title: Diagnostic accuracy of an integrated respiratory guideline in identifying patients with respiratory symptoms requiring screening for pulmonary tuberculosis: a cross-sectional study.
abstract: BACKGROUND
  To evaluate the diagnostic accuracy of the integrated Practical Approach to Lung Health in South Africa (PALSA) guideline in identifying patients requiring bacteriological screening for tuberculosis (TB), and to determine which clinical features best predict suspected and bacteriologically-confirmed tuberculosis among patients with respiratory symptoms.
  
  
  METHODS
  A prospective, cross-sectional study in which 1392 adult patients with cough and/or difficult breathing, attending a primary care facility in Cape Town, South Africa, were evaluated by a nurse using the guideline. The accuracy of a nurse using the guideline to identify TB suspects was compared to that of primary care physicians' diagnoses of (1) suspected TB, and (2) proven TB supported by clinical information and chest radiographs.
  
  
  RESULTS
  The nurse using the guideline identified 516 patients as TB suspects compared with 365 by the primary care physicians, representing a sensitivity of 76% (95% confidence interval (CI) 71%-79%), specificity of 77% (95% CI 74%-79%), positive predictive value of 53% (95% CI 49%-58%), negative predictive value of 90% (95% CI 88%-92%), and area under the receiver operating characteristic curve (ARUC) of 0.76 (95% CI 0.74-0.79). Sputum results were obtained in 320 of the 365 primary care physicians TB suspects (88%); 40 (13%) of these were positive for TB. Only 4 cases were not identified by the nurse using the guideline. The primary care physicians diagnostic accuracy in diagnosing bacteriologically-confirmed TB (n = 320) was as follows: sensitivity 90% (95% CI 76%-97%), specificity 65% (95% CI 63%-68%), negative predictive value 7% (95% CI 5%-10%), positive predictive value 99.5% (95% CI 98.8%-99.8%), and ARUC 0.78 (95% CI 0.73-0.82). Weight loss, pleuritic pain, and night sweats were independently associated with the diagnosis of bacteriologically-confirmed tuberculosis (positive likelihood ratio if all three present = 16.7, 95% CI 5.9-29.4).
  
  
  CONCLUSIONS
  The PALSA guideline is an effective screening tool for identifying patients requiring bacteriological screening for pulmonary tuberculosis in this primary care setting. This supports the randomized trial finding that use of the guideline increased TB case detection.
authors.affiliation: Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Mowbray, 7700, Cape Town, South Africa. renglish@uctgsh1.uct.ac.za
authors.forename: René G
authors.initials: RG
authors.lastname: English
authors.forename: Max O
authors.initials: MO
authors.lastname: Bachmann
authors.forename: Eric D
authors.initials: ED
authors.lastname: Bateman
authors.forename: Merrick F
authors.initials: MF
authors.lastname: Zwarenstein
authors.forename: Lara R
authors.initials: LR
authors.lastname: Fairall
authors.forename: Angeni
authors.initials: A
authors.lastname: Bheekie
authors.forename: Bosielo P
authors.initials: BP
authors.lastname: Majara
authors.forename: Carl
authors.initials: C
authors.lastname: Lombard
authors.forename: Robert
authors.initials: R
authors.lastname: Scherpbier
authors.forename: Salah Eddine
authors.initials: SE
authors.lastname: Ottomani
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009726:Nurses; D018579:Patient Selection; D010820:Physicians; D017410:Practice Guidelines as Topic / Q000592:standards*; D011320:Primary Health Care; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D012120:Respiration Disorders / Q000175:diagnosis* / Q000503:physiopathology; D012680:Sensitivity and Specificity; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis*