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(Chest. 1999;116:1841-1842.)
© 1999 American College of Chest Physicians

Screening of Tuberculosis

Is It a Real Prediction Model?

Javier Perez, MD and William Rodriguez, MD

San Juan VA Medical Center San Juan, Puerto Rico

Correspondence to: Javier Perez, MD, San Juan VA Medical Center, Pulmonary Medicine Section, 10 Calle Casia, San Juan, Puerto Rico, 00921

To the Editor:

We read with great interest the article by Tattevin et al (May 1999)1 regarding the diagnosis of tuberculosis and the predictive model for diagnosis that they propose. In recent years, and certainly motivated by the increasing number of cases and the appearance of nosocomial outbreaks, measures directed to diagnose tuberculosis early and to isolate patients with active disease have been promoted.2 3 We agree with Tattevin et al about the disappointing results that the application of predictive models for diagnosis have had: no model is yet feasible for application in our clinical practice.

On the other hand, the greater is our concern about nosocomial outbreaks, the higher is the number of patients isolated and the more numerous are the samples for which acid-fast bacillus (AFB) smear and culture are requested. Are all those samples really necessary? Should a specialist screen the AFB smear and culture requests before they are performed? For this purpose, we performed a survey in our hospital that was designed to answer both questions.4 For a 60-day period, two pulmonologists independently evaluated every request for an AFB smear and determined whether it was adequately ordered or not. During that period, 134 smears were requested, and 81% of smear results were negative. According to the opinions of both pulmonologists, the requests for AFB smear in 99 samples (73%) were not justified. Disagreement between the two specialists occurred only in 13 samples that ultimately yielded negative results. None of those samples that tested positive escaped the screening of both specialists (100% of sensitivity). When evaluating the economic impact of those unnecessary samples, and even considering the costs derived from the specialist’s consultation, we determined that nearly $12,000 of unnecessary costs had been incurred. Moreover, the social and personal costs incurred by every patient who was unnecessarily isolated cannot be calculated. Because of these findings, we wonder whether it would be cost-efficient for one specialist to screen every patient with suspected tuberculosis on their arrival at the hospital. Considering the application of a predictive model to identify active cases early, it would require trained clinicians for adequate performance. Thus, the use of trained personnel to evaluate these patients could save money and avoid worrisome social and personal situations.

References

  1. Tattevin, P, Casalino, E, Fieury, L, et al (1999) The validity of medical history, classic symptoms and chest radiographs in predicting pulmonary tuberculosis. Chest 115,1248-1253[Abstract/Free Full Text]
  2. Cohen, R, Muzzafar, S, Capellan, J, et al (1996) The validity of classic symptoms and chest radiographic configuration in predicting pulmonary tuberculosis. Chest 109,420-423[Abstract/Free Full Text]
  3. Bock, NN, McGowan, JE, Ahn, J, et al (1996) Clinical predictors of tuberculosis as a guide for respiratory isolation policy. Am J Respir Crit Care Med 154,1468-1472[Abstract]
  4. Alicea, E, Casal, J, Rodriguez, W (1998) The evaluation of samples for AFB smear and culture: is there a need for subspecialist screening [abstract]. Am J Respir Crit Care Med 157,A184




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