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Understanding the TB Cohort Review Process: Instruction Guide
2006
Return Table of Contents
Essential Element 1: Preparation for a Cohort Review
This chapter provides information for preparing for a cohort review
session. Each of the four areas of cohort review preparation
is explained in detail, and the necessary tools are provided.
For some areas, case studies or exercises are suggested to help
individual readers or groups learn necessary skills.
1. Shared TB Program Objectives
In order for cohort reviews to be successful, all staff should
know the objectives of the TB program. Staff who have shared
in the development or articulation of these objectives may be more
vested in their accomplishment. Working toward the same goals
instills accountability within each TB team member for TB cases,
contact investigations, and program outcomes.
To guide TB control efforts, several levels of objectives have
already been set by other agencies such as CDC, or state and local
health departments. Examples of these objectives were presented
in “Table 2: Examples of TB Program Objectives” on page 3.
It is essential that staff members understand how their efforts
aid the TB control program in meeting these objectives.
The following exercise assists TB control teams with understanding
the importance of developing shared objectives.
Exercise 2: Developing TB Program Objectives
- Read the CDC National TB Program Objectives below.
- How do the outcomes in your program area compare to the CDC
National Objectives?
- Write any specific state-level TB control objectives in the
second box. How do the outcomes in your program area compare
with the objectives listed?
- Write any specific local-level TB control objectives in the
third box. How do the outcomes in your program area compare
with the objectives listed?
Read
CDC National TB Program Objectives |
- At least 90% of confirmed TB patients will complete treatment
within 365 days.
- At least 90% of TB patients with positive AFB sputum-smear
results will have contacts identified.
- At least 95% of contacts to TB patients with positive
AFB sputum-smear results will be evaluated.
- At least 85% of infected contacts who are started on treatment
for LTBI will complete treatment within 365 days.
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Insert
state-level objectives for TB control |
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Insert
local-level objectives for TB control |
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- Are there any new objectives your program area would like to
set? If so, what are they?
For a cohort review, the objectives become the standards to which
the outcomes of case management and contact investigation efforts
are compared. The objectives also dictate which data elements
need to be collected in the TB registry and presented at the cohort
review session. For example, in order to determine what percentage
of contacts of smear-positive patients were evaluated, data must
be collected on smear results, number of contacts identified, and
number of contacts evaluated.
After the cohort review, if some new aspect of the program needs
to be strengthened, objectives can be revised or new objectives
can be added for the next cohort review. For example, one
TB program believed that the timeliness of conducting the
first interview with a newly diagnosed TB patient was an area that
needed improvement. Therefore they set an objective that was
SMART, an objective that is specific, measurable, attainable, realistic,
and time-framed. The objective was that “At least 90% of persons
identified with TB disease will be interviewed by health department
staff within 3 business days of case notification.” Starting
at the next cohort review, the date the case was reported and the
date of the initial interview were part of the standard case presentation
format. By adding these data elements, the program was able
to track this timeliness variable and measure improvement over time.
2. Comprehensive Case Management
Comprehensive case management is essential in TB control and elimination
efforts. Cohort review brings together data from many of the
components of case management and provides a qualitative assessment
of the effectiveness of case management activities.
Case management is a system in which a specific health department
employee, typically a case manager, is assigned primary responsibility
for managing the patient’s case. Systematic, regular review
of patient progress is conducted, and plans are made to address
any barriers to adherence. All reported cases should be assigned
to a case manager, whether they are seen at a health department
clinic or in the private sector. The case manager is responsible
for ensuring that patients adhere to treatment, comply with medical
visits, and complete treatment. In addition, case managers
are also responsible for making sure that contacts are identified
and evaluated, and that they complete treatment for LTBI, if appropriate.
In general, case managers are expected to
- Follow all policies and protocols for case management
to ensure that patients adhere to treatment, comply with medical
visits, and complete treatment.
- Follow all policies and protocols for contact investigation
to ensure that contacts are identified and evaluated, and that
they complete treatment for LTBI if appropriate.
- Communicate periodically with clinic and outreach workers to
ensure all aspects of patient care are being addressed and troubleshoot
any problems that arise.
- Participate in case review meetings with their supervisor and
the TB control team.
- Prepare information on each case, present the information at
the cohort review session, and follow up on suggestions made at
the cohort review session.
Exercise 3: Reviewing Case Management Protocols
Discuss the following questions with your
TB control team.
- What case management policies and protocols does your
program area have?
- How are existing case management policies and protocols
leading to successful outcomes compared to your objectives?
- How are contact investigations included in the policies
and protocols?
- What modifications of the policies and protocols would
be useful to help staff do a better job?
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For more information on case management protocols and training,
see the Resources section at the end of this document.
Improvement. Therefore they set an objective that was SMART,
an objective that is specific, measurable, attainable, realistic,
and time-framed. The objective was that “At least 90% of persons
identified with TB disease will be interviewed by health department
staff within 3 business days of case notification.” Starting
at the next cohort review, the date the case was reported and the
date of the initial interview were part of the standard case presentation
format. By adding these data elements, the program was able
to track this timeliness variable and measure improvement over time.
3. Reliable TB Registry
A reliable TB registry is an essential tool of the cohort review
process. Typically, programs use a registry database to collect
TB patient and contact investigation information. A locally
developed database provides the universe of patients from which
the cohort is drawn. The date on which the case is counted
determines the cohort in which the case will be reviewed.
A reliable TB registry will include
- General patient information: name, address, telephone
number, date of birth, sex, race, ethnic origin, date of
entry into the United States (if foreign born), and country
of origin.
- Medical history: disease site, laboratory results (smear,
culture, susceptibility, conversion), radiology, drug regimen,
adherence, if on DOT, evaluation dates, completion of treatment
or other disposition, provider name or code, etc.
- Contacts: name, address, telephone number, sex, date of
birth, relationship to patient, TST status, medical evaluation,
and information about LTBI treatment (started treatment,
regimen, disposition).
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The data analyst will use the registry to generate the list of
TB cases to be reviewed in a given cohort, being certain to include
the data elements needed to evaluate program objectives. He
or she will distribute the lists to case managers and supervisors
so they can be prepared to present these cases.
The following lists are prepared and distributed ahead of time:
- Preliminary cohort list. Distributed 5–6 months
before a cohort review. This list provides diagnostic and
preliminary treatment and contact information. The supervisor
and case manager use this list to track the cohort of patients
from a quarter and to begin preparation of case presentations
for a cohort review.
- Final cohort list. Distributed 1–2 months before
a cohort review. This list provides updated treatment information
from the registry and the results of the contact investigation.
The supervisor and case managers use this list to hold practice
review sessions and complete final preparation of the case presentations.
Typically, a “line listing” is all that is needed—one line for
each case. The information may be more complete for the final
cohort list because more time has elapsed.
See:
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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