N599 Module 5 assignment: capstone analysis and results, a full sample

What Happened in Six Months: Results of a Project to Help Clinic Patients Finish Preventive Tuberculosis Treatment

Student Name

Master of Science in Nursing Program, Aspen University

N599: Nursing Capstone

Instructor Name

Month Day, Year

What Happened in Six Months: Results of a Project to Help Clinic Patients Finish Preventive Tuberculosis Treatment

This section reports the results of six months in which the county clinic offered weekly rifapentine and isoniazid with doses verified by nurses through smartphone video, compared with the preceding twelve months. Results are presented in the order of the measures described in the methods: participants and choices, the primary outcome of treatment completion, change over time, and secondary measures of dose observation, adverse events and nursing time. The data are from a composite project constructed for teaching and reported following quality improvement reporting guidance (Ogrinc et al., 2016).

Participants and Choices

During the six-month implementation period, 84 adults started treatment for latent tuberculosis infection, compared with 164 in the twelve-month baseline period, a similar monthly rate. Their median age was 34, 52% were women, and 81% were born outside the United States, similar to the baseline group. Forty-nine patients (58%) chose the weekly regimen with video-observed dosing, 21 (25%) chose the weekly regimen without video, most because they did not have a smartphone or preferred not to record themselves, and 14 (17%) continued on daily rifampin, eight because of contraindications or drug interactions and six by preference. No patient was excluded from the evaluation.

Choices differed by age and language. Patients choosing video observation were younger, with a median age of 29, than those choosing the weekly regimen without video, whose median age was 43. Among the 16 patients who needed an interpreter for Dari, Pashto, Somali or Spanish, nine chose video observation after the nurse demonstrated the application with the interpreter present, a proportion close to that among English speakers. Four patients who initially chose video observation switched to weekly phone contact during treatment, most because of phone problems, and are analyzed in the group they chose at the start.

Treatment Completion

Completion was defined as 11 or more weekly doses within 16 weeks for the weekly regimen, the definition used by Belknap et al. (2017), and 120 doses within six months for daily rifampin. The table compares completion across groups and with the baseline.

Overall completion rose from 57.9% at baseline to 78.6% during implementation, a difference of 20.7 percentage points. The difference was statistically significant (chi-square = 10.40, df = 1, p = .001), and the 95% confidence interval for the implementation completion rate was 68.7% to 86.0%, entirely above the baseline rate. Completion was highest among patients who chose video observation. Because patients chose their option rather than being assigned, the subgroup differences may reflect who chose each option, for example patients with smartphones and more stable schedules, as well as the effect of the option itself.

Change Over Time

The team charted completion for each monthly group of patients who began treatment. During the baseline year, monthly completion ranged from 41% to 73%, with a median of 58%. All six implementation months fell above the baseline median, ranging from 69% to 88%. A run of at least six successive months above or below the median is an accepted signal of a shift in a process rather than random variation (Benneyan et al., 2003), so the run chart supports the conclusion that the change in completion was real and sustained during the implementation period. The final monthly cohort, whose treatment ended after the reporting date, was followed until all its patients either completed or stopped.

The implementation months also showed less variation than the baseline year. Monthly completion during the baseline year spanned 32 percentage points, while the implementation months spanned 19, suggesting that the new approach made completion more predictable as well as higher. Because each monthly cohort contained between 11 and 17 patients, however, individual monthly rates remain sensitive to a few patients, and the run chart should be read for its overall pattern rather than for any single month.

Secondary Measures

Among the 49 patients using video observation, 91% of scheduled weekly videos arrived on the scheduled day or the following day, and a further 5% arrived within the rescheduling window after a reminder. The most common reasons for late videos were work schedules and phone problems. Of the 18 patients who did not complete treatment during implementation, seven stopped after moving or losing contact, five chose to stop despite counseling, three stopped because of adverse events and three did not complete within the time allowed. The three adverse events were two flu-like reactions after the third and fourth weekly doses and one rash; all resolved after stopping, and none was serious. The nursing time log showed a median of five minutes to review each video and send a reply, and a median of 14 additional minutes per patient over the course of treatment for reminders and calls, compared with an estimated 40 minutes per patient for monthly visits and follow-up calls at baseline.

Patients' end-of-treatment surveys, completed by 58 of the 66 patients who finished, added context to these figures. The feature most often named as helpful was not needing to come to the clinic, cited by 41 patients, followed by hearing back from a nurse after every dose, cited by 33. The most common response to what nearly made patients stop was side effects in the first weeks, named by 19 patients, which points to where teaching and early follow-up could be strengthened.

Summary of Findings

During six months, most patients chose the nurse-supported video option, and the proportion finishing treatment climbed by nearly 21 percentage points, a gain that passed the significance test and held in every month charted. Completion was highest among patients using video observation, most weekly videos arrived on time, adverse events were few and mild, and the approach appeared to require less nursing time per patient than the previous approach. These findings are interpreted, with their limitations, in the discussion section.

References

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

Benneyan, J. C., Lloyd, R. C., & Plsek, P. E. (2003). Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care, 12(6), 458-464. https://doi.org/10.1136/qhc.12.6.458

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411