Literature research
paneikvnu
wk10proj_sample_paper_observed_therapy.pdf
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Evaluating the Evidence for Directly Observed Therapy in the Treatment of Tuberculosis
Walden Student
Walden University
NURS 6052, Section 2, Essentials of Evidence-Based Practice
Dr. Trudy Tappan
May 7, 2016
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Evaluating the Evidence for Directly Observed Therapy in the Treatment of Tuberculosis
Tuberculosis continues to be an issue of concern in the United States and around the
world. In 2014, there were 9.6 million people diagnosed with tuberculosis and 1.5 deaths
worldwide (Centers for Disease Control and Prevention [CDC], n.d.a). In the United States,
there were 9,421 new cases of tuberculosis that same year (CDC, n.d.a). This paper will explore
the case management of tuberculosis in the United States, focusing on the value of directly
observed therapy for tuberculosis clients. The purpose of this paper is to explore the evidence
around the use of directly observed therapy in tuberculosis clients. This will be accomplished by
formulating a researchable question, exploring the existing research, and formulating a plan to
distribute the evidence to local public health nurses.
Part I - Identifying a Researchable Problem
Tuberculosis Treatment and Directly Observed Therapy
For clients who have been diagnosed with active tuberculosis disease, appropriate
treatment is crucial. With proper medication, the majority of tuberculosis cases can be
successfully treated (World Health Organization [WHO], 2016). Without treatment, tuberculosis
is fatal in approximately two-thirds of all cases (WHO, 2016). Recommended treatment for
tuberculosis involves treatment with antibiotics for 6 to 9 months (Centers for Disease Control
and Prevention [CDC], n.d.b). When clients with tuberculosis do not take the medication as
prescribed either by skipping doses or by ending treatment earlier than recommended, drug-
resistant tuberculosis can develop (CDC, n.d.b).
To increase successful tuberculosis treatment and decrease the development of drug-
resistant tuberculosis, the Centers for Disease Control and Prevention (n.d.c) recommends case
management of all tuberculosis cases. One component of case management that the CDC
Comment [T1]: APA Numbers:
Please make sure you are using numbers correctly. Review
pages 111-115 in APA to make sure you are apply the proper
rules governing the use of numbers in scholarly writing.
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recommends is directly observed therapy (DOT). DOT involves an individual, often a healthcare
worker, observing the client as the client takes his or her medications (CDC, n.d.c). Including
DOT with all tuberculosis clients is standard care in many local health departments in the United
States (CDC, n.d.c). At the local health department at which I’m where I am employed, DOT is
most often performed in the client’s home.
The cost of performing DOT for tuberculosis clients includes staff salary and travel
expenses. There are also costs to the client, including time and inconvenience. Additionally,
there is often stigma attached to a diagnosis of tuberculosis (Juniarti & Evans, 2011). It can be
difficult maintain a sense of privacy with frequent home visits by local public health staff.
Because of the financial and personal costs involved with DOT, it is important to evaluate
carefully the value of DOT.
Exploring Research Questions around DOT
Several research questions can be posed around the topic of DOT and tuberculosis. The
first question posed is: does case management and directly observed therapy lead to a higher cure
rate for clients diagnosed with tuberculosis? Although this is a valid question, the topic is quite
broad. When conducting research, it is helpful to narrow the topic to an appropriate level
(Walden University Library, 2012). The second question that I posed was: is case management
without the use of directly observed therapy as effective as case management with directly
observed therapy for clients with active tuberculosis disease? This question focuses on the value
of case management in addition to DOT, and for this research study, I want to limit my research
to the value of DOT. The third question I asked was: does directly observed therapy cause an
increase in perceived stigma for clients being treated for tuberculosis disease? Although this is
an important consideration around DOT, the question is quite narrow. When questions are too
Comment [T2]: Writing refinement
It
Do not start a sentence with it.
This is not scholarly writing. It is an indefinite pronoun.
Starting a sentence with it causes your readers to pause
momentarily, while they figure out what it is. It makes your
sentences clumsy.
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narrow, there may not be sufficient research available (Walden University Library, 2012). The
fourth question I asked was: is the use of remotely observed therapy through the use of
technology as effective as in-person directly observed therapy in clients being treated for active
tuberculosis disease? Again, this is a valid question, but more narrow than I’d like my research
question to be. The fifth question I asked was: does directly observed therapy increase
compliance with the medication regime for the entire course of treatment in adults with active
tuberculosis disease compared to those who do not receive directly observed therapy. This
question seems appropriate regarding the scope and is, therefore, the question that will be
explored in the remainder of this paper.
PICOT Question
Composing a well-worded research question is an important first step in conducting
research for evidence-based practice (Polit & Beck, 2012). The acronym PICOT can be used to
frame research questions; PICOT stands for population, intervention, comparison, outcome, and
time (Polit & Beck, 2012). The PICOT question that this paper will explore is this: does directly
observed therapy increase compliance with the medication regime for the entire course of
treatment in adults with active tuberculosis disease compared to those who do not receive
directly observed therapy? The Population is adults with active tuberculosis disease. The
intervention is directly observed therapy. The comparison component is those who do not
receive observed therapy. The outcome is compliance with the medication regime. The time
component is the entire length of treatment, which is typically 6 to 9 months (CDC, n.d.a). By
using the PICOT format, I assured the essential elements of the research are address in the
research question.
Keywords
Comment [T3]: Contractions are not part of scholarly writing. Write "it is," never "it's." Write "do not," never "don't."
Write I am, not I’m – I’ve should be I have
Do not write "he'll" when you mean "he will" Use should not, could not, would not, instead of the
contractions
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Identifying search terms is another important step in searching for research. The research
question identified will demonstrate which keywords to use in a search. Keywords are often
based on the independent variables, dependent variables, and population that are identified in the
question (Polit & Beck, 2012). When the research question is written using the PICOT format,
the five key points of the PICOT question can be used to identify keywords (Polit & Beck,
2012). Additional keywords can be identified after an initial search by reviewing the subjects
area of a citation (Walden University Library, 2012). The keywords that I used for my research
include tuberculosis, TB, directly observed therapy, DOT, directly observed treatment,
antitubercular agents therapeutic use, tuberculosis drug therapy, tuberculosis therapy, medication
compliance, and monitoring. I used a combination of keywords in my search, including at least
one word or phrase to reference tuberculosis disease and directly observed therapy in each
search. These keywords are based on the PICOT question, with a focus on the population of
tuberculosis clients, the intervention of directly observed therapy for tuberculosis treatment, and
the outcome of medication compliance. It was not necessary to include the comparison or time
elements from the PICOT question to identify appropriate resources for the research.
Part II - Literature Review
A good literature review provides the reader with a summary of the current knowledge on
a subject or topic (Polit & Beck, 2012). This literature review explores current research on the
effectiveness of directly observed therapy (DOT) on increasing tuberculosis treatment
completion rates to help inform nursing practice in the United States. To use the best available
evidence, I searched for filtered studies, specifically systemic reviews.
DOT and Tuberculosis
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Cases of tuberculosis continue to occur in the United States (CDC, n.d.d). Those
diagnosed with active tuberculosis disease need to take the full course of medication, usually
involving six to nine months of treatment (CDC, n.d.b). DOT is an intervention, recommended
by the World Health Organization, aimed at increasing completion of the full course of treatment
for tuberculosis (Karumbi, 2015). Those who do not complete the entire course of treatment are
at risk for reoccurrence of symptoms (CDC, n.d.b). The research summary that follows will
evaluate the evidence to help answer the following research question: does directly observed
therapy increase compliance with the medication regime for the entire course of treatment in
adults with active tuberculosis disease compared to those who do not receive directly observed
therapy?
Literature Review Summary
Karumbi (2015) published a recent systemic review of 11 studies in the Cochrane
Database of Systematic Reviews database. According to Karumbi, the current research does not
support the routine use of DOT for tuberculosis clients. Karumbi noted, however, that there was
value in DOTs when the management of the tuberculosis case was limited to a monthly clinic
visit. Karumbi did not find support for DOTs when the client had more frequent visits to a
healthcare professional.
The National Guidelines Clearinghouse (NGC) is a well-known source for clinic practice
guidelines (Robeson, Dobbins, DeCorby, & Tirilis, 2010). NGC guidance states that DOT is not
routinely recommended; DOT is only recommended for clients that are experiencing
homelessness or near homelessness and for clients with a history of noncompliance with
treatment (National Collaborating Centre for Chronic Conditions, 2011). This guidance is
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similar to that suggested by Karumbi, however, the factors that necessitate DOT be conducted
differ between the studies.
DOT may be conducted at a clinic and or in at a home or community location (Wright,
Westerkamp, Korver, & Dobler, 2015). Wright, Westerkamp, Korver, and Dobler (2015)
conducted a systemic review that addressed the differences between DOTs conducted in a clinic
compared with those conducted in the community. Wright et al. found that community-based
DOTs were more effective at improving tuberculosis treatment success. Although this review
provides useful information, it has limited benefit because those not receiving DOT were not
included in the review (Wright et al., 2015). Excellent pointThis study was included in this
literature review because, in the United States, DOT can be provided in community or home
locations for client convenience (CDC, n.d.c).
To have a broader understanding of the costs and benefits of DOT from the client’s
viewpoint, this literature review includes a qualitative study. Zuñiga (2012) conducted a case
study of a woman receiving DOT for tuberculosis. This case study, conducted in the United
States, was chosen for inclusion in this literature review because an understanding of the cost of
an intervention is needed to make an informed decision about practice. Zuñiga found that the
client experienced psychological impacts from the DOT, including stress and fear. Over time,
the stress and fear turned to paranoia, with the client feeling as if she were continuously being
watched (Zuñiga, 2012). This study highlights the need to consider quality of life issues when
assessing the cost and benefits of DOT.
The final study included in this literature review was cited in the article by Zuñiga (2015)
as evidence supporting DOT. Chaulk and Kazandjian (2003) conducted a systemic review
providing support to the use of DOT. This systemic review was unique in two ways. First, it
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was based on studies conducted in the United States (Chaulk & Kazandjian, 2003). The
systemic review by Karumbi (2015) and the guidance from the NGC both were based on studies
carried out in numerous different countries (National Collaborating Centre for Chronic
Conditions, 2011). Second, it classified DOTs into three categories: patient-centered DOTs,
which included incentives along with DOTs; standard DOTs, which included only incentives that
would cover transportation or treatment costs related to tuberculosis; and modified DOT, which
only included DOT during hospitalization (Chaulk & Kazandjian, 2003). Chaulk and
Kazandjian found that patient-centered DOT was the most effective. Interestingly, Chaulk and
Kazandjian found that all three types of DOT were more effective than unsupervised therapy,
although no incentives were provided for those receiving unsupervised therapy.
Analysis of Findings
This literature review produced research with conflicting information. In evaluating why
Chaulk and Kazandjian (2003) found DOT to be effective in improving successful tuberculosis
treatment while Karumbi (2015) and others did not, a few factors need to be evaluated. Chaulk
and Kazandjian’s study is over 12 years old and is based on studies done in the United States.
Several studies had additional factors that were considered when assessing the value of DOT.
Karumbi considered the frequency of medical or nursing care a client received in addition to the
DOT. NGC’s recommendation was altered for clients that are experiencing homelessness or
with a history of noncompliance with treatment (National Collaborating Centre for Chronic
Conditions, 2011). Chaulk and Kazandjian considered the benefits using incentives with DOT.
Zuñiga (2012) pointed out the need to consider the personal costs of DOT to the clients.
Karumbi did not address quality of life issues in the review. Chaulk and Kazandjian addressed
quality of life issues but focused on the added benefit of incentives more than psychological
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impact of DOTs on clients. The differences between the research findings reviewed here make it
difficult to draw decisive conclusions.
Preliminary Conclusion
Based on this literature review, it appears that additional research is needed to answer
convincingly the question regarding the value of DOT in improving tuberculosis cure rates.
Specifically, research is needed on the effectiveness of the use of incentives without the use of
DOT. To be most useful to practitioners in the United States, this research should be conducted
in the United States. None-the-less, the best and most recent evidence points to the use of DOT
only with specific clients (Karumbi, 2015; National Collaborating Centre for Chronic
Conditions, 2011).
Part III – Translating Evidence into Practice
PICOT Questions Significance to Nursing Practice
The PICOT question that this paper has researched is: does directly observed therapy
increase compliance with the medication regime for the entire course of treatment in adults with
active tuberculosis disease compared to those who do not receive directly observed therapy?
This is a significant question for public health nurses who are often responsible for conducting or
overseeing staff who conduct DOTs. With limited funding, the wise use of public health nurses
time is vital. Controlling the spread of tuberculosis is an important goal for public health nurses,
but it is important that the interventions are evidence based.
DOTs and Nursing Practice Supported by Evidence
The research cited in this paper supports the conditional use of DOT. The conditions
under which it was supported varied between the studies. Because the study by Karumbi (2015)
is a recent systemic review of 11 studies, those findings should be heavily weighed. Karumbi
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found value for DOT only for clients who were infrequently seen by healthcare providers. The
target population for this paper is tuberculosis clients who reside in Minnesota; the standard
practice in Minnesota involves a weekly assessment visit conducted or supervised by a public
health nurse (Minnesota Department of Health, n.d.). Therefore, all tuberculosis clients in
Minnesota should be seen more than once per month. Consideration should also be given to the
findings of Robeson, Dobbins, DeCorby, and Tirilis (2010) who identified that clients
experiencing homelessness or near homelessness benefit from DOT. Additionally, Chaulk and
Kazandjian (2003) found that when DOT is conducted, the use of incentives increases treatment
compliance. When these studies are considered together, there is support for limiting DOT to
clients that are high risk and using incentives whenever DOT is utilized. Because public health
nurses can carefully assess their clients and determine who is at high risk for non-compliance
based on a variety of factors, my recommendation based on this research is that DOT is only
conducted with clients that are high risk for non-compliance, including those experiencing
homelessness. I would also recommend the use of incentives with all clients receiving DOT.
This approach allows for those who will most benefit from DOTs to receive the service. It also
allows public health nurses to redirect some of their time from DOTs on low-risk clients to other
valuable activities. This change in practice would benefit the clients; those at high-risk would
receive the needed DOT, and those at low-risk would be spared the inconvenience, stigma, and
intrusion into life activities that can come with DOT.
Disseminating Evidence and Influencing Practice
Research studies have limited value if the findings are not made available to practitioners.
The findings from this literature review provide guidance on practice changes that I want to
share with public health nurses in my unit. The first step in the process is to share the research
Comment [T4]: Which ones specifically?
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contained in this paper with my colleagues that perform or oversee DOT visits. I have already
moved forward with this first step by talking about this research to the supervisor of the nurses
who care for tuberculosis clients. The nursing supervisor expressed interest in the research and
suggested the material be presented at a staff meeting. The IMRAD format, which stands for
introduction, method, results, and discussion, can be used when presenting findings at a meeting
(Polit & Beck, 2012). The following questions summarize the IMRAD format: “why was the
study done…how was the study done…what was learned…[and] what does it mean?” (Polit &
Beck, 2012, p. 682). I would use these questions to frame the presentation to nurses about the
findings from this literature review.
The next step in the process would be determining if practice changes should be made
and how those changes should be implemented. If the group decided that they would like to
change the current practice of conducting DOTs on all clients with active tuberculosis disease,
then a plan would be created to begin the implementation of the change. The change in practice
would start small-scale (Cullen & Adams, 2012). If the change was determined to be successful,
then the practice changes could be fully implemented. Cullen and Adams (2012) discuss the
value of change agents, or champions, in changing nursing practice. I would assess the interest
in this subject during the presentation and seek out respected nurses to serve as champions for
this process. In addition to interest, I would consider experience and knowledge level of nurses
recruited to fill the role of a champion (Aitken et al., 2011). Those willing for to fill the role of
champion would be given training and tools to allow them to be successful in their role (Aitken
et al., 2011). I would also seek support from senior leadership as their support for evidence-
based practice changes can increase staff acceptance of the change (Cullen & Adams, 2012).
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My local public health department is supportive of evidence-based practice. The
department highly values education and scholarship. Making changes within the organization is
supported by a Quality Improvement Council. The changes in practice that have resulted from
quality improvement initiatives have been supported by senior leadership and widely
communicated to staff throughout the health department. The culture of this health department
supports the implementation of changes based on evidence. This is good to hear!
Concerns would likely arise due to departing from standard practice within the state. The
Minnesota Department of Health (n.d.) supports the use of DOT. However, the Minnesota
Department of Health website states “DOT is especially critical for patients with drug-resistant
TB, HIV-infected patients, and those on intermittent treatment regimens” which supports
conditional use of DOT (para. 3). None-the-less, it would be vital to ensure that this practice
change was in compliance with state rules and regulations. Making this change would
necessitate careful communication between the local and state health departments. I would
recruit supportive senior leadership to discuss this proposed practice change with appropriate
state staff. It would be essential to report on the outcomes of this communication with staff
nurses implementing the change.
I would anticipate some nurses would be more likely to implement this practice change
than others. Cullen and Adams (2012) note that early adopters of change can positively
influence late adopters. I would identify early adopters of this practice change and ask them to
report on the impact on both the nurse and the client at a staff meeting. I would also ensure that
all the nurses affected by this change would have access to the research articles that support this
change (Cullen & Adams, 2012). This change would take commitment, time, and clear
communication to be successfully implemented.
Comment [T5]: Interesting assessment
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Summary
This paper provides an overview of the process of developing a research question,
conducting a literature review, and planning for implementation of a practice change in the use
of directly observed therapy for clients with tuberculosis disease. A research question was
formulated using the PICOT model. The question addressed in this paper is: does directly
observed therapy increase compliance with the medication regime for the entire course of
treatment in adults with active tuberculosis disease compared to those who do not receive
directly observed therapy? The goal of this paper is to identify evidence to support the nursing
practice of directly observed therapy (DOT).
A literature review was conducted on the effectiveness of DOT in increasing the
tuberculosis medication compliance. Five studies were included in this paper: three were
systemic reviews, one was a critically appraised topic, and one was a case study. This paper
focused on filtered systemic reviews because they are the most useful in informing practice (Polit
& Beck, 2012). The findings from the literature review provided useful, although sometimes
conflicting, information on the value of DOT. Overall, the research seemed to indicate that
DOTs are useful for specific population groups due to risk factors for not completing
tuberculosis therapy. Future research on the effects of incentives without the use of DOT would
strengthen the available evidence regarding the value of DOT and be useful for informing
practice.
This paper includes a plan for disseminating the research and using it to inform practice.
The research findings would be presented using the IMRAD (introduction, method, results, and
discussion) format to nurses at a staff meeting. Support for the proposed practice changes would
be sought from both senior leadership and staff who can champion the change. An important
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component would be communication with the state health department to ensure the change falls
within state requirements. The strong support for evidence-based practice within my local health
department would increase the likelihood of this practice change being successfully
implemented.
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References
Aitken, L. M., Hackwood, B, Crouch, S., Clayton, S., West, N., Carney, D., & Jack, L. (2011).
Creating an environment to implement and sustain evidence based practice: A
developmental process. Australian Critical Care, 24(4), 244–254.
doi:10.1016/j.aucc.2011.01.004
Centers for Disease Control and Prevention. (n.d.a). Tuberculosis: Data and statistics. Retrieved
from http://www.cdc.gov/tb/statistics/
Centers for Disease Control and Prevention. (n.d.b). Tuberculosis (TB) treatment. Retrieved
from http://www.cdc.gov/tb/topic/treatment/default.htm
Centers for Disease Control and Prevention. (n.d.c). Self-study modules on tuberculosis.
Retrieved from http://www.cdc.gov/tb/education/ssmodules/module9/ss9reading2.htm
Chaulk, P., & Kazandjian, V. A. (2003). Comprehensive case management models for
pulmonary tuberculosis. Disease Management & Health Outcomes, 11(9), 571-577.
Retrieved from Walden Database
Cullen, L., & Adams, S. L. (2012). Planning for implementation of evidence-based practice.
Journal of Nursing Administration, 42(4), 222–230. doi:
10.1097/NNA.0b013e31824ccd0a
Juniarti, N., & Evans, D. (2011). A qualitative review: The stigma of tuberculosis. Journal of
Clinical Nursing, 20 (13/14), 1961-1970. doi:10.1111/j.1365-2702.2010.03516.x
Karumbi, J. (2015). Directly observed therapy for treating tuberculosis. Cochrane Database of
Systematic Reviews, (5). doi:10.1002/14651858.CD003343.pub4
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Minnesota Department of Health. (n.d.) Directly observed therapy (DOT) for the treatment of
tuberculosis. Retrieved from
http://www.health.state.mn.us/divs/idepc/diseases/tb/lph/dot.html
National Collaborating Centre for Chronic Conditions. (2011). Tuberculosis. Clinical diagnosis
and management of tuberculosis, and measures for its prevention and control. London
(UK): National Institute for Health and Clinical Excellence (NICE), 64 (Clinical
guideline; no. 117). Retrieved from:
http://www.guideline.gov/content.aspx?id=34833&search=directly+observed+therapy+a
nd+directly+observed+therapy+and+tuberculosis
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for
nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Robeson, P., Dobbins, M., DeCorby, K., & Tirilis, D. (2010). Facilitating access to pre-
processed research evidence in public health. Retrieved from Walden Database
Walden University Library. (2012). Evidence-based practice research: Clinical question
anatomy. Retrieved from
http://academicguides.waldenu.edu/healthevidence/clinicalquestion
World Health Organization. (2016). What is TB? How is it treated? Retrieved from
http://www.who.int/features/qa/08/en/
Wright, C. M., Westerkamp, L., Korver, S., & Dobler, C. C. (2015). Community-based directly
observed therapy (DOT) versus clinic DOT for tuberculosis: a systematic review and
meta-analysis of comparative effectiveness. BMC Infectious Diseases, 15210.
doi:10.1186/s12879-015-0945-5
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Zuñiga, J. A. (2012). A woman's lived experience with directly observed therapy for
tuberculosis—a case study. Health Care for Women International, 33(1), 19-28 10p.
doi:10.1080/07399332.2011.630118
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Literature Review Summary Table Citation Type of Study
Design Type
Framework/Theory
Setting Key Concepts/Variables
Findings Hierarchy of Evidence Level
Karumbi (2015)
Type of Study:
Systemic Review
Design Type: n/a
Framework/Theory: None mentioned
This systemic review included 11 separate studies, all of which were randomized control trials (RCT) or quasi-RCTs.
Concepts: Independent Variable: DOT Dependent Variable: Tuberculosis cure rate Controlled Variable: Standard tuberculosis care by health professionals
This systemic review did not find evidence that supports the use of directly observed therapy (DOT) to increase tuberculosis cure rate. However, the systemic review found a small but statistically significant increase in tuberculosis cure rates when DOT was used in clients with infrequent contact with health professional (i.e. once per month or less), as demonstrated by two of the trials included in this systemic review.
Level 1 – Systemic Review of RCT and quasi-RCTs
National Collaborating Centre for Chronic Conditions. Tuberculosis. (2011)
Type of Study: Guideline Summary
Design Type: n/a
Framework/Theory: None mentioned
This guideline provides guidance based on evidence for the care of clients with tuberculosis.
Concepts: Independent Variable: DOT Dependent Variable: Tuberculosis cure rate Controlled Variable: Standard tuberculosis care by health professionals
The use of DOT is not needed for most cases of tuberculosis. DOT may be recommended for tuberculosis clients who are experiencing homelessness or who have a history of poor adherence to treatment. This article included recommendations of ways other than DOT to improve compliance with treatment.
Level 2 – Critically appraised topics
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Citation Study Design Type Framework/Theory
Setting Key Concepts/Variables
Findings Hierarchy of Evidence Level
Wright, Westerkamp, Korver, & Dobler (2015)
Type of Study: Systemic Review
Design Type: n/a Framework/Theory: None mentioned
This systemic review included eight studies; one study was a RCT, the remaining seven studies were none- randomized studies.
Concepts: Independent Variable: Clinic based DOT and community- based DOT Dependent Variable: Tuberculosis treatment success and the number of clients lost to follow- up Controlled Variable:
Community-based DOT was found to be better than clinic- based DOT for improving treatment success. This study was limited in that there was only one RCT. It was also limited in that there was no comparison with those not receiving any DOT. Although community-based DOT was more effective in improving treatment success, there was no difference in decreasing the number of clients lost to follow-up.
Level 1 – systemic review
Zuñiga (2012) Type of Study: Case study
Design Type: observational
Framework/Theory: Phenomenology
This qualitative study involved a researcher conducting an interview in a private office with one study participant.
Concepts: This study was based on the lived experience of a woman being treated with DOT in the United States. Independent Variable: n/a Dependent Variable: n/a Controlled Variable: n/a
The DOT was found to have negative psychological impacts on the participant, including stress, fear, and eventually paranoia.
Level 6 – Case Studies (unfiltered)
Chaulk & Kazandjian (2003)
Type of Study:
Design Type: n/a Framework/Theory: None mentioned
This systemic review examined research done on DOT in the United States.
Concepts: Independent Variable: Patient- centered DOT (which includes the use of incentives), standard DOT, modified DOT (DOT only while hospitalized), and nonsupervised therapy Dependent Variable: Tuberculosis treatment completion rates Controlled Variable: Standard medical treatment of tuberculosis
This systemic review found increased completion rates of tuberculosis treatment with DOT over nonsupervised treatment. What the authors describe as patient-centered DOT had the best completion rates. Patient- centered DOT included the use of incentives along with directly observed therapy. The completion rates for unsupervised therapy with incentives was not included in this review.
Level 1 - Systemic Review
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