Understanding the TB Cohort Review Process: Instruction Guide
2006
Return Table of Contents
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
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.
- 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.
- 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 |
|
“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
|