title: Chest radiograph reading and recording system: evaluation in frontline clinicians in Zambia.
abstract: BACKGROUND
  In Zambia the vast majority of chest radiographs (CXR) are read by clinical officers who have limited training and varied interpretation experience, meaning lower inter-rater reliability and limiting the usefulness of CXR as a diagnostic tool. In 2010-11, the Zambian Prison Service and Ministry of Health established TB and HIV screening programs in six prisons; screening included digital radiography for all participants. Using front-line clinicians we evaluated sensitivity, specificity and inter-rater agreement for digital CXR interpretation using the Chest Radiograph Reading and Recording System (CRRS).
  
  
  METHODS
  Digital radiographs were selected from HIV-infected and uninfected inmates who participated in a TB and HIV screening program at two Zambian prisons. Two medical officers (MOs) and two clinical officers (COs) independently interpreted all CXRs. We calculated sensitivity and specificity of CXR interpretations compared to culture as the gold standard and evaluated inter-rater reliability using percent agreement and kappa coefficients.
  
  
  RESULTS
  571 CXRs were included in analyses. Sensitivity of the interpretation "any abnormality" ranged from 50-70 % depending on the reader and the patients' HIV status. In general, MO's had higher specificities than COs. Kappa coefficients for the ratings of "abnormalities consistent with TB" and "any abnormality" showed good agreement between MOs on HIV-uninfected CXRs and moderate agreement on HIV-infected CXRs whereas the COs demonstrated fair agreement in both categories, regardless of HIV status.
  
  
  CONCLUSIONS
  Sensitivity, specificity and inter-rater agreement varied substantially between readers with different experience and training, however the medical officers who underwent formal CRRS training had more consistent interpretations.
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA. germanh@uab.edu.|Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. germanh@uab.edu.
authors.forename: German
authors.initials: G
authors.lastname: Henostroza
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA.|Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.|Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA.
authors.forename: Jennifer B
authors.initials: JB
authors.lastname: Harris
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Nzali
authors.initials: N
authors.lastname: Kancheya
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Venerandah
authors.initials: V
authors.lastname: Nhandu
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Stable
authors.initials: S
authors.lastname: Besa
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Robert
authors.initials: R
authors.lastname: Musopole
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA.|Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Annika
authors.initials: A
authors.lastname: Krüüner
authors.affiliation: Prisons Health Services, Ministry of Home Affairs, Lusaka, Zambia.
authors.forename: Chisela
authors.initials: C
authors.lastname: Chileshe
authors.affiliation: Department of Radiology, University of British Columbia, Vancouver, Canada.
authors.forename: Ian J
authors.initials: IJ
authors.lastname: Dunn
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.|Department of Medicine, Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Stewart E
authors.initials: SE
authors.lastname: Reid
mesh_terms: D000328:Adult; D002983:Clinical Competence; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening; D015588:Observer Variation; D011159:Population Surveillance; D011330:Prisons / Q000706:statistics & numerical data; D013902:Radiography, Thoracic / Q000592:standards; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014397:Tuberculosis, Pulmonary / Q000000981:diagnostic imaging*; D015024:Zambia
keywords: Chest Radiograph Reading and Recording System (CRRS); Zambia; chest radiograph; x-ray