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Panel PhysicianQuality Assessment Program

(QAP) Training

Immigrant, Refugee and Migrant Health Branch (IRMH)Division of Global Migration and Quarantine (DGMQ)

Centers for Disease Control and PreventionAtlanta, Georgia cdcqap@cdc.gov

February 18, 2010

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Outline: Session 1

• Panel Physician Program• Fraud Prevention• General Medical Examination• Classifications• Waivers• Mental Health Conditions (Alcohol)• Drug Abuse/Addiction

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Outline: Session 2

• Tuberculosis (TB) medical screening– Background– 1991 versus 2007 TB Technical Instructions– TB Laboratory– Directly Observed Therapy (DOT)

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Outline: Session 3

• QAP: On-Site Visits• Radiology• Vaccination Requirement• HIV: New Final Rule• Syphilis• Other Sexually Transmitted Infections• Hansen’s Disease

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Outline: Session 1 Detail

• Panel Physician Program• Medical Fraud Prevention• Medical History and Physical Exam• Classifications• DS Forms• Waivers• Mental Health Conditions (Alcohol)• Drug Abuse/Addiction

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Panel Physician Program: Basics

• Statistics– 670 panel sites (1 or more panel physicians)– > 1,000 laboratory and radiology facilities

• Purpose– Examine U.S.-bound immigrants and refugees for

diseases of public health significance– 450,000 immigrants and ~60,000 refugees

annually– TB: Disease of greatest public health concern

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Source: U.S. Department of Homeland Security Refugee admissions: 61,498 (2008)

Annual Estimate of Migrants Entering the U.S.

Non-immigrants: 28 millionShort-term transit: 30 million

Others: 1.5 million

Immigrants: ~1 million

Refugees: 50,000-70,000

Total: ~60 million

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Roles CDC/DGMQ

• Write Technical Instructions for overseas medical examination for immigrants and refugees

• Provide quality assessment of panel physicians performing overseas medical examination

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Roles CDC/DGMQ

• QAP– Assist in implementation of revised Technical

Instructions – Evaluate quality of overseas medical

examination at major panel sites (including laboratory and radiology facilities)

– Recommend changes to DOS/Consular Affairs– No direct authority over panel physicians or

facilities– Assess potential panel sites – Reduce medical fraud

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Panel Physician Selection

• “Less is better”• Need must exist

– At least 2000 immigrant medicals/year • Easier oversight and monitoring of quality• Fewer opportunities for fraud

– Less “panel shopping”

• Recommend primary care physicians– Family practice– Internal Medicine– Pediatrics

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Panel Physician Selection (Cont’d.)

• Confer with local resources– RMO, other physicians or health

personnel– Expatriate facility may not be optimal

choice– Lack of TB expertise and experience

» Sputum collection» Laboratory diagnostics

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RolesDepartment of State/Consular Affairs

• Grant or deny visas• Panel physician monitoring and maintenance

– Screen Department of State (DS) medical forms for completeness and accuracy

– Enter into and renew panel physician agreements annually• Investigate complaints against panel physicians

– Consider IRMH as a resource– Notify IRMH of significant complaints or decision to

terminate agreement – Use MedSig document (in DOS FAM) for onsite evaluation

of physicians and facilities

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CDC

DGMQGlobal AIDS

Program

QuarantineBranch

IRMH

WE ARE IRMH

SIMPLIFIED CDC ORGANOGRAM

IRMH’s Role in Migration Health •Write Technical Instructions• Ensure quality of overseas medical exam

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RolesPanel Physician

• Ensure that person undergoing medical examination = person applying for visa

• Perform physical and mental examination• Determine classification(s)• Record results• Does not decide visa eligibility

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Purpose of Medical Examination

• Determine whether the alien

– Has a physical or mental disorder that renders alien ineligible for a visa or for refugee admission (Class A)

– Has a physical or mental disorder (Class B) that may

• interfere with ability to care self or attend school or work, or

• may require extensive medical treatment or institutionalization in the future

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What the Medical Examination is Not

• A thorough review of applicant’s health

• A routine medical examination

• Opportunity for applicant to receive treatment for chronic conditions that are not inadmissible (advise of condition and type of referral needed)

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Inadmissible communicable diseases of public health significance

CFR (Title 42, Part 34)

Tuberculosis, active Syphilis, untreated Chancroid, untreated Gonorrhea, untreated Granuloma Inguinale, untreated Lymphogranuloma Venereum, untreated Hansen’s disease (untreated multibacillary)

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Inadmissible communicable diseases of public health significance

CFR (Title 42, Part 34), Cont’d.

• October 2008 added specific infectious disease emergencies, for which a risk-based approach requires increased screening in a specified area and population, due to a significant threat to the U.S. population – Quarantinable diseases (e.g., SARS, pandemic flu)– Category 1 International Health Regulation (IHR)

diseases (polio, smallpox)– Category 2 and 3 IHR diseases if determined to be

communicable diseases of public health significance

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Class A Medical Conditions

– Inadmissible– Treatment or waiver required for admission– Examples

• TB (laboratory positive) • STIs (untreated) • Mental Disorders with Harmful Behavior

(including Alcohol Abuse) • Substance Abuse (no waiver for immigrants)

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Class B Medical Conditions

– Admissible– Substantial departure from normal health– Examples:

• TB (laboratory negative) • STIs (treated),• Mental Disorders without Harmful Behavior • Substance Abuse (in remission)

– Stateside notifications for TB

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Medical Fraud Prevention

• TIs require panel physician to ensure that person appearing for medical examination

= person applying for the visa

• Identity verification at each station of exam– Photo for each form– Signature

• Specimen Collection– Direct observation of sputum collection– Direct observation of drug specimens

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Medical Fraud Prevention, Cont’d.

• Sputum and blood specimen labeling– Random number or bar coded

• No name on specimen container• Appointed person at panel physician site

reconciles number or code with name– At panel physician office or laboratory

depending on site of collection

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Blood-Tinged Sputum Specimen

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Anonymous Specimen Labeling

• Numbered or bar coded• No name on container • Appointed person at

laboratory or panel physician site reconciles number or code with name

• Label should be on the container, not cap, and difficult to remove

Source: DTBE, CDC

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Medical Fraud Prevention

• Report/DS Form Delivery– Class A conditions--- physician to report

immediately and directly to Consulate• To prevent “panel-shopping”

– Forms indicating Class A or Class B TB conditions should not be hand-carried by the applicant to the Consulate

• 1991 TB Instructions: A, B1 and B2• 2007 TB Instructions: A and B1

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Medical History

• Panel physician or staff member obtains• Review of

– Hospitalizations– Institutionalizations– All illnesses or disabilities resulting in a

substantial departure from normal state– Drug and alcohol use, harmful behavior– TB history: Chest radiographs and Rx records

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Immigrant Visa Medical Examination Waiting Room

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Review of Records and Systems

• Records:– Police, military, school, employment

• Harmful behavior?• Substantial departure from well-being

• ROS:– Cardiovascular, pulmonary, neuropsychiatric– Symptoms suggestive of infectious disease,

especially TB

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Medical Examination

• To determine presence of Class A or B• Physical

– Eyes, ears, nose, throat, extremities, heart, lung– Abdomen, lymph nodes, skin (not breasts)– External genitalia (visual, palpation)

• Mental status– Intelligence, thought, comprehension– Judgment, affect, behavior

• Required diagnostic tests

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Vital Sign Station and Scales

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Diagnostic Testing

• All aliens ≥15 years of age

• Aliens <15 years of age if there is a reason to suspect disease

• Required for TB* and syphilis

• All other disorders diagnosed through history and physical examination

*2007 TB TI: 2 years of age and older

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Required Overseas Medical Screening1991 TB TI Screening

Pas t Medical His tory Phys ical

Examination

-Ches t X ray Phlebotomy

SyphilisSero logy

SputumSamples

-Acid fas tMicros copy

>15 Years of age

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Department of State Medical Forms

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DS Medical Forms

• Four forms (1 summary, 3 worksheets):– DS-2053/2054 Medical Examination for Immigrant

or Refugee Applicants (summary)

– DS-3024/3030 Chest X-Ray Classification Worksheet

– DS-3025 Vaccination Documentation Worksheet

– DS-3026 Medical History and Physical Examination Worksheet

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DS-2054 Medical Examination Summary

Classification Section

Under 2007 TB TI, Class B2 TB is someone with a positive skin test or positive IGRA

(usually a child)

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DS Medical Forms

• Consistent information on DS-2053/2054 and worksheets

• Errors crossed out → initials of person correcting and date of correction

• Examining physician and applicant must sign and date DS-2053/2054 form

• Panel physician to keep one copy of DS-2053/2054 and all worksheets for one year

• Consular officer to check that medical exam has not expired and to adjust length of validity of visa to length of validity of medical exam

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Copies of DS Forms

YesYesN/ARefugee

NoYesNoImmigrant

YesYesYesImmigrant

3 Copies of 4 DS Forms

Original of 4 DS Forms

Class A, Or Class B TB Condition

Alien Type

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QAP

Immigrants andRefugees

IRMH

, /Panel Phys ic ians IOMand DOS DGMQ

Health Departments

CBP or IOM

Quarantine Stations

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Medical Waivers and Alcohol Abuse Cable

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Waivers for Medical ConditionsBasic Points

• IRMH/CDC is involved in the waiver process for immigrants based on the following medical conditions:

– Mental/Physical Disorders with associated harmful behavior

– Tuberculosis

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Waivers for Medical Conditions Basic Points

• IRMH/CDC is not involved in the waiver process for non-immigrants. *

• There is no waiver for Substance Abuse or Substance Addiction.

*Other than K visa applicants (fianceés)

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Waivers for Medical Conditions IRMH/CDC Review

• IRMH/CDC’s role in the waiver process is one of review only– To ensure appropriate testing, evaluation, diagnosis and

classification by panel physician– To ensure U.S. Health Care Provider has been identified

• IRMH/CDC has a consultant psychiatrist that reviews mental and substance abuse cases– To provide diagnosis and classification– Panel Physician should have a specialist

(psychologist/psychiatrist) identified for referral of mental disorder/substance abuse cases)

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Waivers for Medical Conditions IRMH/CDC Review

• Routine requests for review should be forwarded via mail to the following address:

Immigrant, Refugee and Migrant Health Branch (WAIVERS)Division of Global Migration and Quarantine (E-03) Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333

• Routine processing time is 3-4 weeks.

• Urgent requests should be sent via fax 404-639-4441– Attn: IRMH/Waiver ‘Urgent’– Processing time is 2-3 days

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IRMH/CDC Review of Waivers Based on Class A Conditions

Memo requesting advisory opinion, DS medical forms and supporting medical documents

Memo requesting advisory opinion, DS medical forms, and supporting medical documents, including mental status or psychiatric evaluation

Memo requesting advisory opinion, DS medical forms, and supporting medical documents

Memo requesting advisory opinion, DS medical forms with HIV test results, and supporting medical documents

Request for Advisory Opinion of Diagnosis and Classification

Routine request:~ 4 weeksUrgent request:~7 days

Routine request:~ 4 weeksUrgent request:~7 days

~ 7 daysRoutine request:~ 4 weeksUrgent request: ~1-2 days

IRMH/CDC processing time

Routine request by mail to: CDC, 1600 Clifton Rd, Atlanta, GA 30330, MS-E03Urgent request by fax to 404-639-4441 Attention:IRMH/Waiver ‘Urgent’

Routine request by mail to: CDC, 1600 Clifton Rd, Atlanta, GA 30330, MS-E03Urgent request by fax to 404-639-4441 Attention:IRMH/Waiver ‘Urgent’

All requests by fax to 404-639-4441 Attention:IRMH/QAP/TB Waiver

Routine request by mail to: CDC, 1600 Clifton Rd, Atlanta, GA 30330, MS-E03Urgent request by fax to: 404-639-4441 Attention:IRMH/Waiver ‘Urgent’

Sendingdocuments to IRMH/CDC

None-Not applicable-I-601/I-602 waiver-DS medical forms-supporting medical documents including mental status or psychiatric evaluation

-I-601/I-602 waiver-DS medical forms-supporting medical documents

I-601waiver with page 4 of the I-601 waiver completed or I-602 with HIV attachment form, and DS medical forms with HIV test results and supporting medical documents

Documentsto be sent to IRMH/CDC (Copies only)

No waiver available for immigrants

Review Only-to ensure appropriate mental diagnosis and correct classification-to ensure US Healthcare Provider is identified

Review Only-to ensure appropriate testing/evaluation and correct classification

Review Only-to ensure appropriate testing and correct classification-to ensure US Healthcare Provider is identified

CDC Role

Class A Substance Abuse/ Addiction

Class A Mental Disorder with Associated Harmful Behavior (includes Alcohol Abuse)

Class A TBClass A HIV Infection

Condition

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CDC Review of Waivers Reminders

• Only copies (no originals) should be sent • Routine request should be sent via mail• Urgent request should be sent via fax 404-639-4441

– Attn: IRMH/Waiver ‘Urgent’

• IRMH/CDC will provide written response • A request for an advisory opinion of diagnosis and

classification may be made to IRMH/CDC

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Mental Health Conditions (Including Alcohol Abuse)

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Definitions

• Mental disorder– Currently accepted psychiatric disorder, according to the

current Diagnostic and Statistical Manual • Published by the American Psychiatric Association

• Harmful behavior (for this examination)– Dangerous action or series of actions that has

• Resulted in psychological or physical injury to the alien or another person OR

• Threatened the health or safety of the alien or another person OR

• Resulted in property damage

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Classifications

• Determined by 1991 Technical Instructions• Class A

– Current evidence of mental disorder and– Associated harmful behavior or history of harmful

behavior judged likely to recur

• Class B– Current evidence of mental disorder and– No currently associated harmful behavior and no

history of harmful behavior that is judged likely to recur

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Major Mental Health Diagnostic Categories (Not All-Inclusive)

• Mental retardation• Dementias• Disorders

PsychoticDelusionalMoodDissociativeAnxiety-relatedSomatoform

• DisordersPersonalityAdult anti-socialConductAdjustmentSexualImpulse Control

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Mental Health Evaluation

• Refer to 1991 Technical Instructions• Review medical history for

– Hospitalization or institutionalization for psychiatric illness

– History of harmful behavior– Diagnosis of mental disorder with which harmful

behavior may be associated or in which harmful behavior is an element of the diagnostic criteria

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Mental Health Evaluation, Cont’d.

• Review other records, if available– Police– Military– School– Employment

• Interview applicant – Psychiatric illnesses– History of associated harmful behavior

• Interview applicant’s family when appropriate

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Mental Health Evaluation, Cont’d.

• As part of the physical exam, perform mental status examination– Intelligence– Thinking– Cognition (comprehension)– Judgment– Affect (mood)– Behavior

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Diagnosis and Classification

• Overseas evaluation should determine:– Diagnosis– If Class A or B (harmful behavior?)

• Technical Instructions require panel physician to refer to specialist if panel unable to make diagnosis or classification (fraud prevention)

• CDC consultant psychiatrist conducts review of cases on regular basis or as needed

• A request for an advisory opinion of diagnosis and classification may be made through the Consulate to IRMH/CDC

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Alcohol Abuse (2007 Cable-Applicants w/ Drunk

Driving Hits)

• Alcohol Abuse– Not evaluated as Substance Abuse– Evaluated as Mental Disorder with Associated

Harmful Behavior– Need both

• Mental disorder diagnosis• Associated harmful behavior (current or history judged

likely to recur)– If panel physician unable to make diagnosis of alcohol

abuse, the panel must refer to specialist

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Alcohol Abuse

• If Panel Physician refers to specialist– Panel must provide the reason (s) for referral – Panel must indicate that the evaluation should address

(1) the determination of a mental disorder diagnosis (alcohol abuse) and

(2) whether there is current or a history of associated harmful behavior to self, others, or property and if there is a history of harmful behavior, is it judged likely to recur

• There are no specific forms for the specialist’s report

• The specialist’s report must be included with the medical record including the DS forms provided to the Consulate

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Alcohol Abuse Reminders

• 2007 DOS cable applies to IV and NIV’s

• Complete medical exam needed for NIV’s if they require medical evaluation for alcohol abuse

• Need BOTH mental disorder diagnosis and associated harmful behavior to be Class A

• May request CDC to review medical exam documents and provide an advisory opinion

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Substance Abuse and Addiction

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Substance Abuse and Addiction

• Panel physician responsibility– Interview and examine applicant– Review records– Determine if there is current or past nonmedical use of a

psychoactive substance– If yes, determine whether substance in Section 202 of the

Controlled Substances Act (CSA); see Appendix A of TI– Determine whether Class A or Class B

• Technical Instructions require panel physician to refer to specialist if panel unable to determine diagnosis or classification (fraud prevention)

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Drug Classes in Section 202 of the CSA (Not All-Inclusive)

• Amphetamines and Related Substances• Cannabinoids• Cocaine and related substances• Hallucinogens• Opioids and related substances• Phencyclidine (PCP) and related substances• Sedative, hypnotic, or anxiolytic substances

(tranquilizers)

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Definitions

• Psychoactive abuse/dependence includes 2 groups– Nonmedical users of any drug currently listed in Section

202 of the Controlled Substances Act • Illegal in U.S.• Click on Appendix A of the 1991 Technical Instructions

at http://www.cdc.gov/ncidod/dq/panel_1991.htm• No associated harmful behavior required

– Abusers of drugs not listed in Section 202 of the Controlled Substances Act

• Determination of Class A or B status– Same as for a mental health or physical condition.

There must be current associated harmful behavior, or a history of harmful behavior judged likely to recur

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Definitions, Cont’d.

• Remission (Class B)– No nonmedical use of a drug listed in Section 202

of the CSA for 3 or more years– No nonmedical use of a drug NOT listed in

Section 202 of the CSA for 2 or more years

• Nonmedical use– Considered to be more than experimentation with

substance– Experimentation = single use

• Consult specialist if needed

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Substance Abuse and Addiction

• No waiver available for immigrants• IRMH/CDC not involved in waiver for NIVs*• A request for an advisory opinion of

diagnosis and classification may be made to IRMH/CDC

• Alcohol Abuse is separate from Substance Abuse/Addiction

NIV = Non-immigrant visa

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Thank You

Questions?