints of nonproductive cough, fever, chills, night sweats x 1 month; TST + (12mm); sputum smear negative; culture M.tb, pansusceptible; CXR abnormal, noncavitary
1/31	Telephone call to private provider to obtain medication regimen; clinical diagnosis of TB; patient on INH/RIF (inappropriate treatment)
2/1	Had conference call with TB physician and private provider regarding inappropriate regimen; treatment regimen changed to IRZE
2/2	Telephone interview with patient; contacts identified; patient reports taking prescribed medications
2/3	Follow-up telephone call to private physician; permission given to health department to continue follow-up treatment and care, including DOT
2/4	Patient started on DOT
4/01	Continues on DOT
6/15	Continues on DOT
8/15	Completed treatment; sputum smear negative / culture negative
Contacts	3 contacts identified; 3 evaluated; all TST negative

Step Two: Analysis of Forms

Have a supervisor or coworker review the forms that you have prepared for the sample cases. Ensure that all of the information provided is included on the forms. Together, review the forms for incomplete/missing information that was not provided in the case study. Try to determine what additional information a reviewer might expect to be presented and what aspects of the case management might have been handled differently. You will be able to compare your analysis with that of the reviewer later in the document.

“I believe that in our practice today, to have the time commitment of having direct care staff sitting with the medical staff – which we don’t do in our hurried and busy lives – that is where real learning and education and a real team bonding occurs. And it wouldn’t occur in any other way if we didn’t stop and do this cohort process…”

Kim Field, RN, MSN, TB Program Manager, Washington State Department
of Health TB Program

Sample Cohort Presentation Form I Pulmonary or Laryngeal TB
1. Patient Information: Registry number __________ Date case reported __________ ______ year-old ________ (male/female) born in _______________ (country) HIV status (+ / – / refused / unknown) Protease inhibitor or NNRTI (name)¹: _________
2. TB Information: TST ___ mm, read on _____ (date) Sputum smear results: (+ / –) if + ______plus² Culture _____ (+, -, or not done) Pansusceptible, or MDR or rifampin-resistant or other resistance (_______________) Cavitary, or abnormal (noncavitary), or normal CXR³ Culture conversion? Y/N Date: ________________
3. Treatment Information: Completed therapy ______ Taking TB medications_____ Has completed _____ months of treatment Likely to complete by ___________ (date) Drug regimen ____________________ Check other disposition below: ___Refused ____Lost ____Died ____Moved⁴ ____Reported at death On DOT? ___ Yes No If no, why not? ____________________________ On DOT ______ months of which ________ months were > 80% adherent If patient is a child 18 years old or younger: Source identified? Y/N Name/Registry number ___________⁵
4. Contacts
#		#
	Identified		Started treatment for LTBI⁸
	Appropriate for evaluation⁶		Completed treatment for LTBI
	Evaluated⁷		Current to care⁹
	Infected (TST+) without disease (confirmed by CXR)		Discontinued treatment for LTBI (adverse reaction/ died/ moved/ refused/ lost to follow-up)
	Infected, with disease

Sample Cohort Presentation Form I Pulmonary or Laryngeal TB
1. Patient Information: Registry number __________ Date case reported __________ ______ year-old ________ (male/female) born in _______________ (country) HIV status (+ / – / refused / unknown) Protease inhibitor or NNRTI (name)¹: _________
2. TB Information: TST ___ mm, read on _____ (date) Sputum smear results: (+ / –) if + ______plus² Culture _____ (+, -, or not done) Pansusceptible, or MDR or rifampin-resistant or other resistance (_______________) Cavitary, or abnormal (noncavitary), or normal CXR³ Culture conversion? Y/N Date: ________________
3. Treatment Information: Completed therapy ______ Taking TB medications_____ Has completed _____ months of treatment Likely to complete by ___________ (date) Drug regimen ____________________ Check other disposition below: ___Refused ____Lost ____Died ____Moved⁴ ____Reported at death On DOT? ___Yes No If no, why not? ____________________________ On DOT ______ months of which ________ months were > 80% adherent If patient is a child 18 years old or younger: Source identified? Y/N Name/Registry number ___________⁵
4. Contacts
#		#
	Identified		Started treatment for LTBI⁸
	Appropriate for evaluation⁶		Completed treatment for LTBI
	Evaluated⁷		Current to care⁹
	Infected (TST+) without disease (confirmed by CXR)		Discontinued treatment for LTBI (adverse reaction/ died/ moved/ refused/ lost to follow-up)
	Infected, with disease

Sample Cohort Presentation Form I Pulmonary or Laryngeal TB
1. Patient Information: Registry number __________ Date case reported __________ ______ year-old ________ (male/female) born in _______________ (country) HIV status (+ / – / refused / unknown) Protease inhibitor or NNRTI (name)¹: _________
2. TB Information: TST ___ mm, read on _____ (date) Sputum smear results: (+ / –) if + ______plus² Culture _____ (+, – , or not done) Pansusceptible, or MDR or rifampin-resistant or other resistance (_______________) Cavitary, or abnormal (noncavitary), or normal CXR³ Culture conversion? Y/N Date: ________________
3. Treatment Information: Completed therapy ______ Taking TB medications_____ Has completed _____ months of treatment Likely to complete by ___________ (date) Drug regimen ____________________ Check other disposition below: ___Refused ____Lost ____Died ____Moved⁴ ____Reported at death On DOT? ___Yes No If no, why not? ____________________________ On DOT ______ months of which ________ months were > 80% adherent If patient is a child 18 years old or younger: Source identified? Y/N Name/Registry number ___________⁵
4. Contacts
#		#
	Identified		Started treatment for LTBI⁸
	Appropriate for evaluation⁶		Completed treatment for LTBI
	Evaluated⁷		Current to care⁹
	Infected (TST+) without disease (confirmed by CXR)		Discontinued treatment for LTBI (adverse reaction/ died/ moved/ refused/ lost to follow-up)
	Infected, with disease

Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

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Division of Tuberculosis Elimination
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