Screening by specialists to reduce unnecessary test ordering in patients evaluated for tuberculosis.
OBJECTIVE
To determine if screening by specialists could reduce unnecessary test ordering and reduce costs related to diagnostic workup in patients undergoing evaluation for tuberculosis.


METHODS
Prospective evaluation of expert opinion in consecutive patients suspected of having tuberculosis.


METHODS
A large municipal hospital.


METHODS
Patients for whom sputum acid-fast smears were ordered.


METHODS
For patients from whom sputum acid-fast bacilli smears and cultures were requested, the chest radiograph and a brief clinical history were presented separately to two pulmonologists with considerable experience in tuberculosis. Each expert reviewed each case independently (and was blinded to the opinion of the other) and indicated if he thought sputum smear examination and culture was, in fact, necessary. Final clinical diagnosis and microbiological information were correlated with the experts' opinion.


RESULTS
Ninety-seven patients had sputum smears ordered and had chest radiographs available for review. The two experts believed that sputum examination (smear and culture) was indicated in only 51.5% and 52.6% of cases, respectively. Interobserver agreement was 84.4%. Ultimately, six cases of active tuberculosis were diagnosed. Each expert detected all proven cases of tuberculosis, although one case occurred in a patient with a poor quality radiograph about which the experts offered no opinion.


CONCLUSIONS
Screening by experienced clinicians may be effective in reducing unnecessary test ordering and reducing costs related to diagnostic workup in patients evaluated for tuberculosis.
Divinagracia
R M
RM
Division of Pulmonary and Critical Care Medicine and the Bellevue Chest Service, New York University Medical Center and School of Medicine, NY, USA.
Harkin
T J
TJ
Bonk
S
S
Schluger
N W
NW
D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019411:Clinical Laboratory Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D015272:Pulmonary Medicine; D012307:Risk Factors; D013183:Sputum / Q000382:microbiology; D013194:Staining and Labeling; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis*; D019564:Unnecessary Procedures