Title: TB R
1TB RR System's strong points
- Standardized system implemented widely
- Collection of follow-up information on each
patient over long course of treatment - Data sources succinct, cleverly designed for
tabulation, cross-referencing - Definitions that are clear, serve both epi and
clinical purposes - Outcomes based on mutually exclusive irrevocable
categories that are assessed by cohort - Works as a completely paper-based system up to
central level in developing countries - Known benchmarks (e.g. proportion cases smear )
2TB records treatment card
3TB records patient register
Tool of DHO (not all of the data in TC)
1 row 1 course of treatment Does not "track" a
change in regimen (re-reg)
Handy use of multiple col. (probably ART pgm
cannot afford this luxury)
Ordered by date of reg.
Transfer-out outcome is really a subset of
unknowns (transfer-out cases with outcome
unknown). It is responsibility of the initial
registration (only) to report the outcome. The
receiving unit registers for mgmt/monitoring, but
record is disregarded when making cohort reports.
- Default outcome does not exactly say what
happened to the patient and his episode of TB.
Defaulters may or may not be lost patients. Or
they may be known to be dead. Still, the default
outcome is irrevocable. It is a point of closure
on the current regimen.
4TB records lab register
5TB quarterly reports
6TB quarterly reports
7Implementation of district TB register2
scenarios
Centralized registration
De-centralized registration
Patient presents centrally (1), is examined and
diagnosed (2), registered (3) and takes observed
treatment at same site or (preferrable) at
peripheral facility near his home where treatment
card is kept (4).
Patient presents to peripheral facility and is
examined (1), sputum is sent to one of several
labs (2), patient begins treatment with treatment
card (3) at a later date, district supervisor
visits facility and registers case (4),
transcribing from treatment card.
8Some notes about TB system
- Drug planning is relatively simple (few
deviations from defined regimen) Can estimate
monthly/quarterly needs from the case-finding
report. - Duration of follow-up relatively limited (6-9
mo), and limited pieces of follow-up info
(follow-up smears). Patients may travel to
higher level registration/diagnostic center for
follow-up smears. - Outcomes are mutually exclusive and irrevocable
events (e.g., once defaulted, end of story for
that "case" because end of the road for the use
of that regimen.)
9Some notes about TB system (2)
Each arrow represents a patient's treatment
across time, with some outcome reached
Q3
Q2
Q1
Q4
- Cohort analysis common time period of initiating
treatment (versus a common period when outcome is
reached highly variable). - Useful to monitoring trends in programme
performance. - Involves a long delay in assessment (to allow
everyone to have a chance to finish their
regimen), but works nicely in context of SCC (std
duration). - Cohort exclusions are few, so cohort N is stable
10Issues for ART monitoring
- Substitutions and switches in ARV regimens are
not uncommon. - Implications (probably)
- Default (interruption) outcome may not have same
significance / usefulness. - Definition and significance of "failure"?
- Need frequent reports for drug planning (monthly)
- So register (and reporting) must be facility
based.
11Issues for ART monitoring (2)
- Treatment duration is forever only irrevocable
outcome for the patient is death. - Implication/Issues
- Might not make sense to monitor only outcome of
the original regimen course (where 2nd regimen
entails re-registration on new line in the
register book). Rather, it might make sense to
monitor outcomes of patients (up to a certain
point 2 yrs?), and keep all info on one line in
the register (no re-registration). - Probably cannot expect initial registration unit
to follow transferred patients outcomes
quarterly for 2 yrs, so - transferring could be a legitimate and final
outcome, but then - cohort N will become fuzzy due to transfer-in
cases this would be a sacrifice in transparency
at lower level OK at higher levels)
12Issues for ART monitoring (3)
- Substitutions/switches are important
status/events to monitor. - Implication
- Substitution/switch (1st/2nd-line) events could
be viewed as part of the outcome definition,
e.g., - those alive and still on original regimen
- those alive and on substituted regimen
- those alive and on switched 2nd line regimen.
13ART outcome analyses are tricky
- Possibilities "How many patients stopped
treatment" - In the most recent month? Cross-Sectional
- From Jan-Mar of this year? Cross-Sectional
- Ever (since beginning of pgm)? Cumulative
- As of their 6 month of treatment? Survival
analysis - Example of cohort analysis
- "How many patients entering ART during a given
time period had a "stopped treatment" outcome one
year after the close of that time period." - Hand-outs suggest a minimum way to get
cross-sectional and cohort data of interest to
programmes using a paper-based system. (More
data available in the register for computerized
analyses).
This is a "transient" (not irrevocable) status
/ event / outcome.