SCREENING BY SPECIALISTS TO REDUCE UNNECESSARY TEST ORDERING IN PATIENTS EVALUATED FOR TUBERCULOSIS

Study objective: To determine if screening by specialists could reduce unnecessary test ordering and reduce costs related to diagnostic work up in patients undergoing evaluation for tuberculosis. Design: Prospec tive evaluation of expert opinion in consecutive patients suspected of having tuberculosis. Setting: A large municipal hospital. Patients: P atients for whom sputum acid-fast smears were ordered. Intervention: F or patients from whom sputum acid-fast bacilli smears and cultures wer e requested, the chest radiograph and a brief clinical history were pr esented 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 sput um smear examination and culture was, in fact, necessary. Final clinic al diagnosis and microbiological information were correlated with the experts' opinion. Measurements and main results: Ninety-seven patients had sputum smears ordered and had chest radiographs available for rev iew. The two experts believed that sputum examination (smear and cultu re) was indicated in only 51.5% and 52.6% of cases, respectively. Inte robserver agreement was 84.4%. Ultimately, six cases of active tubercu losis were diagnosed. Each expert detected all proven cases of tubercu losis, although one case occurred in a patient with a poor quality rad iogaph about which the experts offered no opinion. Conclusions: Screen ing by experienced clinicians may be effective in reducing unnecessary test ordering and reducing costs related to diagnostic workup in pati ents evaluated for tuberculosis.