Kim Field, RN, MSNKim Field, RN, MSNWashington State Department of HealthWashington State Department of Health

kim.field@doh.wa.govWebsite: Website: www.doh.wa.gov/cfh/tb

April 2009April 2009

The Cohort Review Process in The Cohort Review Process in Washington StateWashington State

The Cohort Review Process in The Cohort Review Process in Washington StateWashington State

WA StateWA State

WA State TB MorbidityWA State TB MorbidityA Medium Incidence StateA Medium Incidence State

• Population of over 6 million; approx. 80,000 births annually

• 2004 TB Data: 244 TB cases (3.9/100,000) vs. (4.9/100,000) incidence in the U.S.

• Highest incidence in King County: 133 cases (7.4/100,000)

– Comprised 55% of total TB cases in 2004

WA State Profile: TB FundingWA State Profile: TB Funding

• 39 counties comprise 34 Local Health Jurisdictions (LHJs)

• 74 local TB staff including managers, PHNs, administrative, outreach workers

• $890,000 of $1.4 million federal funds to 4 LHJs

• $5.6 million available in local funds for LHJs

2005-2009 State TB Objectives2005-2009 State TB ObjectivesA National Measurement of Our Success as a StateA National Measurement of Our Success as a State

1999-2003

• 90% of TB patients completed a course of TB treatment within 12 months of initiation

• 75% of patients were on DOT

State Objectives, by 2009

• 95% of TB patients will complete a course of TB treatment within 12 months of initiation

• 85% of patients being treated for active TB will be on DOT

2005-2009 TB Objectives, Cont.2005-2009 TB Objectives, Cont.A National Measurement of Our Success as a StateA National Measurement of Our Success as a State

1999-2003

• HIV status was reported for 89% of all reported cases

• Drug susceptibility results were reported for 99% of all culture-positive TB cases

State Objectives, by 2009

• HIV status will be reported for 90% of all newly reported TB cases

• Drug susceptibility results will be reported for 95% of all culture-positive TB cases

2005-2009 TB Objectives, Cont.2005-2009 TB Objectives, Cont.A National Measurement of Our Success as a StateA National Measurement of Our Success as a State

1999-2003

• Contacts were identified for 82% of sputum smear+ cases

• 57% of contacts to sputum smear+ cases were evaluated

• 47% of infected contacts started on treatment, completed (reporting delay)

State Objectives, by 2009

• Contacts will be identified for at least 90% of sputum smear+ cases

• 75% of contacts to sputum smear+ cases will be evaluated

• 70% of infected contacts started on treatment will complete

Impact of Cohort Review in WA StateImpact of Cohort Review in WA StatePre (2001) and Post (2004) ImplementationPre (2001) and Post (2004) Implementation

Case SummaryCase Summary

Outcome Measures

2001 (n=261 cases)

2004 (n=245 cases)

Completion of Therapy 90% 93% DOT Usage 74% 99% Proportion of MDR Cases 2% 1% Lost to Follow-up 2% 1% HIV Test Not Offered @ Time of Screening

22%

7%

Pre (2001) and Post (2004) ImplementationPre (2001) and Post (2004) ImplementationContact SummaryContact Summary

Outcome Measures

2001 (n=911 contacts)

2004 (n=1,115 contacts)

Contacts Identified per Smear + Case (average number of contacts identified)

8.36 10.61

Refused to Continue Therapy 10% 7% Completed Therapy (at time of report) 37% 45% Infected But Did Not Receive Therapy 32% 26%

Post ImplementationPost ImplementationCase Summary Case Summary

Outcome Measures

2003 (n=250 cases)

2004 (n=245 cases)

Completion of Therapy 91% 93% DOT Usage 91% 99% Died During Therapy + Reported at Death 6% 4% Lost to Follow-up 2% 1% Treatment Not Completed within 12 months 0% 0% HIV Test Not Offered @ Time of Screening 13% 7%

Post ImplementationPost ImplementationCase Summary: Timeliness MeasuresCase Summary: Timeliness Measures

(Washington Modification to NYC Model)(Washington Modification to NYC Model)

2003 (n=250 cases)

2004 (n=245 cases)

Timeliness Measures

Mean Days

Mean Days

Timeliness of Lab Sputum Collection 1.11 1.08 Timelines of Reporting from Local Health to State Health Department

12.97 9.09

Timeliness of Reporting from the Lab to Local Health

4.64 1.06

Timeliness of Susceptibility 27.30 23.00

Post ImplementationPost ImplementationContact SummaryContact Summary

Outcome Measures

2003 (n=1,332 contacts)

2004 (n=1,115 contacts)

Contacts Identified per Smear + Case (average number of contacts identified)

12.05 10.61

Proportion of Contacts Identified to Smear+ Cases

44% 76%

Timeliness Measures Timeliness of Identifying Contacts Smear + 4.47 1.42 Cavitary Chest X-Ray 11.96 6.88

Washington State Cohort Review Washington State Cohort Review 2007: Fourth Quarter2007: Fourth Quarter

Percentage of cases on directly observed therapy (DOT), North/South regions

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct - Dec 2006 (n=31) Oct - Dec 2007 (n=36)

80% 91%

Percentage of cases offered an HIV test at time of TB screening, North/South regions

0%

20%

40%

60%

80%

100%

Oct - Dec 06 (n= 31) Oct - Dec 07 (n= 36)

90% 92%

Percentage of infectious cases (smear +) “likely to complete” medications, North/South

regions

20%

40%

60%

80%

100%

Oct - Dec 06 (n= 9) Oct - Dec 07 (n= 10)

89% 90%

Percentage of infectious cases lost to follow-up or refused to continue treatment after

starting, North/South regions

0%

20%

40%

60%

80%

100%

Oct - Dec 2006 (n=9) Oct - Dec 2007 (n=10)

0% 0%

Median number of days between sputum collection and receipt at a lab, North/South

regions

1.00 1.00

0.00

0.50

1.00

1.50

2.00

Oct - Dec 2006 (n= 31) Oct - Dec 2007 (n=36)

Median number of days between the smear + date and LHJ report of case to DOH,

North/South regions

0.00

2.50

0.00

5.00

10.00

15.00

Oct - Dec 2006 (n=9) Oct - Dec 2007 (n=10)

Cases: October - December 2007Cases: October - December 2007 North/South regions North/South regions

• 80% of cases completed treatment; 89% expected to complete– 11% moved or died– 3% lost

• 91% were on DOT (100% for smear+)

• 8% not offered an HIV test

• 17% had medical adherence issues

• 9% had personal adherence issues

• 6% provider interrupted therapy

Cases: Oct - Dec 2007Cases: Oct - Dec 2007 North/South regions, cont’d North/South regions, cont’d

Median Number of Days: Timeliness MeasuresMedian Number of Days: Timeliness Measures

• 3 cases had an MTD test– Of those that didn’t (n=4 smear-culture+ cases)

• Median of 10 days between date sputum was collected and date they started meds

• Lab Sputum Collection: 1 day

• Culture Testing: 17.5 days

• Susceptibility: 21 days

Contacts: October – December 2007Contacts: October – December 2007 North/South regionsNorth/South regions

• 139 contacts identified to 36 cases; ~8 per case, median of 5.5• 80% of smear + cases identified contacts (2 case didn’t)• 10 smear + cases identified 86 contacts• 82% tested

– 57% evaluated for TB– 21% infected– 21% infection rate (diseased + infected)

• 17% were infected by didn’t start treatment • 83% of infected started treatment and of those…

– 20% completed (4 contacts)– 55% currently on or not closed out in our database– 20% Provider discontinued meds (contacts to pediatric cases)

(4 contacts)– 5% Moved (1 contact)

Contacts and ReferencesContacts and References

• Kim.Field@doh.wa.gov 360-236-3447

• http://www.doh.wa.gov/cfh/TB/Manual/Forms/CohortPresentation.pdf

• http://www.doh.wa.gov/cfh/TB/Manual/Forms/CohortDictionary.pdf

References References

• S:\CFH\IDRH\TB Services\Cohort Review\Generic Forms