N599 Module 1 assignment: capstone problem statement and project question, a full sample

Finishing What We Start: The Problem of Incomplete Latent Tuberculosis Treatment at a County Clinic and a Capstone Project Question

Student Name

Master of Science in Nursing Program, Aspen University

N599: Nursing Capstone

Instructor Name

Month Day, Year

Finishing What We Start: The Problem of Incomplete Latent Tuberculosis Treatment at a County Clinic and a Capstone Project Question

A composite county health department in a mid-sized city runs a tuberculosis clinic that diagnoses and treats latent tuberculosis infection, the dormant form of infection that causes no symptoms and is not contagious but can progress to active, transmissible disease. Most of the clinic's patients were born in countries where tuberculosis is common, and many are recently resettled refugees, students or workers holding more than one job. Over the past twelve months, 164 patients started treatment for latent infection, most of them on four months of daily rifampin taken at home. Only 95 of them, 58%, completed treatment. The other 69 patients remain at risk of developing active tuberculosis, and every case that develops will mean illness for the patient, a contact investigation for the clinic and possible transmission to family and coworkers.

This paper defines the problem that the capstone project will address, places it in the context of tuberculosis prevention in the United States, explains why the clinic's current approach produces incomplete treatment, and states the project question that the remaining sections of the capstone will answer.

Background and Significance

Treating latent tuberculosis infection is central to eliminating tuberculosis in the United States, because most new cases arise from reactivation of infection acquired years earlier rather than from recent transmission. Treatment works: shorter regimens containing rifamycins are now preferred because they are as effective as older regimens and more likely to be completed. National guidelines now recommend three rifamycin-based regimens, a dozen weekly doses of rifapentine combined with isoniazid, four months of daily rifampin, and three months of daily isoniazid and rifampin, over the longer isoniazid-only regimens (Sterling et al., 2020).

Completion, however, is where many patients fall away. Pooling 58 studies that together followed more than 748,000 people, one systematic review found large losses at several steps between screening and cure, including completion of treatment among those who start it (Alsdurf et al., 2016). A patient who does not complete treatment receives little protection, while the health system has spent the effort of testing, evaluation and prescribing. Improving completion is therefore one of the most efficient ways a clinic can prevent future cases.

Why Patients at This Clinic Do Not Finish

A review of the 69 incomplete courses, together with interviews with the clinic's two public health nurses and outreach worker, points to four contributing factors. First, daily medication for four months is a heavy burden for patients who feel well and do not see a benefit, and missed doses accumulate quietly. Second, the clinic's follow-up relies on monthly in-person visits that patients working hourly jobs struggle to attend; most incomplete courses ended after a missed monthly visit. Third, contact between visits is limited to phone calls from a single outreach worker, often unanswered. Fourth, even with interpreters, language barriers make it hard to explain why a person without symptoms should take pills for months.

The factors suggest two levers. A shorter regimen with weekly rather than daily dosing reduces the burden, and a way of observing doses that does not require travel could maintain contact without clinic visits.

The timing of dropout matters as much as its causes. Of the 69 incomplete courses, 41 ended within the first six weeks, most often in the gap between the first and second monthly visits, when the patient had no contact with the clinic for a month and side effects, such as nausea or orange-colored urine, were still unfamiliar. A further 17 ended in the second or third month after a missed visit, and 11 ended because the patient moved or could no longer be reached. The pattern suggests that the first weeks of treatment, not the last, are where an intervention can do the most good, and that contact in those weeks should be frequent and easy for the patient.

Evidence Pointing to a Solution

Both levers have support. Sterling et al. (2011) randomized adults to the dozen supervised weekly doses or to nine months of daily isoniazid; the short course prevented tuberculosis no less well, and 82.1% of its patients finished, against 69.0%. For observation, smartphone video-observed therapy allows patients to record themselves taking each dose and send the video to a nurse. In a randomized trial among patients with active tuberculosis, many with complex social needs, Story et al. (2019) found that seven in ten patients on video observation had four in five of their early doses seen, compared with about three in ten watched in person. Neither study was conducted in a clinic like this one, and the second concerned active rather than latent disease, but together they suggest that a weekly regimen observed by video could fit the lives of the clinic's patients.

The Project Question

The capstone project will implement and evaluate a nurse-led change in the clinic's standard approach. The project question, in PICOT form, is: among adults starting treatment for latent tuberculosis infection at the county clinic (P), does a three-month course of weekly rifapentine plus isoniazid, with a nurse watching a phone video of every dose (I), compared with four months of daily rifampin taken at home and checked at monthly appointments (C), increase the proportion of patients who complete treatment (O) during a six-month implementation period (T)?

This is quality improvement work, not a research study: it applies an evidence-based change to local practice and measures its effect, using the clinic's own records. Secondary questions concern which patients choose video observation, how many weekly videos are missed and why, and how much nursing time the approach requires. Patients who prefer daily rifampin, or who have contraindications to rifapentine, will continue to receive it with improved follow-up.

Success will be judged against a target set with the clinic's nurses and medical director before implementation begins: overall completion of at least 75% during the six months, a gain of about 17 percentage points over the baseline. The target is ambitious but realistic in light of completion rates reported in trials and cohort studies of the weekly regimen, and setting it in advance prevents the team from redefining success after seeing the results.

Conclusion

Incomplete treatment of latent tuberculosis infection at the county clinic leaves nearly half of treated patients unprotected and wastes much of the effort that brought them into care. Local review suggests that daily dosing and monthly travel are central barriers, and the evidence suggests that a weekly regimen observed by video could reduce both. The capstone project will test that approach in the clinic's own population, asking whether it increases treatment completion. The sections that follow review the literature, set out a guiding framework, describe the project's design, and report and discuss its results.

References

Alsdurf, H., Hill, P. C., Matteelli, A., Getahun, H., & Menzies, D. (2016). The cascade of care in diagnosis and treatment of latent tuberculosis infection: A systematic review and meta-analysis. The Lancet Infectious Diseases, 16(11), 1269-1278. https://doi.org/10.1016/S1473-3099(16)30216-X

Sterling, T. R., Njie, G., Zenner, D., Cohn, D. L., Reves, R., Ahmed, A., Menzies, D., Horsburgh, C. R., Crane, C. M., Burgos, M., LoBue, P., Winston, C. A., & Belknap, R. (2020). Guidelines for the treatment of latent tuberculosis infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recommendations and Reports, 69(1), 1-11. https://doi.org/10.15585/mmwr.rr6901a1

Sterling, T. R., Villarino, M. E., Borisov, A. S., Shang, N., Gordin, F., Bliven-Sizemore, E., Hackman, J., Hamilton, C. D., Menzies, D., Kerrigan, A., Weis, S. E., Weiner, M., Wing, D., Conde, M. B., Bozeman, L., Horsburgh, C. R., & Chaisson, R. E. (2011). Three months of rifapentine and isoniazid for latent tuberculosis infection. New England Journal of Medicine, 365(23), 2155-2166. https://doi.org/10.1056/NEJMoa1104875

Story, A., Aldridge, R. W., Smith, C. M., Garber, E., Hall, J., Ferenando, G., Possas, L., Hemming, S., Wurie, F., Luchenski, S., Abubakar, I., McHugh, T. D., White, P. J., Watson, J. M., Lipman, M., Garfein, R., & Hayward, A. C. (2019). Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: A multicentre, analyst-blinded, randomised, controlled superiority trial. The Lancet, 393(10177), 1216-1224. https://doi.org/10.1016/S0140-6736(18)32993-3