Understanding the TB Cohort Review Process: Instruction
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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
- Establish political and managerial commitment
- Modify the elements of cohort review to fit your program area’s
1. Establishing Political and Management Commitment
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:
|Cases counted from:
||will be reviewed on:
|January 1 – March 31
|April 1 – June 30
|| January 15
|July 1 – September 30
|October 1 – December 31
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
Director of TB Control
2. Modifying the Elements of the Cohort Review
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
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
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
- A city or county health department may prefer a face-to-face
meeting in one large room. Case managers, contact investigators,
public health nurses, data analysts, supervisors, and
clinicians can be called to a mandatory meeting. Travel
within the city, county, or region is a normal part of
- In large geographic areas where travel may be a challenge
for face-to-face meetings, video and teleconference technology
should be considered to facilitate 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
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
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
Kim Field, RN, MSN, TB Program Manager, Washington State Department
of Health TB Program
Case Study: Washington State Department of Health
Cohort Review Process
Process in Washington
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
Review cases counted April–June
2004 and their contacts
Review cases counted July–Sept 2004 and their
Review cases counted Oct–Dec 2004 and their
Review cases counted Jan–March 2005 and their
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
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
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
Lost to follow-up
Treatment not completed within
HIV test not offered at time of
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
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
- 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)
- 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
|Treatment not completed within 12 months
|Timeliness of identifying contacts to smear-positive cases (mean days)
*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
- 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)
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.
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention