What Helps Patients Finish Latent Tuberculosis Treatment? A Literature Review for a Nurse-Led Capstone Project
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Master of Science in Nursing Program, Aspen University
N599: Nursing Capstone
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What Helps Patients Finish Latent Tuberculosis Treatment? A Literature Review for a Nurse-Led Capstone Project
The capstone project aims to lift the share of patients who finish preventive tuberculosis treatment at one county's clinic, currently 58%, by switching to a three-month weekly rifapentine regimen whose doses nurses confirm through recorded video. This literature review examines the evidence on that approach. Sources were identified through PubMed and CINAHL using combinations of latent tuberculosis, treatment completion, rifapentine, directly observed therapy, video-observed therapy and self-administered therapy, limited to English and to studies of adults. Priority was given to randomized trials, large cohort studies and national guidelines. The review is organized by theme rather than by study, and it closes by identifying the gap the project addresses.
Shorter Regimens and Completion
The strongest and most consistent finding is that shorter rifamycin-based regimens are completed more often than longer ones. In a large randomized trial, Sterling et al. (2011) compared 12 once-weekly doses of rifapentine and isoniazid given under direct observation with nine months of self-administered daily isoniazid. The weekly regimen was at least as effective in preventing tuberculosis, with cumulative rates of 0.19% and 0.43%, and treatment completion was 82.1% compared with 69.0%. Drug-related liver toxicity was less common with the weekly regimen, though discontinuation for adverse events was slightly more frequent.
Real-world data compare the weekly regimen with the four-month daily rifampin regimen now used at the county clinic. In a retrospective cohort of 1,333 adults at a U.S. tuberculosis clinic, 89% of them born outside the United States, Haas et al. (2021) found that completion with self-administered weekly isoniazid and rifapentine was 79% compared with 68% for daily rifampin among adults aged 18 to 49, and 87% compared with 64% among those aged 50 and older, with fewer adverse events in the older group. National guidelines now recommend both regimens as preferred options (Sterling et al., 2020). Together, these studies suggest that switching from daily rifampin to the weekly regimen is likely to raise completion on its own.
How Doses Are Observed
The second theme concerns whether doses must be observed. Direct observation in person was the original standard for the weekly regimen, but it requires weekly visits that many patients cannot make. In a randomized trial with 1,002 participants, most at U.S. sites, Belknap et al. (2017) compared directly observed therapy with self-administered therapy with and without text-message reminders. Completion was 87.2% with direct observation, 74.0% with self-administration and 76.4% with self-administration plus reminders. In the United States, self-administration without reminders was noninferior to direct observation, although completion was still numerically lower, and reminders did not add benefit. The finding supports self-administration where observation is not feasible, but it also shows that observation increases completion when it can be provided.
The trial carries two points worth drawing out for this project. First, the difference between observed and self-administered treatment was larger at sites outside the United States, a reminder that the effect of observation depends on the setting and the population. Second, text-message reminders sent automatically did not improve completion, which suggests that what helps patients is contact with a person who responds to them rather than reminders alone. The project's design, in which a nurse reviews each weekly video and replies, draws on that distinction.
Video-Observed Therapy
Video observation offers a middle path: the patient records each dose on a smartphone and a nurse reviews it, preserving observation without travel. The strongest evidence comes from active tuberculosis. In a randomized trial in London, Story et al. (2019) assigned 226 patients, 58% of whom had histories of homelessness, imprisonment, substance use or mental health problems, to video-observed or in-person directly observed therapy. Seventy percent of the video group completed at least 80% of scheduled observations in the first two months, compared with 31% of the in-person group. The trial's population and daily dosing differ from latent infection treatment, so its effect size cannot be transferred directly. Evidence specific to video observation of the weekly latent infection regimen in U.S. health departments is limited, which is part of the gap this project addresses.
Who Is Most at Risk of Not Finishing
The final theme concerns losses along the cascade of care. A systematic review of 58 studies involving more than 748,000 people found substantial losses at several steps from screening to treatment completion, and examined characteristics associated with loss (Alsdurf et al., 2016). Local review at the county clinic points to similar risks: patients working hourly jobs, recent arrivals and those who miss the first monthly visit. These patterns suggest the intervention should reduce travel, begin contact early and use interpreters for teaching about why treatment matters when there are no symptoms.
The cascade review also shows why completion is the step a clinic can influence most directly. Losses before treatment starts depend partly on referral systems and on whether clinicians recommend treatment at all, which are outside a nurse-led project's reach. Once a patient has accepted treatment, however, the clinic controls the regimen offered, the frequency and form of contact and the teaching provided, so completion is where changes in nursing practice can have their clearest effect. This reasoning supports the project's focus on completion rather than on the full cascade.
Synthesis and Gap
Across the literature, three conclusions are well supported. Shorter weekly regimens are completed more often than daily regimens. Observation of doses increases completion compared with self-administration, though self-administration is acceptable when observation is not feasible. And video observation can achieve higher observation rates than in-person observation in populations facing barriers to travel. What is less well established is how a nurse-led program combining the weekly regimen with video observation performs in a U.S. county clinic serving recently arrived, working patients, how many patients will choose video observation, and what it requires of nursing staff. The capstone project addresses that gap at the local level by implementing the combination and measuring completion, uptake and nursing time against the clinic's own baseline.
The literature also carries some cautions for the project. Most trials enrolled patients who agreed to be randomized and who may have been more motivated than the clinic's patients, and the video trial involved daily rather than weekly dosing. The project will therefore compare its results with the clinic's own baseline rather than expecting to match trial figures, and it will report any difference in the patients who choose each option.
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
Belknap, R., Holland, D., Feng, P.-J., Millet, J.-P., Caylà, J. A., Martinson, N. A., Wright, A., Chen, M. P., Moro, R. N., Scott, N. A., Arevalo, B., Miró, J. M., Villarino, M. E., Weiner, M., & Borisov, A. S. (2017). Self-administered versus directly observed once-weekly isoniazid and rifapentine treatment of latent tuberculosis infection: A randomized trial. Annals of Internal Medicine, 167(10), 689-697. https://doi.org/10.7326/M17-1150
Haas, M. K., Aiona, K., Erlandson, K. M., & Belknap, R. W. (2021). Higher completion rates with self-administered once-weekly isoniazid-rifapentine versus daily rifampin in adults with latent tuberculosis. Clinical Infectious Diseases, 73(9), e3459-e3467. https://doi.org/10.1093/cid/ciaa1364
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
How this N 599 Module 2 example is structured
Aspen does not publish N599 module prompts, so check your classroom and capstone guide for the exact instructions. This example describes the search, synthesizes studies under four themes with exact findings and limits, states what the evidence supports across studies, and identifies the specific gap the capstone project addresses.
N599 Module 2 questions, answered
What does N599 Module 2 usually ask for?
After the problem statement, Aspen's capstone typically requires a literature review that synthesizes evidence on the project question and identifies the gap the project will address. Check your capstone guide for the number and type of sources required.
How is a synthesis different from a summary?
A summary describes studies one by one. A synthesis organizes findings by theme, compares studies, explains agreements and differences, and draws conclusions that no single study could support alone.
How many sources does a capstone literature review need?
It depends on the program's guide, but the review should include the strongest available evidence, such as randomized trials and systematic reviews, plus relevant guidelines, and enough studies to support each theme.
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