Implementation of proficiency testing in conjunction with a rechecking system for external quality assurance in tuberculosis laboratories in Mexico

SETTING: In developing countries, tuberculosis is diagnosed by identification of acid-fast bacilli (AFB) on sputum smears. OBJECTIVE: To evaluate the quality of AFB microscopy, the Mexican Secretary of Health National Reference Laboratory implemented proficiency testing for its network of 637 laboratories. DESIGN: A total of 586 (92%) laboratories were inspected and 430 technicians evaluated by proficiency testing consisting of 10 slides with known numbers of AFB. Results were compared with those of slide rechecking and with proficiency testing performed 2 years later. RESULTS: Of the 430 technicians evaluated by proficiency testing in 1998, 196 (46%) scored less than 80% and received intensive training in 1999. From a previous mean score of 65% their results increased to 90% (P < 0.0001). In 2001, they again underwent proficiency testing, and the mean score was 83%. The main factors affecting proficiency testing results were the type of laboratory in which the microscopists worked and the number of low-positive slides (1-9/100) in the test. Laboratories whose work was rechecked had better scores (P = 0.002). Proficiency testing scores and the estimated sensitivity of the microscopist's laboratory were associated (P = 0.01). CONCLUSION: External quality assessment and training improve diagnostic performance. Rechecking and proficiency testing are both viable measures of laboratory performance.