In collaboration with
Anita Kurian, MPH, MBBS
Patrick Moonan, MPH
Stephen E. Weis, D.O
Date: June 27, 2005

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

Draft of
Performance
Indicators
CDC
M/E Practices
State Department of Health
County Health
Department
TB 400 A, TB 400 B
Initial set of 144 indicators selected
Stakeholder
Focus Groups
Program Staff
Matrix of
34 indicators finalized
Evaluation Staff
TB 340, TB 341
State database
(TIMS, State lab)
Local database
(HIV database, PNS screenings)
Selected program
Staff Interviews

Number of
Participants
FOCUS
GROUP
I
12
FOCUS
GROUP
II
8
FOCUS
GROUP
III
6
FOCUS
GROUP
IV
12
Professional
Level
Medical
Directors
Project managers
Clinicians
Mid-level supervisors
Clinic/
Outreach
Nurses
Contact investigators
Outreach workers
Clerks
Medical records staff
Nurses
(TDH 2/3)
Contact
Investigators
(TDH 2/3)

Conceptual Framework to Evaluate TB Surveillance and Action 1
Feedback
Analysis
Confirmation
Reporting
Registration
Detection
Training
Communications
Support Activity
Public Health Surveillance
Supervision
Data-Information-Messages
Resource provision
Acute (Epidemic-Type)
Public Health Action
Response
Planned (Management-
Type) Response


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
 Local database – HIV database maintained by Medical records clerk, and the PNS roster maintained by the contact investigators.

State databases – TIMS, and state laboratory database.

• 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

• 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

• 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%

• 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%

• 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%

• 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%

Conclusions

Few of the national TB goals were not only met but exceeded.

National TB goal 4 - The national TB goal of at least 75% of all newly reported TB cases will have the HIV status reported (TC).
 National 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.

National TB goal 7 - At least 90% of newly reported sputum
AFB-smear positive TB cases will have contacts identified .


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.

One of the national TB goals that was not achieved pertained to the activity of contact investigation –

National goal 8 - At least 95% of contacts to sputum AFBsmear positive TB cases will be evaluated for infection and disease (TC).

National goal 4 – At least 75% of cases will have HIV status known. In Reg 2/3 four out of 10 refused test.


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.

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 2 nd TST (R2/3).

More field staff for Region 2/3 – nurses, administrative, and contact investigators.