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.

“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

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

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:

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

Table 14:  Sample Legend for Tally Sheet

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).

Use the formulas below to calculate the indices and rates.

Table 16:  Indices/Rates for Treatment of TB Disease

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

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

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

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

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

First Quarter Cohort Review
Indices/Rates for TB Cases

Table 20:  Sample Report Card—Indices for Contact Investigation

First Quarter Cohort Review
Indices for Contact Investigation

 “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

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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