Project
Evaluating Tuberculosis Surveillance
and Action in an Urban and Rural Setting
A collaborative effort between
‰ Center for Disease Control and Prevention,
Division of Tuberculosis Elimination
‰ University of North Texas Health Science Center Fort worth
‰ Texas Department of Health
‰ American Lung Association
‰ Florida Department of Health
Kristine Lykens, Ph.D.
In collaboration with
Anita Kurian, MPH, MBBS
Patrick Moonan, MPH
Stephen E. Weis, D.O
Date: June 27, 2005
Performance Analysis Methods
Draft of
Draft of
Performance
Performance
Indicators
Indicators
TB
TB400
400A,
A,TB
TB400
400BB
Stakeholder
Stakeholder
Focus
FocusGroups
Groups
CDC
CDC
M/E
M/EPractices
Practices
Initial set
of 144
indicators
selected
Program
ProgramStaff
Staff
State
Statedatabase
database
(TIMS,
(TIMS,State
Statelab)
lab)
Local
Localdatabase
database
(HIV
(HIVdatabase,
database,
PNS
PNSscreenings)
screenings)
Conceptual Framework to Evaluate TB Surveillance and Action1
Training
Training
Supervision
Supervision
Communications
Communications
Resource
Resourceprovision
provision
Support
SupportActivity
Activity
Acute
Acute(Epidemic-Type)
(Epidemic-Type)
Response
Response
Analysis
Analysis
Confirmation
Confirmation
Public
PublicHealth
HealthSurveillance
Surveillance
Public
PublicHealth
HealthAction
Action
Reporting
Reporting
Registration
Registration
Detection
Detection
FOCUS
GROUP
III
FOCUS
GROUP
IV
12
8
6
12
Professional
Level
Medical
Directors
Mid-level
supervisors
Outreach
workers
Project
managers
Clinic/
Outreach
Nurses
Clerks
Clinicians
Contact
investigators
Medical
records staff
Selected
Selectedprogram
program
Staff
StaffInterviews
Interviews
County
CountyHealth
Health
Department
Department
Feedback
Feedback
FOCUS
GROUP
II
TB
TB340,
340,TB
TB341
341
Matrix of
34
indicators
finalized
Evaluation
EvaluationStaff
Staff
State
StateDepartment
Department
of
ofHealth
Health
Number of
Participants
FOCUS
GROUP
I
Data-Information-Messages
Data-Information-Messages
Planned
Planned(Management(ManagementType)
Type)Response
Response
Nurses
(TDH 2/3)
Contact
Investigators
(TDH 2/3)
Data Sources
‰ Registered Public Health Records – TB 400 A, TB 400 B,
TB 340, TB 341.
‰ Selected staff interviews – Medical Director, Program
Manager, Outreach supervisor, Medical records clerk,
Billing clerk.
‰ Local and State level databases
ƒ Local database – HIV database maintained by Medical records
clerk, and the PNS roster maintained by the contact
investigators.
ƒ State databases – TIMS, and state laboratory database.
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Tarrant County
• Fort Worth is Central City
• County population over 1.5 million
• Tuberculosis program
–
–
–
–
Central Clinic
DOT and Contact Investigation centralized
Growing immigrant population
Site for several TB research projects
Selected Results – Tarrant Co.
• TB suspects who received visit within 3
working days – 65%
• TB suspects with completed evaluation
within two weeks – 91%
• TB cases receiving Directly Observed
Therapy (DOT) – 100%
• TB cases who completed DOT – 99%
Selected Region 2/3 Preliminary
Results
• TB suspects who received visit within 3
working days – 63%
• TB suspects with completed evaluation
within two weeks – 78%
• TB cases receiving Directly Observed
Therapy (DOT) – 90%
• TB cases who completed DOT – 89%
DHHS Region 2/3
• 37 rural counties without Public Health
Departments.
• Central office in Arlington, TX
• Sub-Offices staffed by PH nurses
• TB program case-managed by nurses
• Contact investigation by nurses
• DOT by PH and contracted nurses
Tarrant Co. Results (continued)
• TB cases with documented HIV status –
94%
• TB cases without any identified contacts –
4%
• Contacts with completed TB skin tests
– With night shelter cases – 86%
– Without night shelter cases – 57%
Selected Region 2/3 Preliminary
Results (continued)
• TB cases with documented HIV status –
50% (4/10 refused test)
• TB cases without identified contacts – 0%
• TB contacts with completed TB skin tests –
55%
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Conclusions
‰ Few of the national TB goals were not only met but
exceeded.
¾National TB goal 4 - The national TB goal of at least 75% of all
‰ One activity amenable for intervention was the activity of
‘contact investigation’. An audit of 280 TB 341 forms
revealed that only 25 (8.9%) of the TB 341 forms had all
the data fields completed/updated.
newly reported TB cases will have the HIV status reported (TC).
¾National TB goal 5 - At least 90% of patients with newly
diagnosed TB, for whom therapy for one year or less is
indicated, will complete therapy within 12 months (TC). 89% in
R2/3.
¾National TB goal 7 - At least 90% of newly reported sputum
AFB-smear positive TB cases will have contacts identified.
Recommendations
‰ Have an Integrated data base**
‰ Designate a separate ‘medical records clerk’ to
update the TB 340s and TB 341s. (TC)
‰ Cross train staff for contact info update (TC).
‰ Improve communication between the contact
investigators and the clinic staff (TC).
‰ Conduct either a patient satisfaction survey or
focus group involving patients to obtain feedback
regarding the services provided by the program.
‰One of the national TB goals that was not achieved
pertained to the activity of contact investigation –
¾National goal 8 - At least 95% of contacts to sputum AFBsmear positive TB cases will be evaluated for infection and
disease (TC).
¾National goal 4 – At least 75% of cases will have HIV status
known. In Reg 2/3 four out of 10 refused test.
Recommendations (cont’d)
‰ Educate the contacts of the cases regarding the
importance of preventive therapy.
‰ Streamline the process so that intake process and
clinical evaluation can occur on the same day.
‰ Review process for patients visiting the medical
clinic for different services to reduce wait time for
the patients (TC).
‰Increase follow-up for 2nd TST (R2/3).
‰More field staff for Region 2/3 – nurses,
administrative, and contact investigators.
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