Surveillance Data in Action: Tuberculosis Indicators

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Surveillance Data in ActionTuberculosis
Indicators

• Melissa Ehman, MPH
• Tuberculosis Control Branch (TBCB)
• Division of Communicable Disease Control
• Center for Infectious Diseases
• California Department of Public Health
• October 15, 2008

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Objectives

• Review California TB indicators
• Consider indicators relevant to HIV/TB
• Discuss possible next steps in developing
  cross-cutting indicators

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TB Indicators Project (TIP)

• Partnership between TBCB and TB programs of the
  16 local health departments (LHDs) with the
  highest TB morbidity
• Formal process for using indicators to evaluate
  and improve program performance
• Implemented beginning in 2000

STATE TIP TEAM Program Liaison Epidemiologist Fis
cal Analyst
LOCAL TIP TEAM TB Controller Program
Manager Epidemiologist Staff
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How Did We Create Indicators?

• Defined goal areas
• Reviewed standards
• Identified available data sources
• Developed indicators
• Assessed indicators according to set criteria
• Ethical
• Useful
• Representative
• Understandable
• Data Accessible
• Robust (Valid)
• Reliable
• Set objectives

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TIP Indicators

• Identification and Reporting
• TB Case Rate
• Timely Reporting
• Complete Reporting
• Culture Identification
• Completion of Therapy
• Recommended Initial Therapy
• Timely Treatment
• Culture Conversion
• Appropriate DOT
• Inappropriate SAT
• Timely Completion of Therapy
• Not Defaulting from Treatment

• Contact Investigation
• Contact Identification
• Contact Evaluation
• Contact LTBI Treatment Initiation
• Contact LTBI Treatment Completion
• Sentinel Events
• Pediatric TB Cases
• TB Deaths
• Infrastructure
• Program Capacity (self-assessment)

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Culture Conversion TIP IndicatorReport
sss
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Culture Conversion TIP Indicator Methods
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Culture Conversion TIP IndicatorGoal, Indicator,
Objective

• Goal C Ensure timely completion of appropriate
  therapy for all persons with tuberculosis
• Indicator C3 Proportion of sputum
  culture-positive TB cases with documented
  conversion to sputum culture-negative within 90
  days of initiation of treatment
• Objective At least 70 of sputum
  culture-positive TB cases will have documented
  conversion to sputum culture-negative within 90
  days of initiation of treatment, for cases
  counted in 2006

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TIP Process

• Complete Infrastructure Self-Assessment
• Review indicator data
• Analyze and plan
• Verify problem
• Determine reasons for problem
• Develop interventions
• Implement interventions
• Evaluate and reassess

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TIP Benefits and Challenges

• Improvements in many key areas
• Program performance
• Staff capacity and communication
• Data quality
• TB patient care processes
• Challenges
• Limitations with using TIP indicator data
• Competing priorities for LHD and TBCB staff

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Outcomes Summary
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LHD Assessment of TIP

• Methods
• In 10 jurisdictions where long-term TIP
  outcome data are available, structured interviews
  were conducted by TBCB staff with LHD key
  informants.
• Results
• On a scale of 1 (low) to 5 (high), TIP
  participants reported
• Average satisfaction with results 4.2
• Average contribution of TIP to results 3.4

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Web-Based Indicator Reports

• Secure system access (www.tbdata.ca.gov)
• Access to California-wide TIP reports for all
  users
• For TIP participants, access to individual county
  reports
• System always available
• Tailored reports
• By year
• By indicator
• Data updated several times per year

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CDCs Proposed TB Indicators

• A set of indicators will be included in the TB
  Cooperative Agreements for new funding period
  2010-2014
• Several prioritized indicators will be visualized
  in a web-based system modeled on the TIP online
  reports, starting 2009
• One new TB indicator intersects with HIV
• Increase the proportion of TB cases with positive
  or negative HIV test result reported to 88.7 by
  2015

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Possible HIV/TB Indicatorsfor Discussion

• HIV Testing of Persons with TB
• TB cases alive at diagnosis with positive or
  negative HIV test result reported
• TB Testing of Persons with HIV
• HIV cases alive at diagnosis with positive or
  negative TB test result reported

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Rationale for Testingfrom white paper by the
National TB Controllers Association

• HIV testing of TB patients, suspects and
  contacts
• Detect new HIV infections
• Improved outcomes for TB patients with HIV
• Make referrals to HIV care and support services
• Initiate and coordinate TB and HIV treatment
• Prioritize contacts for TB investigation
• Educate patients about TB/HIV
• TB testing of known HIV-infected patients, and
  treatment of TB and LTBI
• Prevent transmission among a highly vulnerable
  population and prevent future TB disease
• Educate patients about risks and consequences of
  TB

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Next Steps

• Do we agree on the need for indicators?
• Discuss possible indicators
• What are the next steps to being able to measure
  them?

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Want More Information?
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Acknowledgements

• Local health department staff participating in
  TIP
• TB Control TIP staff David Beers, Anne Cass,
  Bryan Faulstich, Jennifer Flood, Michael Joseph,
  Lisa Pascopella, Gayle Schack, Stephanie Spencer,
  Joan Sprinson, Lisa True, Jan Young
• Division of TB Elimination Evaluation Workgroup,
  CDC