Cohort Review Process in the New York City Bureau of Tuberculosis Control

1
Cohort Review Processin the New York CityBureau
of Tuberculosis Control

• Sonal S. Munsiff, MD
• Director, Bureau of Tuberculosis Control
• New York City Department of Health and Mental
  Hygiene

2
TB Control The 5 components of DOTS

• Political commitment

• Diagnosis by microscopy

• Adequate supply of the right drugs

• Directly observed treatment

• Accountability

3
TB Situation in NYC in 1992

• Rising rates for over a decade
• Several ineffectual attempts to improve situation
  in 1980s
• Very little money and not enough staff
• Case rate of 50.2 in 1991
• Completion rate about 60 for the past few years
  STP had few patients
• Several prolonged MDRTB outbreaks

4
Tuberculosis Cases and RatesNew York City, 1978
- 1991
NYC DOH
5
Tuberculosis rates by boroughNew York City, 1991
Cases per 100,00/year
6
Patients with resistant isolatesNew York City,
1991(N466)
Percent resistant
7
TB in New York CityThe Solution - 1

• Courted and received support from public health
  officials, hospitals, universities
• Obtained more funding from federal, state and
  local governments
• Upgraded laboratories and health code to obtain
  rapid, accurate results
• Provided intensive education to staff and NYC
  providers

8
TB in New York CityThe Solution - 2

• Already had a good supply of medicine
• Implemented Directly Observed Therapy (DOT)
• Revised Health Code to detain persistently non
  adherent patients
• Improved case management
• Developed Cohort Review Process

9
Accountability !
10
Cohort Review ProcessWhat is it?

• Systematic review of every case of TB for
  treatment completion and contact investigation
• Group process, using staff from every level of
  the organization
• Individual and group accountability
• Proactive process
• Closely tied to national TB goals and indicators

11
CDC Objectives

• gt 90 of newly diagnosed patients will complete
  therapy within 365 days
• gt 90 of sputum AFB-smear positive TB cases will
  have contacts identified
• gt 95 of contacts to sputum AFB-smear positive TB
  cases will be evaluated for infection and disease
• gt 85 of infected contacts who are started on
  treatment for latent TB infection will complete
  therapy

12
NYC Objectives

• 95 of all smear positive cases are interviewed
  within three days of assignment
• 85 of all other cases are interviewed within
  five days of assignment
• Appropriate treatment regimens are used
• DOT is pursued as the standard of care
• Timeliness of interventions
• 95 of all issues which arose at the prior cohort
  are resolved or at least followed up with by the
  next cohort

13
Case Management Flow Chart
14
Cohort Review ProcessHow is it done?

• Quarterly meetings of all staff responsible for
  patient care
• Standard case presentations
• Director reviews each case in all aspects of care
• Epidemiologist calculates results and provides
  immediate feedback
• Development of new goals

15
Cohort Review ProcessFormat

• Network epidemiologist presents a summary of key
  demographic and clinical characteristics
• Each case is reviewed, a preliminary disposition
  is given to each case
• Contact investigation results to relevant cases
  are presented
• Preliminary summary of outcomes for this cohort
  are compared with national and NYC objectives
• Final outcomes of patients and contacts from
  cohort of 6 months ago are presented

16
Cohort Review ProcessWhat is Evaluated?

• Current status of each patient
• cured or current to care and likely to complete
  in 365 days
• Died, moved, lost, refused treatment or unlikely
  to complete treatment within 365 days
• DOT status and compliance to DOT
• Review of contact or source case investigation
• Measurable results
• Completion of treatment within 365 days
• Contact index
• Contact evaluation and outcome of those on
  treatment of LTBI

17
Cohort Review Process Key Points - 1

• Use intermittent DOT whenever possible
• Treatment should be completed in lt 365 days of
  start of gt 2 anti-TB meds
• Still responsible for case despite patient moving
  to another jurisdiction
• Importance of interstate follow-up
• Patients likely to complete treatment within 365
  days have actual outcomes reviewed at a future
  presentation

18
Cohort Review Process Key Points - 2

• Contacts of extra-pulmonary and clinically
  confirmed pulmonary cases not obtained
• All children have source case/contact
  investigations conducted
• Contacts with documented history of prior
  positive TST are evaluated but not re-tested.
• Despite death of patient, contact investigation
  still conducted
• Outcome of contacts on LTBI treatment reviewed at
  the cohort

19
Cohort Review ProcessObstacles to good outcome

• Inappropriate treatment regimen prescribed
• Patient leaves hospital AMA or is lost early in
  treatment
• DOT not universal
• Private physicians least likely to refer for DOT
• Catching up on case management before the cohort
• Lag in data entry

20
Treatment Completion Rates 1989-2003
21
Cohort Review ProcessGoals

• Evaluate process of public health intervention
  to
• ensure appropriate regimen used
• ensure timely treatment completion
• improve timeliness of interventions
• shorten time between contact identification and
  testing
• improve management of infected contacts
• analyze outcome to develop appropriate
  interventions

22
Cohort Review ProcessStrengths

• Director reviews every case
• Public accountability for case management and
  follow-up of contacts
• National objectives tracked
• Can be modified to add/delete items as needed
• Consistent with global principles of TB control

23
Cohort Review ProcessLimitations

• Timeliness of some aspects of care cannot be
  assessed
• May be too late to make interventions
• Details of problems in case management cannot be
  addressed
• Several items we want to evaluate are not easily
  captured on TB Registry

24
Cohort Review Process Future Goals

• Obtain better data for some indicators through a
  better TB Registry
• Document the usefulness of cohort reviews through
  the tracking of important cohort issues
• Publish a paper on the cohort review as an
  effective management tool for TB control programs
  worldwide
• Assist other Bureaus, such as Tobacco Control, as
  well as other TB programs, in implementing cohort
  reviews when managing cases