Automated chest-radiography as a triage for Xpert testing in resource-constrained settings: a prospective study of diagnostic accuracy and costs
Open accessAbstract
Molecular tests hold great potential for tuberculosis (TB) diagnosis, but are costly, time consuming and HIV-infected patients are often sputum scarce. Therefore, alternative approaches are needed. We evaluated automated digital chest radiography (ACR) as a rapid and cheap pre-screen test prior to Xpert MTB/RIF (Xpert). 388 suspected TB subjects underwent chest radiography, Xpert and sputum culture testing. Radiographs were analysed by computer software (CAD4TB) and specialist readers and abnormality scores were allocated. A triage algorithm was simulated in which subjects with a score above a threshold underwent Xpert. We computed sensitivity, specificity, cost per screened subject (CSS), cost per notified TB case (CNTBC) and throughput for different diagnostic thresholds. 18.3% of subjects had culture positive TB. For Xpert alone, sensitivity was 78.9%, specificity 98.1%, CSS $13.09 and CNTBC $90.70. In a pre-screening setting where 40% of subjects would undergo Xpert, CSS decreased to $6.72 and CNTBC to $54.34, with eight TB cases missed and throughput increased from 45 to 113 patients/day. Specialists, on average, read 57% of radiographs as abnormal, reducing CSS ($8.95) and CNTBC ($64.84). ACR pre-screening could substantially reduce costs and increase daily throughput with few TB cases missed. These data inform public health policy in resource-constrained settings.
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We expected a lower CAD specificity in our setting as CXR is known to be less sensitive in immunocompromised patients with pulmonary TB.
“We therefore expected a lower CAD specificity in our setting as CXR is known to be less sensitive in immunocompromised patients with pulmonary TB [38–41].”
From Accuracy of computer-aided chest X-ray in community-based tuberculosis screening: Lessons from the 2016 Kenya National Tuberculosis Prevalence Survey (2022) · cites this paper as [40]
The majority of studies reporting on CAD threshold determination only included individuals who met criteria for microbiological testing.
“The majority of studies reporting on CAD threshold determination only included individuals who met some criteria for microbiological testing, such as having symptoms and/or abnormal chest radiographs [8, 16–27].”
From Computer-aided detection thresholds for digital chest radiography interpretation in tuberculosis diagnostic algorithms. (2024) · cites this paper as [22]
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- Authors
- Philipsen, R. H. H. M., Sánchez, C. I., Maduskar, P., Melendez, J., Peters-Bax, L., Peter, J. G., Dawson, R., Theron, G., Dheda, K., & van Ginneken, B.
- Affiliations
- Radboud University Medical Center (NL)
- University of Cape Town (ZA)
- Corresponding author
- Philipsen, R. H. H. M.
- Venue
- Scientific Reports
- Published
- 2015-07-27
- Volume
- 5
- Issue
- 1
- Pages
- 12215-12215
- ISSN
- 2045-2322 (ISSN-L)
- PMC
- PMC4515744
- OpenAlex
- W1014541510
- Cited by
- 77
- References
- 0
- Citations by year
- 2026: 2 · 2025: 8 · 2024: 5 · 2023: 10 · 2022: 11 · 2021: 11 · 2020: 10 · 2019: 8 · 2018: 6 · 2017: 3 · 2016: 3
- FWCI
- 3.11
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Scientific Reports (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion, other-oa)
- Funders
- European and Developing Countries Clinical Trials Partnership
- Topics
- Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
- Health Sciences › Medicine › Surgery › Infectious Diseases and Tuberculosis
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Lung Cancer Diagnosis and Treatment
- Keywords
- tuberculosis diagnosis, Xpert MTB/RIF, triage, computer-aided detection, CAD4TB, diagnostic accuracy, throughput, resource-limited settings, people living with HIV, sputum culture, prescreening
- MeSH terms
- Machine Learning, Adult, Female, Humans, Male, Netherlands, Pattern Recognition, Automated, Prospective Studies, Sensitivity and Specificity, Radiography, Thoracic, Triage, Tuberculosis, Pulmonary, Utilization Review, Reproducibility of Results, Prevalence, Health Care Costs, Molecular Diagnostic Techniques, Resource Allocation
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