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 workup in patients undergoing evaluation for tuberculosis. Design: Prospective evaluation of expert opinion in consecutive patients suspected of having tuberculosis. Setting: A large municipal hospital. Patients: Patients for whom sputum acid-fast smears were ordered. Intervention: 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 ease 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. Measurements and main 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 eases, respectively. Interobserver agreement was 84.4%. Ultimately, six cases of active tuberculosis were diagnosed. Each expert detected all proven eases of tuberculosis, although one ease 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.