Transcript When medical evaluation is considered completed?

Improving Initial Evaluation for
Persons with Class A/B TB
Conditions
Sharon Sharnprapai
Massachusetts Department of Public Health,
Bureau of Infectious Disease
Division of Tuberculosis Prevention and Control
Refugee Immigrant Health Program
Background
 Newly arrived persons with class A/B TB
condition with abnormal chest x-ray are at
increased risk for progression to active TB.
 It is essential that the persons are evaluated for TB
soon after entry into the US.
National TB Program Objectives and
Performance Target for 2015
Evaluation of Immigrants and Refugees
MA goal – 75%
MA goal – 85%
MA goal – 75%
MA goal – 75%
CDC - not yet determined the “N%” for these indicators
Working Definition
When medical evaluation is considered initiated?
When medical evaluation is considered completed?
Working definitions developed:

Medical evaluation initiated -> If Initial tuberculosis skin test
(TST) was done or nursing assessment was done to determine that
a TST was not needed.

Medical evaluation completed -> American Thoracic Society
(ATS) classification was assigned to the newly arrived either by the
TB clinic staff or another medical provider.
2009 Massachusetts Data
Total Notifications Received
N=242
Medical evaluation initiated
180 (74%)
Not evaluated
N=62 (26%)
Within 30 days (Goal 75%)
Within 60 days
Within 90 days
Medical evaluation completed
Within 90 days
Appropriate for Rx Initiation
Treatment Initiated
Treatment Completed
121 (67%)
147 (82%)
158 (88%)
175 (97% of initiated)
92 (51% of initiated)
N=91
60 (66%)
41 (68%)
Goal of Evaluation
To increase the rate of initial medical evaluation
How ?
• Need to understand why the newly arrived
persons did not receive initial medical evaluation
•Develop plans to address issues
Survey - Why not receive initial evaluation
Total New Arrival 2009
N=242
Medical evaluation initiated N=180 (74%)
Not evaluated N=62 (26%)
Survey Methods - Phone call to nurse case managers at
the local health departments (LHD) for each of 62
newly arrived persons


Questions to nurses:
Did you receive notification about the arrivals from the
TB Division &
Were you able to contact the newly arrived; if not, why?
Survey Results
Of the 62 newly arrived; Nurses able to provide
information for 49 persons (79%)
________________________________
Of the 49 persons,
 Nurses not able to locate 15 persons (31%)
 14 persons (29%), follow-up may have been

initiated by the nurses, however, records of followup were not found; and
5 persons (10%) moved soon after arrival in MA.
Survey - Identified Issues
1. Home address of the newly arrived persons
supplied through the CDC’s Electronic Disease
Notification System (EDN) can be incorrect. This
can led to the LHD nurses not being able to locate
some persons, and caused delays when the
notification had to be re-routed to a different
jurisdiction.
Example – address given 123 Summit street
Brookline but actually home in Brighton.
Survey - Identified Issues (continued)
2. If the LHD nurses are unable to locate the
newly arrived persons, they often held the
“follow-up worksheet”. TB Division is then
unaware of the disposition and unable to help
LHD nurses to locate the person in a timely
manner.
Action Plans
1. Verify the address of the newly arrived
persons using Google before the notification is
sent to the LHD nurses. If the address is invalid,
we will contact the sponsor by phone to obtain
the new address.
Confirming the validity of address may help
LHD nurses locate the newly arrived and
reduce delay of notification.
Action Plans (continued)
 Institute active follow-up by calling the
LHD nurses to obtain updated status reports
about the newly arrived persons and answer
questions regarding follow-up procedures if the
“TB follow-up worksheet” has not been
returned within 30 days after the notification is
sent to the LHD nurses.
 A check-list was developed to help guide the
LHD nurses in the medical evaluation process.
Check list
Limitations
Because 2009 data were used, LHD nurses had
difficulties recalling why initial medical
evaluation was not initiated or the nurses
assigned to provide case management to the
newly arrived had left the health department.
Next Steps

Verification of addresses has initiated. The number of
notifications with invalid addresses will be tracked. The
implementation of active follow-up will start in October.

The rate of initial medical evaluation persons arriving in
2013 will be compared to those who arrived in 2009-2011
to evaluate the extent to which our initiatives have
increased the initial medical evaluation rate.

For 2013, focus on increasing the rate of treatment
initiation and treatment completion.
Acknowledgements
Marisa Chiang
Jennifer Cochran
Pat Iyer
Maura McGarty
Kate Penrose
Andrew Tibbs
Questions