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In Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

BACKGROUND : Automated radiologic analysis using computer-aided detection software (CAD) could facilitate chest X-ray (CXR) use in tuberculosis diagnosis. There is little to no evidence on the accuracy of commercially-available deep learning-based CAD in different populations, including patients with smear-negative tuberculosis and people living with HIV (PLWH).

METHODS : We collected CXRs and individual patient data (IPD) from studies evaluating CAD in patients self-referring for tuberculosis symptoms with culture or nucleic acid amplification testing as the reference. We re-analyzed CXRs with three CAD (CAD4TB version (v) 6, Lunit v3.1.0.0, and qXR v2). We estimated sensitivity and specificity within each study and pooled using IPD meta-analysis. We used multivariable meta-regression to identify characteristics modifying accuracy.

RESULTS : We included CXRs and IPD of 3727/3967 participants from 4/7 eligible studies. 17% (621/3727) were PLWH. 17% (645/3727) had microbiologically-confirmed tuberculosis. Despite using the same threshold score for classifying CXR in every study, sensitivity and specificity varied from study to study. The software had similar unadjusted accuracy (at 90% pooled sensitivity, pooled specificities were: CAD4TBv6, 56.9% [95%CI:51.7-61.9]; Lunit, 54.1% [44.6-63.3]; qXRv2, 60.5% [51.7-68.6]). Adjusted absolute differences in pooled sensitivity between PLWH and HIV-uninfected participants was: CAD4TBv6, -13.4% [-21.1, -6.9]; Lunit, +2.2% [-3.6, +6.3]; qXRv2: -13.4% [-21.5, -6.6]); between smear-negative and smear-positive tuberculosis was: CAD4TBv6, -12.3% [-19.5, -6.1]; Lunit, -17.2% [-24.6, -10.5]; qXRv2, -16.6% [-24.4, -9.9]. Accuracy was similar to human readers.

CONCLUSIONS : For CAD CXR analysis to be implemented as a high-sensitivity tuberculosis rule-out test, users will need threshold scores identified from their own patient populations, and stratified by HIV- and smear-status.

Tavaziva Gamuchirai, Harris Miriam, Abidi Syed K, Geric Coralie, Breuninger Marianne, Dheda Keertan, Esmail Aliasgar, Muyoyeta Monde, Reither Klaus, Majidulla Arman, Khan Aamir J, Campbell Jonathon R, David Pierre-Marie, Denkinger Claudia, Miller Cecily, Nathavitharana Ruvandhi, Pai Madhukar, Benedetti Andrea, Khan Faiz Ahmad


Tuberculosis, accuracy, chest X-ray, deep learning, individual patient data meta-analysis