Automated chest X-ray reading for tuberculosis in the Philippines to improve case detection: a cohort study

BACKGROUND: DetecTB (Diagnostic Enhanced Tools for Extra Cases of TB), an intensified tuberculosis (TB) case-finding programme targeting prisons and high-risk communities was implemented on Palawan Island, the Philippines.OBJECTIVE: To evaluate the performance of TB detection based on computerised chest radiography (CXR) readings.DESIGN: Data from 14 094 subjects were analysed from September 2012 to June 2014. All CXRs were read by a physician and by software. Individuals with TB symptoms or CXR abnormalities according to the physician underwent Xpert^® MTB/RIF testing, the remaining persons were considered TB-negative (screening reference). A subset of 200 CXRs was read by an independent human reader (radiological reference). This reader also re-read a subset of the most abnormal cases as identified using the software but read as normal by the physician (discordant cases).RESULTS: A total of 10 755 individuals were included in the analysis, 2534 of whom had a positively assessed CXR; 298 cases were Xpert-positive. Using the screening reference, the area under the receiver operating characteristic curve for software readings was 0.93 (95%CI 0.92-0.94), with a sensitivity of 0.98 (95%CI 0.97-0.99) and a specificity of 0.69 (95%CI 0.40-0.98). Based on the radiological reference, the physician performed slightly worse than the software (sensitivity, 0.82, 95%CI 0.74-0.89 and specificity, 0.87, 95%CI 0.81-0.96 vs. sensitivity, 0.83, 95%CI 0.71-0.93 and specificity, 0.87, 95%CI 0.75-0.95), although this was not statistically significant. Of the 291 discordant cases, 70% were assessed as positive, resulting in a 22% increase in TB detection when extrapolated to the full cohort.CONCLUSION: The performance of automated CXR reading is comparable to that of the attending physicians in DetecTB, and its use as a second reader could increase TB detection.