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CHEST X-RAY: A COST-DIAGNOSTIC
BENEFIT ANALYSIS
CHEST X-RAY: A COST-DIAGNOSTIC BENEFIT ANALYSIS

Conventional versus 100 mm Image Intensifier Radiography

'U
 CHEST X-RAY: A COST-DIAGNOSTIC BENEFIT ANALYSIS
Conventional versus 100 mm image Intensifier Radiography

RdNTGEN-THORAX: EEN KOSTEN-DIAGNOSTISCHE BATEN ANALYSE

Conventionele- versus 100 mm beeMversterker -rontgen opnamen
(met een samenvatting in net Nederlands)

PROEFSCHRIFT

TER VERKRUGING VAN DE GRAAD VAN DOCTOR

AAN DE RUKSUNIVERSITEIT TE UTRECHT
OP GEZAG VAN DE RECTOR MAGNIFICUS
PROF. DR. J. A. VAN GINKEL
INGEVOLGE HET BESLUIT VAN HET COLLEGE VAN DEKANEN
IN HET OPENBAAR TE VERDEDIGEN
OP VRIJDAG 13 DECEMBER 1991 DES NAMIDDAGS TE 2.30 UUR

door

LEONARDUS HENRICUS LAMBERTUS WINTER

gaboran op 30 november 19f9 ta Voerendaal
Promotoren : Prof. Dr. P.F.G.M. van Waes, RUU
Prof. Dr. C.B.A.J. Puytaert, RUU

Co-promotor : Dr. F.P. Ottes, BAZIS, Leiden

o 1991 Loek H.L Winter

Niets uit dez« uitgave mag worden verveelvoudigd «n/of openbaar gemaakt door middel van
druk, fotokopie, microfilm of op welke andere wijze ook, zonder voorafgaande schriftelijke
toestemming van de auteur.

No part of this book may be reproduced in any form, by print, photocopy, microfilm or any
other means, without written permission from the author.

Printed in the Netherlands by Oen Haag Offeet

ISBN 90 9004625 9
Aan mijn ouders

Aan de nagedachtenis van

mijn moeder

Voor Gonneke
'Heut seid ihr alle eingeladen'
St&phan Suike, 1979
DANKWOORD

Van allen die professioneel of emotioneel een bijdrage geleverd hebben bij
het tot stand komen van dit proefschrift, wil ik enkelen bijzonder danken.
In de eerste plaats mijn ouders, zij gaven mij de juiste morele steun om de
middelbare school periode op de juiste wijze te starten en te doorlopen.
Een onuitputbare belangstelling en financiële achtergrond heb ik van hen
ervaren tijdens mijn geneeskunde studie. Het is jammer dat mijn moeder
deze dag niet mag meemaken.
Leo van Rozelaar. Een spannende periode in mijn leven werd jaren tevoren
ingeluid door een 'executive flight' vanuit Innsbruck. Later volgden nog vele
vluchten als ook andere uitstapjes die de zin van het leven benadrukken.
Helaas hebben we samen ook leed gedeeld. Je enthousiasme en door-
zettingsvermogen hebben zowel mijn 'schooltje' als 'werkje' positief
beïnvloed.
Speciale dank aan de Almelose radiologen (en E.J.Haanraadts) die me niet
alleen het 'ABC' in de radiologie geleerd hebben maar ook de keuze van dit
onderwerp bepaald hebben.
Assistenten, oud-assistenten en röntgenstaf van het AZU. Honderden uren
telefoneren en faxen hebben geresulteerd in dit proefschrift. Jullie steun,
inspiratie en congrestijd waren onontbeerlijk voor het welslagen.
Paul van Waes, je stimulans en enthousiasme zijn zeer waardevol geweest
bij het tot stand komen van dít proefschrift.
Carl Puylaert, je levensattitude en wijsheid reiken verder dan de begeleiding
van wetenschappelijk onderzoek.
Bijzonder dankbaar ben ik Prof.Dr. R.G. Fraser en Dev. P. Chakraborty, PhD
voor de uiterst deskundige begeleiding en statistische analyse van de
uitgevoerde fantoom experimenten.
Voorts wil ik Dr. F.H. Barnevefd Binkhuysen, Dr. LB. Beentjes, F. Buscher
ing., Ir. H. Julius, Drs. J.v.d. Kaaden, Drs.lr. R A M A Keulen, Drs. M. Meys,
Dr. F.P. Ottes, H. Vlasbloem ing. (Okietft) en Mr.Drs. H.R.G. Winter danken
voor hun kritische bijdragen bij de bewerking van het manuscript
Ook dank aan mevrouw M.J.Kuijpers voor de vormgeving van de tekst en
mevrouw I.Jansen voor het verzorgen van de illustraties. Drs. G.LM.Braat
dank ik voor het ontwerpen van de voorpagina.
Taalkundige correcties zijn verzorgd door mevrouw G.Bieger-Smith en Dev.
P.Chakraborty, PhD. Hiervoor hartelijk dank.
Tenslotte dank ik mijn echtgenote die me de morele steun gegeven heeft op
momenten dat de haalbaarheid van dit proefschrift moeilijk leek.
 CHEST X-RAY: A COST-DIAGNOSTIC BENEFIT ANALYSIS
Conventional Versus 100 mm Image Intensifier Ftadiograpfiy
by Loek H.L Winter
 CHEST X RAY: A COST-DIAGNOSTIC BENEFIT ANALYSIS
Conventional versut 100mm linage IntentiRer Radiography

PART I GENEHAL INTRODUCTION

1. GENERAL INTRODUCTION AND BASIC PRINCIPLES 17

General Introduction 18
Chest Rontgenographta Techniques 20
Large Field of View Image fntensifiers 25

2. REVIEW OF THE UTERATURE AND AIM OF THE STUDY 31

3. METHODOLOGY 41
Determination of Diagnostic Image Quality 43
Description of ROC analysis 46
A modified ROC method: FROC 53
Clinical images or Phantom images 53
Summary 55

PART II THE COST-DIAGNOSTIC BENEFIT ANALYSIS

PART II A THE DIAGNOSTIC BENEFITS 57

4. DESCRIPTION OF PHANTOM SIMULATION 59

Imaging Systems 60
Phantom Characteristics 62
Simulation of Pulmonary Nodular Disease 63
Simulation of Interstitial Pattern Disease 67

5. DIAGNOSTIC ACCURACY OF LFOV-II CHEST RONTGENOGRAMS

A Simulated Pulmonary Nodule Detection Study 71

10
6. THE EFFECT OF MINIFICATION ON DIAGNOSTIC ACCURACY
A Simulated Pulmonary Nodule Detection Study 79

7. DIAGNOSTIC ACCURACY OF LFOV-II CHEST RONTGENOGRAJyfS

A Simulated Interstitial Pattern Disease Study 87

8. THE INFLUENCE OF RADIOLOGICAL TRAINING ON DIAGNOSTIC

PERFORMANCE. A Phantom Study 97

PART II B THE COSTS 107

9. MEASUREMENT OF RADIATION DOSE 109

Dosimetry 110
Dose Measurements 112

10. A COST ANALYSIS 121

Cost Model 123

11. UTERATURE 133

12. SUMMARY and GENERAL CONCLUSIONS 146

13. SAMENVATTING en CONCLUSIES 149

14. APPENDIX 153

List of Abbreviations 185
List of Publications 186
Curriculum Vitae 188

VlJL
 CHEST X-RAY: A COST-DIAGNOSTIC BENERT ANALYSIS

Conventional rotus 100 mm Image fntansmar Radiography

 CHEST X-RAY: A COST-DIAGNOSTIC BENEFIT ANALYSIS
Conventional Versus 100 mm Image Intensifier Radiography

PART I GENERAL INTRODUCTION

 CHAPTER I

GENERAL INTRODUCTION AND BASIC PRINCIPLES

 1.1 GENERAL INTRODUCTION

The chest radiograph is one of the most useful diagnostic tools available to
the physician. It provides an enormous amount of information about internal
thoracic anatomy.
Its importance is reflected in the number of chest radiographs made yearly,
e.g. 2.5 million in the Netherlands which represents approximately 30% of all
radiographic examinations8'19"64'103.
The chest radiograph is the primary method for detecting lung cancer,
which is the leading cause of cancer deaths35.
Despite the large number of chest radiographs made yearly, this procedure
has not evolved into a consistent method.
Due to rapid technological evolution and different demands, a variety of
equipment is available for chest radiography.
Kundel75 states: "A way has to be found whereby variables describing image
quality can be combined with other factors such as financial costs, time
utilization and patient dose. Until this time we must basically approach the
problem of system evaluation by adopting independent measures of each of
these factors, while realizing that it is their mutual effect that must be
ultimately considered".

Two Image Intensifier techniques, which because of the large input area are
suitable for chest imaging, have become available (Large Field of View
Image Intensifies, LFOV-II).
Both modalities supply 100 mm (10x10cm) images to the observer. The first
LFOV-II consists of a triple mode (57,47,33cm) Large Entrance Field Image
Intensifier (LEF-II), the second one uses a scanning Slit-shaped Image
Intensifier (S-il).

In general, the radiologist is responsible for assessment of the clinician's

demands and the resulting need for new modalities. For evaluation of these

18
LFOV-II technologies, a review of the literature does not offer sufficient
insight into the pro's and con's.
According to Kundel's statement, determination of the clinical value of these
new chest X-ray modalities requires evaluation of the following aspects;
diagnostic image quality, radiation dose and cost per chest X-ray.
Several questions regarding the 'diagnostic benefits' and 'costs' must be
answered:

A. The 'diagnostic benefits';

1. What leads to a visual impression of image quality and thus, how
does one define and determine image quality ?
2. Are clinical trials sufficiently representative or are phantom studies
mandatory ?
3. I* phantom studies are carried out, what pathology can be
simulated.
4. Does the variation in the size of the image format (35x43 cm
versus 100 mm) influence diagnostic image quality ?
5. What requirements do the observers have to fulfill ?

B. The 'costs';
6. What is the radiation exposure of these Image Intensifier chest
radiographs ?
7. Considering the Dutch reimbursement system, which costs are
relevant and can savings be achieved ?

The objective of this study is to evaluate th**se techniques from a

radiologists' point of view. The main focus of the study is to determine
diagnostic image quality.

In chapter 1 the basic principles of the conventional full size (C-FS) and
LFOV-II chest rdntgenographic techniques are described.
The literature is reviewed and the aim of the study is discussed in chapter 2.

19
The fundamentals of observer performance experiments carried out to
determine diagnostic image quality are considered in chapter 3.
The statistical methodology used (ROC: Receiver Operating Characteristic
and FROC: Free response Receiver Operating Characteristic) is reviewed in
this chapter. Two phantom models have been developed, one using
simulated pulmonary nodules and the other using simulated interstitial
disease, both based on a commercially available chest phantom (chapter 4).
In chapter 5 the diagnostic image quality or diagnostic accuracy is
assessed using a phantom model with simulated pulmonary nodules.
The influence of different image sizes on diagnostic accuracy is discussed
in chapter 6.
Chapter 7 is comparable to chapter 5, except that this phantom study is
based on simulation of interstitial disease.
The influence of radiological training on diagnostic accuracy is discussed in
chapter 8.
Radiation doses were measured by Thermoluminescent-dosimetry (TLD). A
theoretical analysis of the results is presented in chapter 9.
In chapter 10, a cost model based on the Dutch reimbursement system is
described.

1.2 CHEST RONTGENOGRAPHIC TECHNIQUES

Full Size technique

A film-screen combination Is usually used to record the radiologic image.
The typical film is a double emulsion, sandwiched between two intensifying
screens. The screens convert the X-ray photons to light photons which then
expose the film. During the last decade screens made of rare-earth
phosphors nave become available. Compared with calcium tungstate
screens, the former offer higher speeds and lower radiation doses103.
The most common technique for chest radiography is the 'Mgh-kNovortage
technique' in which the kHovoftage ranges from approximately 110 to 140

20
 kVp with a comparatively short exposure time of 0.01-0.04 seconds. With
this technique a grid or airgap is required to reduce secondary radiation92.
For the 'low-kilovoltage technique' the kilovoltage ranges from
approximately 60 to 80 kVp but then the exposure time must be relatively
long, 0.1-0.5 second, in order to deliver sufficient radiation to produce a
radiograph of adequate density92.
Less common procedures for chest rontgenography are the supervoitage
technique (250-350 kVp)50'54114, the slit-equalization radiographic techniques
with a linearly moving beam111'112'148 and the slit radiographic technique with
a rotating wheel coHimator127'135.
The 'high-kilovoltage technique' is preferable due to the lower absorbed
radiation dose, better penetration, wider image latitude, greater tolerance for
technical errors and finally greater diagnostic accuracy41'88122.

Figure l a . Schematic representation of tft« conventional full size technique. The X-ray image
is detected by a rare-earth film screen combination. (X « X-ray tub*, BG« bucky
grid, F * film, S « rare-earth screen).

21
For this reason the 'gold' standard used in our comparative study was the
commonly accepted 'high-kilovoltage technique' in conjunction with a grid
and fast rare-earth screens (MR 400, Agfa).
The conventional full size film screen radiography equipment is shown
schematically in figure 1a and in the clinic in figure 1b.

Figure 1b. A photograph of the conventional full size film screen equipment.

Photospot Technique
The photospot technique is the production of images on mini-size (70 or
100 mm) film. Various photospot techniques are available: Rdntgen
photofluorography (RP) and Large Field of View Image Intensifier
radiography (LFOV-M).

22
Rontgenphotofluorography (ODELCA)
Since the late 1930's RP has been used especially for mass chest screening
for pulmonary tuberculosis and lung carcinoma. This technique was very
popular because the small size of the photofluorographic films reduced the
costs of films and chemicals as well as storage.
The fluorescent screen, which consists of ZnCdS(Ag) or Gd2O2S, measures
40x40 cm and covers the whole chest. The optical image generated by the
screen is recorded photographically by means of a 70 or 100 mm camera.
Because image intensification is not part of this technique and light is lost
when the image on the screen is projected onto the 100 mm film, the
radiation dose is unacceptably high (approximately 20 times more than a
modern full size film-screen combination)92100.
As a result, the rontgen photofluorography technique is not part of our
comparative study.

Image Intensifiers in diagnostic radiology

X-ray Image Intensifiers (II) were developed in the early 1950's. The primary
function of the tube is intensification of the X-ray image70.
Several conversions are needed in order to obtain the necessary
intensification. After an X-ray beam passes through the patient, it enters the
II tube. The input fluorescent screen absorbs X-ray photons and converts
their energy into light photons. The light photons strike the photocathode
causing it to emit photoeiectrons. These electrons are accelerated by a
strong electric field caused by a high potential difference between
photocathode and anode. As the electrons flow from the cathode towards
the anode, they are focused by an electrostatic lens onto the output screen
(anode), with minimal distortion of their geometric configuration. When the
electrons strike the output screen, it emits the light photons that carry the
fluoroscopic image to the photographic camera. Thus, in the Intensifier
tube, the image is carried first by X-ray photons, then by light photons
followed by electrons and finally by light photons. The increase in luminance

23
is produced by supplying energy to the electrons during the acceleration
phase and by reducing the size of the image (figure 2).

'-,-r
Figure 2. Schematic representation of an image intensifier.
The components of an X-ray image intensifier are shown. The tube itself is an evacuated
glass envelope or vacuum tube containing five basic elements: 1. Fluorescent input screen 2.
Photocathode 3. Electrostatic focusing lenses 4. Anode 5. Output screen. L= Emitting light.

The imaging properties of X-ray II have been improved during recent years
and consequently the use of photospot films in clinical radiography has
increased. However, the relatively small diameter (35 cm or less) of the
input screens of the image intensifiers commonly available continues to
restrict the use of II tubes in chest radiography30'03.
Two LFOV-II became available; their large input areas make them suitable
for chest imaging: the Urge Entrance Field- II (LEF-II, Siemens TS 57) and
the Slit Image Intensifier (S-ll, Philips Pulmodiagnost 100). A basic
description of these Us is presented in the following paragraphs; technical
details are listed in table 6 (chapter 4.1).

24
 1.3 LARGE FIELD OF VIEW 'MAGE INTENSIFIERS (LFOV-II)

Large Entrance Field Image Intensifier (LEF-II)

The construction of this triple mode X-ray II with large entrance field is
similar to that of Image Intensifies with smaller entrance fields. The 57-cm
image field diameter circumscribes a square field of 40 by 40 cm. The
output image on film is 100 mm across (10x10cm).
Hence, electron optical minification at full field size is a factor 5.7 and
correspondingly less for smaller (i.e.'zoomed') entrance fields. The entrance
field can be reduced to 47 and 33 cm by varying the potentials of the three
focusing electrodes. The vacuum envelope of the II tube consists of a steel
housing, a convex entrance window made of 1.8 mm aluminum, and a glass
output window. The loss of contrast due to scattering by the entrance
window is minimized by this choice of window material. The input
fluorescent screen is made of cesium iodide. The output image on the
output screen is focused by tandem objective lenses onto the film plane of
a 100 mm sheet film magazine camera.
A stationary grid in this device is used to reduce scattered radiation.
Because of the large entrance field of the X-ray II, this equipment suffers
from image distortion. Another disadvantage of the large entrance field is
the influence of the external magnetic field on the electrons within the II.
To prevent distortion the surface of the II is protected with a layer of metal
which absorbs the excess magnetism ('MU metal'). The 57-cm image
intensifier camera assembly is suspended from the ceiling via a telescopic
mounting.
The X-ray source assembly which is similarly suspended, is electronically
centered on the II by means of electromotors (figure Sa.b)43.

25
Figura 3a. Schematic representation of an LFOV- Large Entrance Field - II.

Figura 3b. A photograph of the Large Entrance Field LFOV-II.

26
Slit Image Intensifier (S-ll)
The recently developed chest S-ll is based on the sift-radiography principle.
The radiation beam is collimated through a slit, thus forming a fan-shaped
radiation beam. This beam is directed onto a horizontally oriented
rectangular II which has a width of 40 cm and an effective height of 2.5 cm
(figure 4a,b). The input (cathode) of the II consists of a cesium iodide
scintillation screen coupled to a photocathode, the output (anode) is a
fluorescent screen.

J —

Figure 4a. Schematic representation of the LFOV-Slit image Intensifier.

A high voltage applied between the cathode and anode produces an

amplified (bright) optical image on the output screen.
This Slit-shaped II, known as the PU (proximity-focused linear II), scans the
image plane vertically and behaves as the secondary slit of a slit
radiography system, the primary slit being connected to the X-ray tube. By
using the slit scan principle, scattered radiation is reduced enough to
eliminate the need for a grid. The image plane is focused on 100 mm film by
means of a special lens. The system is regulated electronically, in
combination with a computer-controlled X-ray generator. A rotating anode
X-ray tube is used and, because of the limited tube load, the focal spot can

27
 1

Figure 4b. A photograph of the apparatus.

be small (0.6 cm). The radiation dose needed for an exposure is determined
by means of a test scan using 10% of the estimated dose. This test scan is
followed by the actual exposure in which the II vertically scans the object
plane (chest) in 0.8 seconds.
A disadvantage of this device is the relatively long exposure time which can
lead to motion artifacts, particularly in the horizontal direction and in the
cardiac outline. The effective exposure time is very short in the vertical
direction (slit width divided by scan velocity; focal plane shutter effect)85.

Film viewer
For clinical conferences, the small size of the 100 mm films is a problem
and a film viewer or magnifier is mandatory. Several devices are able to
magnify the 100 mm photospot films to standard sizes8. Magnification is
obtained by means of a video camera or optical devices. Although
acceptable for conferences, the image quality deteriorates and reliable
image interpretation for primary diagnosis is not possible. For primary
diagnosis it is essential to view the 100 mm image directly.

28
 In figure 5 magnification of 100 mm fiJm is shown. For comparison a C-FS
radiograph is also shown.

Figure 5. On the viewing box are 100 mm chest X-ray films and C-FS radiographs. On the
right, film viewer magnification of a 100 mm LFOV-II chest X-ray film.
 CHAPTER 2

REVIEW OF THE UTERATURE AND AIM OF THE STUDY

Introduction
Several studies have appeared since the introduction of the LEF-II (1982)
and the S-ll (1986) techniques described in the last section. Most of these
studies, summarized in tables 1 and 2, were performed to determine their
usefulness for mass screening purposes; only a few considered their
application in clinical practice.

REVIEW OF LITERATURE

Large Entrance Field Image Intensifier technique

A number of investigations of the LEF-II have been published120'39143'
44.57,91.92,113,116 Most autnors repo)1 a hign overa|| jmage quality for this

modality.
For a number of radiographic diagnoses, such as pulmonary coin lesions
and hilar and pleural pathology, anecdotal reports of high sensitivity and
specificity with respect to fuii size radiography43'82'101 have been published.

According to Georgi44, who examined 2651 subjects with the novel LEF-II
technique, the image quality is sufficient for mass screening.
Manninen et al.98 compared this technique with full size radiography by
grading the visualization of various anatomical details essential for a
rontgenographic diagnosis. The LEF-II radiographs were equal to or even
better than high resolution full-size radiographs as far as most anatomical
details, especially mediastinal and retrocardiac structures, are concerned.
The visualization of finer structures of the lung fields in the PA projection
(general appearance of pulmonary vessels, parenchymal network and rib
details) on the photospot fflms was equal to that found for full-size
radiographs.
Mannlnen's findings are in accordance with those of Raithel et al. 1ia who
reported that the image quality of the II photospot films was equal to that of
full-size radiographs for the diagnosis of pulmonary interstitial pathology

32
(fibrosis, asbestosis and silicosis). However, Neufang et al.101, Adamietz et
al.1 and Friedman43 reported limited accuracy in the detection of subtle
interstitial changes due to lack of definition in peripheral areas, especially in
obese patients.

Comparison of image quality with that of full-size techniques was described

in only seven papere38**."182.101-113116. Moreover, even in these studies,
technical details and statistical analysis were lacking.

Although Manninen92 states that the small size of the film has a positive
effect on diagnostic accuracy, literature on this topic is conflicting because
Lehr et al.84 obtained results showing a small negative effect. According to
Manninen, tr.e small film size does cause some problems, one of which is
the difficulty of estimating heart size and the degree of cardiac congestion.

Practical problems also include display of the photospot films since a

conventional viewbox or alternator cannot be used unless the area
surrounding the film is blocked off to minimize glare82"93.

All papers report a reduction in radiation exposure varying from 40 to 90 %

in comparison to full size radiography with medium to fast rare-earth
screens. However, only seven authors39'43'44'91182'1011116 actually carried out
radiation measurements. None of the studies provide adequate information
regarding the number of dosimeters, location of measurements, etc.

Although nearly all papers mention the low costs as an important advantage
of these new technologies, only 3 studies20'92'115 include a global cost
analysis. Moreover, these three papers consider only film, storage and
capital costs, while other cost factors such as maintenance, interest, etc.,
are not taken Into account.

33
Slit Image Intensifier technique
Five preliminary studies of the S-ll technique are available17'3438'85'118.
Buchmann17 and Levels85 presented a paper in which the technology was
described. Without actually comparing S-ll with conventional full-size
radiography, Buchman states that the image quality is sufficient for
screening purposes.
Eckebrecht et al.34 investigated about 3000 screening examinations carried
out in industrial medicine. In this study a comparison with full-si2e
radiography is made but essential technical details are not mentioned. He
concluded that the image quality is comparable to that of the full size
technique.

All studies report a major reduction in patient radiation dose. According to

Ewen et al.39, a reduction in skin radiation dose of 90% was found
compared to full-size radiography, while the skin dose was nearly equal to
that determined for LEF-II radiographs.

A cost analysis was not performed in any of the studies mentioned above.

Discussion and Conclusions

A review of literature on the image quality of the LFOV-II does not yield
satisfactory conclusions because objective analyses were not carried out
(table 1 and 2).

The effect of the small film size on perception and thus on diagnostic
accuracy remains uncertain because literature on this topic is conflicting.

All authors mention a reduction in patient radiation dose for both LFOV ll's.
However, only a few actually performed measurements and the
methodology of these studies Is not dearly described. Furthermore, the
results exhibit large variabllty.

34
Another reported advantage is a savings in costs but only three authors
performed a limited cost analysis.

Regarding the existing literature, it may be concluded that diagnostic

accuracy, radiation dose and costs should be investigated more thoroughly.

AIM OF THE PRESENT STUDY

As stated in the general introduction, several aspects of the 'diagnostic

benefits' and 'costs' have to be evaluated:

A. The diagnostic benefits:

From the review of past work it is clear that an objective assessment of
diagnostic image quality has not yet been carried out. A tool that one can
use nowadays to evaluate diagnostic image quality objectively is the
Receiver Operating Characteristics (ROC) methodology.
The first aim of this thesis is therefore to apply the ROC method to evaluate
these II tubes with respect to the 'gold' standard : high kVp optimized
conventional full size (C-FS) chest radiography. In an ROC study one
usually shows abnormal and normal images to observers. Several difficulties
are encountered when clinical images are used for such studies.
A second aim of this project was to devise alternative methods for
presenting cases, i.e. phantoms. A subsidiary goal was to understand the
influence of the size of the image display on perception.
If phantom studies are carried out, what requirements do the observers
have to fulfill ? Do readers have to be board certified radiologists ?

35
B. The costs:
The basic goal of radbgraphic imaging systems is to maximize diagnostic
image quality but to keep the patient radiation dose acceptable (chapter 9)
and costs low (chapter 10).
Thus, the 'cost' in terms of patient radiation dose has to be evaluated. What
devices can be used and more importantly: can reduction of radiation
exposure, as suggested in the literature, be confirmed.
In the literature, it is presumed that savings in financial 'costs' can be
obtained. To verify this assumption, a cost analysis needs to be carried out.

36
LARGE ENTRANCE FIELD II (LEF-II)
AUTHOR YEAR AIM OF STUDY MO. COMPARED TO RESULTS
Neufang et al. A. 870 pathological 350 standard full High accuracy for
ROFO101 1982 findings are compared size radio- coin lesions, hilar
graphs and pleural patho-
logy, pulmonary
vasculature and
right paratracheal
stripe.Subtle inter-
stitial changes,
hilar, aortic calci-
fications and rib
lesions are not
always visible

B. Admission screening 150 High image quality

C. Radiation Measurements Full-size SOX radiation

(TLO) radiography reduction
in conjunction
with rare
earth screens

Friedmrm A. Screening 3,300 Comparable image

Radiology today 1983 quality for ad-
2. ed.4* mission chest f i In
mass screening
examinations and
follow-up studies

B. Industrial medicine 350 Comparison High degree of

with biplane accuracy in the
chest films evaluation of coin
No technical lesions, pulmonary
details are vasculature and
given. pleuraI changes.
Limited detection of
subtle interstitial
changes.

C. Radiation measurements Comparison Mean skin dose 80%

(TLD) with PA full- lower
size radio-
graphy. No
techn.details
arc given

Table 1: continued on next page

37
AUTHOR YEAR AIM OF STUDY NO. COMPARED TO RESULTS
Raithel et al. A. Detectability of pneu- 36 High kVp full- High image quality,
Electromedica118 1983 moconiosis and asbest- size radio- especially for
osis in industrial graphs. asbestosis and
medicine Limited techn. silicosis detection
detail

B. Radiation measurements High kVp full- Radiation exposure

(Phantom model, device?) size radio- reduced 90%
graphs.Limited
techn. details

C. Cost analysis Conventional Savings up to USD

full-size 75,000 for 18,500
examinations

Heuck et al. Image quality 17,885 - Image quality compa-

Radiology57 1984 sufficient for mass rable to that of
screening? standard full-size

Georgi et al. A. Image quality suffi- 2,651 - Image quality

ROFO*4 1985 cient for mass comparable to that
screening? of full-size

B. Radiation measurements Full-size Radiation exposure

(plexiglass phantom; radiography? reduced 40-80% (de-
type dosimeter?) No technical pendent on entrance
details mode of II)

Mamtnen A. Comparing image quality 27 Full-size Suitable for routine

Thesis82 1965 to full size. Selected
group of 27 patients
with chronic heart
disease or neopli
radiographs chest radiography.
Limitations: deter-
mination of heart
size and degree of
cardiac
decompensation

Radiation measun Full-size Circa 65X reduction

(device?, no.?) radiographs in in radiation in
conjunction exposure
with medium
speed rare
earth screens

Table 1: Continued on next page

38
AUTHOR YEAR AIM Of STUDY MO. COMPARED TO RESULT!
C. Global cost analysis Full-size Decisive savings in
radiography costs (85-90%)

Adamietz et al. 1986 A. Determination of 29,270 High image quality

Rontgenpraxis1 image quality limitations: lower
spatial resolution

B. Radiation measurements Radiation exposure

reduced 70-80%

C. Cost analysis Savings of 87%

Ewen et al. A. Determination of image Rontgenfluoro- Comparable image

Electromedica36 1987 quality (phantom study) graphy and quality
full-size
radiography.
Limited techn.
details

B. Radiation measurements Full-size Reduction of 85%

(Alderson-Rando radiography (skin dose)
phantom; TLD) (fast rare
earth screens)

Powell A. Clinical usefulness for High kVp full Sufficient image

Electromedica 113 1987 outpatients size radio- quality for clinical
graphs. No application
further techn.
descriptions

B. Radiation measurements Conventional Radiation exposure

full-size reduced 80%

C. Cost analysis Conventional Savings up to USD

full-size 40,000 for 25,000
examinations

Busch et al. Cost analysis Conventional Decisive savings in

Electromedia20 1987 full-size costs

Table 1: Continued on next page

39
AUTHOR YEAR AIM OF STUDY WO. COMPARED TO RESULTS
Malchair et al. A. Clinical comparative 90 Standard Excellent image
ISPRAD Florence'.si 1988 study full-size quality of 100 a
radiographs films
No detailed
technical
data given

B. Radiation measurements 10 Standard full- Low skin doses

(TLD) size. No
further
descriptions

Table 1: A summary of studies published in the literature on the Large Entrance Field-II

SUT IMAGE INTENSIFIER (S-ll)

AUTHOR YEAR AIM OF STUDY NO. COMPARED TO RESULTS

Levels 1986 Description of

Ziekenhuis Techniek88 technology

Buchmann Preliminary study No comparison Good image quality

Nedicamundi 17 1986 Description of made for screening
technology purposes

Eckebrecht A. Image quality suffi- 3,000 Full-size Comparable image

Medicamundi34 1987 cient for mass radiographs. quality
screening and preven- No detailed
tive examinations techn. data

B. Radiation measurements Conventional Radiation reduction

full-size of 90%

Ewen et al. Radiation measurements Full-size Reduction of 90%

Electromadica39 1967 (Alderson-Rando radiography (skin dose)
phantom; TLD) (fast rare
earth screens)

Reuter et al. Determination of i 115 Conventional High image quality

Rontgen-BL.118 1988 quality full-size

Table 2: Summry of publications on the Slit Image Intensifier technique

40
 CHAPTER 3

METHODOLOGY
Introduction
In order to evaluate competing rontgenographic techniques, one should
have an objective measurement of the diagnostic image quality. The basic
questions arise: What is diagnostic image quality. How should we define
and determine it?
The basic parameters characterizing physical image quality are image
sharpness or resolution (modulation transfer function, MTF), radiographic
contrast (subject contrast, film gamma) and image noise (Wiener
Spectrum)103. Exact determination of these physical parameters requires
sophisticated instrumentation.
Some studies report that these physical properties do not always correlate
very well with diagnostic image quality*1129'128.
It is clear that diagnostic image quality includes more than information on
spatial resolution and noise46'121.
From the radiologist's point of view the displayed image has three important
features: image fidelity, image informativeness and image attractiveness.
Collectively, these lead to a visual impression of image quality73.
Image fidelity refers to the accurate reproduction of the anatomical details
known to exist in the patient.
Image informativeness or diagnostic accuracy refers to the transmission of
diagnostic information and is expressed as the detectability of some specific
abnormality.
Image informativeness is the most important feature of image quality
because it is specific for each individual patient.
Image attractiveness has to do with the aesthetic properties of the
displayed picture. Is looking at it pleasing or comfortable? As a rule
aesthetic values are socially determined, but they play an important role in
the overall judgement of image quality. The acceptability of a new modality
may ultimately hinge on its aesthetic properties rather than fidelity and
informativeness73.

42
There is little objective information about the best display size for images of
large body parts. In the literature no specifications of image size or format
for optimal transfer of visual information can be found. In this connection it
would be a pity if 100 mm films were rejected on the basis of image
aesthetics rather than diagnostic accuracy73.

The emphasis of this thesis is the determination of diagnostic image quality,

i.e. image informativeness or diagnostic accuracy.
Although aesthetic values (which play an important role in the image
attractiveness) were not determined, we did perform a study in which the
influence on the diagnostic accuracy of the 100 mm display was assessed.

3.1 DETERMINATION OF DIAGNOSTIC IMAGE QUALITY

Introduction
In the process of radiodiagnosis three basic steps are involved: image
generation or acquisition, display and the perception of relevant rontgen
shadows (table 3).
The quality of a diagnostic image is hard to define; moreover, the
perception of a diagnostic image is also influenced by various
62 88
parameters ' . Not only observer-related variables (talent, training, etc.)
play a role but also image-related variables such as the contrast between
the suspected abnormality and the background of the image, the sharpness
or edge gradient of the abnormality and image noise which interferes with
perception of the abnormality. Another important negative characteristic is
'structured noise'103>121: this refers to the presence of overlapping anatomical
structures.
Table 3 shows schematically how image generation and display are
associated with the process of perceiving an X-ray image.

43
 X-Ray Tube
I
Object
I
Input X-Ray Pattern
|
IMAGE GENERATION
i

Imaging system
I
Image Processing
I
System output
Radiographic Image
|
DISPLAY SYSTEM
Display Image
|
OBSERVER'S PERCEPTION
I
detection
identification
interpretation
I
FINAL OUTPUT
DIAGNOSIS

Tabto 3: A achwnatic outline of th» p r o e m of

The question of how to measure diagnostic accuracy has become
increasingly important in recent years due to the introduction of new
radiodiagnostic techniques.

The output of the LFOV-II is an additional factor that has to be investigated.

At present the output is recorded on 100 mm film but the question arises: is
all diagnostic information being presented in the best possible manner to
the radiologist. Specifically, is a larger film size preferable ?
From the radiologist's viewpoint, two methods are available for evaluation of
diagnostic image quality. Both are based on observer performance studies.
In the fi. ot method clinical images are used. In the second phantom images
are used to simulate disease4"24'153.

An early attempt in the 1940's tp use the first method was described by
Birkelo et al. 14 who tried to determine which one of four rontgenographic
systems had the greatest efficiency in screening for tuberculosis. The results
were not conclusive since there was no absolute standard and because
there were large interobserver and intraobserver variations in accuracy.

For comparison of clinical radiographs, visual grading has been used until
recently56'9*114'133.
In the concept of visual grading, subjective comparison of image quality is
achieved by means of a grading scale.

Proto and Lane114 applied a grading scale that ranged from -2 to +2,
equality with the standard system being graded as 0, to the visualization of
a number of anatomical detals and pathological findings in a comparison of
350 kVp chest radiography with a standard 120 kVp technique.

Visual grading has the disadvantage that it is purely subjective. A proposed

method for obtaining a more objective assessment of image quality is ROC
analysis. This method is described in the next paragraphs.

45
3.2 DESCRIPTION OF ROC ANALYSIS

A reliable anr* valid measure of diagnostic accuracy is fundamental to the

evaluation of a medical imaging technique.97140. This involves comparison of
diagnostic decisions with 'truth'. A simple measure of diagnostic accuracy is
the percentage of cases which the physician correctly diagnoses. However,
this is of limited usefulness as a measure of diagnostic accuracy because
disease prevalence (i.e. ratio of pathological images to all images) markedly
affects the results. For example, for a relatively rare disease (only 5% of
patients have the disease) the percentage correct diagnoses will be 95% if
the observer just blindly states that the disease is absent.

Even if disease prevalence is known and fixed, the percentage correct

diagnoses is of limited value. Two diagnostic modalities can yield equal
percentages correct diagnoses but differ in the types of correct and
incorrect decisions they yield. The incorrect diagnoses from one might be
almost all false negative decisions (misses), while those from the other
might be nearly all false positive decisions (false alarms).
The limitations of this parameter forces us to introduce some complexity
into our evaluation scheme: we must identify the effect of disease
prevalence, and we must subdivide the results according to the various
kinds of correct and incorrect decisions97.
The matrix table (table 4) shows how decisions can be subdivided: true
positive (TP), false positive (FP), true negative (TN) and false negative (FN).
These can be expressed in fractions as well.

Both of the obvious limitations of the percentage correct diagnoses can be

overcome by defining diagnostic accuracy in terms of a pair of indices:
sensitivity and specificity"

46
 ACTUAL STIMULUS
RADIOLOGIST RESPONSE.
disease present disease not present

Positive TP; True Positive FP; False Positive

Negative FN; False Negative TN; True Negative

Table 4 : Decision matrix with two stimuli and responses

The sensitivity of a test is the ratio of the number of cases with a positive
diagnosis to the number of individuals with the disease in question. The
sensitivity thus expresses the ability of the test to select individuals with the
disease88'97.
A sensitivity of 100% therefore means that the test selects all individuals with
the disease in question.
The specificity of a test is the ratio of the number of cases with a negative
diagnosis to the number of individuals without the disease. Thus, specificity
measures the ability of a test to distinguish those who do not have the
disease (table 5).
A test with a specificity of 100% therefore rejects aH individuals without the
disease9697.

Number of true positive decisions (TP)

TP(F) = Sensitivity =
Number of actually positive cases
FP(F) = 1 - TN(F)
Number of true negative (TN) decisions
TN(F) = Specificity =
Number of actually negative cases
FN(F) = 1 - TP(F)

Tabte 5: Definition of and relationships between the various IOCKOM described in the text"1"7.

47
Decision Threshold
The test data of almost any diagnostic test, do not fall into one of two
categories that can be ascribed to the presence or absence of the disease.
For example: for diagnostic tests that yield a single number as a result
(such as a 24-hr thyroid uptake, various blood serum tests, etc.), the
distributions of the values for truly positive and truly negative patients
overlap, and no single threshold or decision criterion can be found that
separates the populations (otherwise the test would be perfect!).
Usually a threshold value must be chosen arbitrarily, and different types of
correct and incorrect decisions are made (figure 6). This also applies for
imaging studies, which are diagnostic tests that must be judged
subjectively: decision thresholds must be chosen by the radiologist.

If an image suggests the possibility of disease, how strong must that

suspicion be before an image can be called positive? The decision
threshold that an observer adopts undoubtedly depends on many things:
his 'style', his estimate of prior odds or probability and his assessment of
the consequences of the various possible correct and incorrect decisions.
The concept of decision threshold may be hard to quantify, but in most
situations a decision threshold can be varied (rating method); the various
decision fractions (TP, FP, etc.) wil then also vary. Thus, sensitivity and
specificity are not fixed values. Rather they are mutually dependent values,
both in turn depending on the decision threshold used87.

This threshold, consisting of diagnostic criteria which are seJdomly absolute,

determines the diagnostic decision and hence the sensitivity and specificity.
If the diagnostic criteria are shifted to a higher threshold, fewer normal
cases wiH be caHed abnormal but inevitably more cases with disease w i be
undetected. The result is a lower sensitivity combined with a higher
specificity. Conversely, at a lower threshold the clinician can achieve higher
sensitivity at the cost of a tower specificity, ft must be stressed that these
different results are produced by the same diagnostic test and the same

48
 distribution for distribution for
V) negative cac>es positive cases
•o

3
.Q
O

subjective
decision threshold signal strength
Figure 6: Normal distribution for nagativa caaas (ditaaaa not praaant) and positiva caaat
(diaaaaa praaant). Ona daoiaion thraahotd is arbitrarily choaan.

reader expertise simply by altering the threshold of the diagnostic

decision123. The categories of such a rating scale have descriptive labels
such as:

1 = disease not present

2 = disease probably not present
3 = disease unsure
4 = disease probably present
5 - disease present

In Figure 7 the influence of changing decision thresholds on the distribution

of TP/FP/TN/FN scores is demonstrated.

TheROCcurvt
The interdependence of sensitivity and specMclty, investigated by Swets
[1964], was adapted to rontgen diagnosis by Lusted", Metz" and others;
the principle is that signal-perception psffoffnance is evaluated by means of
'Receiver Operating Characteristics' (ROC) aritfysis*'"*'" 0 .
The construction of a ROC curve requires several pairs of sensitivity
 1+2+3+4+5

2+3+4+5

3 +4 +5

4 +5

decision
thresholds 1 2 34 5
Flgur* 7: attribution* tor rwgathw and poaitfv* C H N ( d l — — not peasant/ diaaaaa pratant)
using tha 'rating rrwthod' with fiva poaaibla decision thraahoMs.

specificity coordinates. Using the rating method to generate several

combinations of FPF and TPF, different points on the ROC curve are
obtained. A ROC curve always passes through (0,0) and (1,1). Excluding
these endpoints, a 5-rating ROC experiment can produce at most 4 distinct
data points. Usually, 5 or 6 categories are used in a rating experiment to
obtain 4 or 5 data points on the ROC curve.
In figure 8 two typical ROC curves are presented. The diagonal line implies
that the TPF Is always equal to the FPF, which means that discrimination is
no better than chance.

50
10 T TPF

0.5-

0.5 1.0
Figure S: Two typical ROC curuM that might rtulft from a obsarvw parformanoa axparimant.
Tha solid diagonal No* redacts a discrimination that is no battsr than chance.

The upper ROC curve (A) implies greater discrimination between normals
and abnormals. The lower ROC curve (B) indicates less discriminating
power. As for as the B-curve is concerned, points near the origin (0,0) are
the result of strictly made decisions in contrast to the less strict (lax)
decisions which w i lead to both higher FP and higher TP fractions. Thus,
ROC analysis provides a measure of disease detectablity that naturally
accounts for both disease prevalence and decision threshold
7140
effects"* .

Comparing imaging modalities

We can now resolve the diemmas that we faced in attempting to compare
the diagnostic image quality of imaging modaNtes.
The index that has emerged as the best of the single parameter indices is
the area below the ROC (the treated AZ)* 1 '" 7 ' 13 *'" 0 . This value varies
between 0.5 and 1.0.

si
For an \ of 1.0 the curve goes through the upper left-hand corner (0,1),
indicating perfect discrimination, while an A, of 0.5 indicates discrimination
at chance level128.
The A, value is found in practice by applying the maximum likelihood
ROCFIT program which is derived from the RSCORE program of Dorfmann
et al.31-32.

The next problem is to determine whether the A, values for two modalities
are significantly different. As a rule we used 5-7 observers for each of the
modalities to be compared.
A paired t-test was applied to the readers' scores to determine whether the
average ROC areas were significantly different.

Requirements for ROC curve test

From the preceding discussion we may conclude that ROC methodology is
an appropriate method for evaluating Imaging techniques. To perform a
valid ROC study, certain criteria have to be met.
- Firstly, there has to be a way of establishing the 'truth' (i.e. is a given case
normal or abnormal?)"'1*
- Secondly, the detection task should be representative of clinical practice
and should be of 'borderline' difficulty since radiographs which are either
too difficult or too easy provide little discrimination information07.
- Thirdly, the number of test radiographs and observers must be sufficiently
large to achieve acceptable statistical precision. About half of the
radiographs have to contain a solitary abnormality (not requiring
localization), the rest should be norm*4'140.
- Fourthly, various series should be randomized and cross- read in order to
reduce the effects of both foreknowledge and learning on diagnostic
accuracy"7.
An appropriate diagnostic task for the application of ROC methodology
appears to be the detection of Interstitial pattern disease (IPD), which is a
diffuse lung abnormality Cone signaTdetectton task)4.

52
3.3 A MODIFIED ROC METHOD: FROC

In certain cases (for example, nodule detection), the observers have to both
detect and locate abnormalities. Conventional ROC methodology cannot be
used in such cases24.
As an alternative to ROC methodology, the 'Free-response' ROC (FROC)
method was Introduced by Bunch et al. in 197818.
In the FROC method multiple nodules are present in an image, and
localization of these nodules to an accepted precision is required in order to
score the reading as a TP response.
Bunch et al.18 describe how a FROC curve may be plotted: the ordinate is
the joint probability for detection and localization and the abscissa is the
mean number of false positive responses per image. Unfortunately the wcrk
of Bunch does not extend to the statistical analysis of an actual FROC data
set. Chakraborty22-23 published a two-parameter mathematical model for the
statistical analysis of FROC data. The model is a generalization of the
binormal model that is used to analyze ROC data. In the paper a maximum
likelihood procedure is described for estimating the parameters of the FROC
model and for extracting an index of performance, A,23.
Chakraborty and Winter88 subsequently extended this to a more general
FROC experiment. The statistical analysis of FROC-data described in these
papers is used for the pulmonary nodule detection (PND) studies in this
thesis22-83-29.

3.4 CLINICAL IMAGES or PHANTOM IMAGES

A major problem of clinical trials is establishment of the truth. Invasive

procedures and additional radiation exposure are required to confirm the
diagnosis of a specific case41*130'193. Cases with raadly proven diagnoses
often are not subtle; as a consequence, the study may be too easy.

53
There are other problems inherent in the use of clinical images. The
radiologist tends to remember the cases, especially the interesting ones.
Also the selection of case samples tends to vary from place to place. For
example, there is no guarantee that the different results reported by Clinics
A and B for the same modality were not due to differences in the cases
selected.

Although clinical image studies are realistic, it can be concluded that

difficulties in the design of clinical studies have restricted their use as a
measure of diagnostic image quality.

The second method depends on phantom images of simulated

4124 251 1104 110 153
disease " "" ' " . Many of the problems encountered with clinical
cases can be circumvented by using a phantom (defined as inanimate
objects designed to demonstrate the characteristics of an X-ray imaging
system; they simulate the type of lesion that one is interested in and may
also simulate the structured background of the normal anatomy).

In phantom methodology there is no doubt of the 'truth'. Pathology can be

varied in degree and localization by the investigator4 and a sufficient number
of normal and subtly abnormal cases can easly be collected.

An important advantage of phantoms is that one does not have to worry

about reader memory. In fact the phantom is not specific and the reader
cannot memorize the nodule configuration. This allows one to use
phantoms to compare different modalities. Clinical cases require complex
and as yet unsatisfactory counterbalancing schemes with long waiting
periods between experiments so that the readers wW forget the images.

54
3.5 SUMMARY

Measurement of diagnostic image quality has become increasingly

important since the introduction of an increasing number of new diagnostic
tests. Several authors state that physical parameters do not correlate well
with the subjective impression of clinical diagnostic image quality.
To determine diagnostic image quality, ROC methodology applied to 'one
signal' detection experiments appears to be the most satisfactory approach.
Conventional ROC analysis will therefore be used in this thesis to analyze
the IPD studies.
The FROC method differs from conventional ROC because more than one
signal can be present on one film and the signal has to be localized. The
FROC methodology will be used in this thesis to analyse the PND studies.

56
 PART II

THE COST-DIAGNOSTIC BENEFIT ANALYSIS

PART II A THE DIAGNOSTIC BENEFITS

 CHAPTER 4

DESCRIPTION OF PHANTOM SIMULATION

Introduction
In this chapter the technical details of the imaging systems studied and
phantom simulation are described. A summary of all technical data is given
in table 6.

4.1 IMAGING SYSTEMS

The 'gold' standard: Conventional Full Size Radiography

For the 'gold' standard C-FS chest equipment was used. This consists of a
triphasic, multi-pulse generator (Siemens pdymat 50) with a Siemens
Biangulix tube, a nominal focal spot of 0.6 mm, a stationary 12:1 grid with
40 lines/cm, focused at 200 cm and 125 kVp. Filtration consisted of 2.5 mm
Al. A rapid speed rare earth screen (Agfa, MR 400), combined with Agfa
Curix wide latitude fHm was used.

LARGE FIELD OF VIEW IMAGE INTENSIFIED PHOTOSPOT TECHNIQUES

Two LFOV-II techniques for chest radiography were evaluated: the LEF-II
(Siemens TS 57) and S-ll (Philips Pulmodiagnost).
Both LFOV-II techniques yield 100 mm photospot films.

Large Entrance Field linage Intensifier (LEF-II)

The LEF-II tube is combined with a 100 mm magazine camera (Siemens,
Sircam 100 L). The diameter of the entrance field can be reduced from its
maximum format of 57 cm to 47 cm or 33 cm by means of an electron-
optical size switchover. The grid Is located at the 200 cm focal point, the
rdntgen tube has a nominal focal spot of 0.6 mm. Filtration consisted of 2.5
mm aluminum. The target-to-image (intensifier) distance is 200 cm, the
voltage 125 kVp.

60
MODALITY C-FS LEF-II S-II

TECHNICAL VARIABLES

Tube Biangulix Biangulix SRO 2550

Generator Polymat 50 Polymt 50 Medio 50 CP
kVp 125 125 125
Focal spot size 0.6 mi 0.6 M I 0.6 mm
Filtration 2.5 M I Al 2.5 M I Al 2.8 mm Al
Focus film distance 200 cm 200 en 120 cm
Entrance field 30x40 cm 40x40 an 40x40 cm
1
33x33 cm (I ) (2.4x40 cm,
24x24 cm (II1) PLI-II)
Screen type MR 400 (Agfa) no no
Film type Curix (Agfa) RP,S (Agfa) RP,S (Agfa)
Film format 35x35 cm 10x10 cm 10x10 cm
35x43 ca (100 Ml) (100 Ml)
Gradient film 2.40-2.50 2.40-2.50 2.40-2.50
Grid 12/40 12/40 no
Exposure control Iontomat M Iontomat N •

Exposure tine 3ns-10 sac 3ms-10sec 35 msec

Resolution on II < 5.2 Ip/m 4.5 Ip/Mi
(2% contrast)
Resolution on film 5.8 Ip/Mi < 5.2 Ip/Mi < 4.5 Ip/m
Processor Agfa Dayt.402 Agfa-sc. 12 Agfa scopix 12
Operation temp. 34.9' 32' 32'

Table 6: Summary of technical factors.

Slit Image Intenaifier (S-ll)
The S-ll is based on slit radiography principles. The Slit-shaped II covers a
40 x 40 cm entrance field by scanning vertically. The II input is 2.4 x 40 cm.
The source-to-image receptor distance is 120 cm.
This tube is coupled with a 100 mm photospotfilm camera.
A microprocessor-controlled 50 kW X-ray generator of the multipulse
converter type is used.
The X-ray generator is derived from the Philips Medio 50 CP with an
automatic exposure control. Total fitration (tube side) is equivalent to 2.8
mm aluminum.

Control of imaging conditions

To test observer evaluation of a large number of images, it is essential to
maintain a standard procedure of production and processing. It is especially
important that the type of film and the processing procedure remain
constant. In the present study Agfa Curtx film was used for the C-FS
radiographs and Agfa RP,S film for both LFOV-II techniques. All test films
for a modality were made during one day in order to keep processing
conditions constant.
For processing the fuH size radiographs, a daylight processor (AGFA 402)
was used with an operating temperature of 34.9* C. Standard operating
conditions and density control were checked regularly (I.e. QA/QC strips
were run) during the experiment For the LFOV-II radiographs we used a
100 mm daylight processor with an operating temperature of 32° C (Agfa
Scopix12).

4.2 PHANTOM CHARACTERISTICS

3M Chest phantom
A 3M anthropornorpnic chest phantom was used. Because it is a
commercial product, Mole Information is avsJabie about the detaled
construction of the phantom. The heart and mediastinum are constructed of
tissue-equivalent plastic.
A human skeleton and the lungs of a dog were used to simulate 'structured
noise'. The entire phantom is embedded in rubber for protective purposes.
The thickness of the phantom simulates that of a medium-sized adult
patient.

4.3 SIMULATION OF PULMONARY NODULAR DISEASE

Two techniques for simulating lung nodules in nodule detection studies have
been described in the literature130.
For the first technique, radiographs are obtained of simulated nodules
fastened onto the surface of or placed within the chest phantom27'47'130.
Various kinds of low contrast test objects can be used as nodules; plastic
beads, plexiglass disks, nylon spheres, paraffin nodules, etc.102-104'100'107'153.
With this approach the effects of scattered radiation and film sensitometric
characteristics, as they affect dinical chest films, are simulated. A
disadvantage is that It is difficult to vary the background of these pulmonary
abnormalities unless multiple phantoms are used136.

The second technique for simulating lung nodules is based on the

photographic superposition of simulated nodular shadows onto the chest
films of patients or phantoms (mask technique)*7'*1'*'12''13*.
Sorenson13* states that nodule simulation films obtained by the
photographic superpositioning technique are not reliable for PND studies
because in reality nodule contrast differs due to film sensitometric
characteristics and scattered radiation effects.
In view of these theoretical considerations we decided to use the first
technique. Because of the physical limitations of the 3M chest phantom, we
used external nodules; see figure 9.

63
 s s
Figure* A achamatic rapraaantatton of ttw 3M chaat phantom with timulatad pulmonary
nodulaa 0.7 cm diamaiar) auparimpoaad on H.

U 1 ' I ' I ' 1 'Hi

10: Photograph of aluminum moid for wax-atyrotoam mixtura to obtain
torihaaKparimant

64
In our study the nodules were prepared by pouring melted paraffin wax,
mixed with fragmented styrofoam, into an aluminum mold with holes of
different sizes (0.3 to 1.1 cm in diameter, figure 10). Wax mixed with
styrofoam nodules was chosen for our investigation because these nodules
simulate the clinicai pattern very closely24.

An example of a normal phantom film and one with nodules is shown in

figure 11 a.b. All nodules were round and of equal density.

Nodule size
The size of the nodules used was determined in a preliminary trial with 5
observers. As discussed in chapter 3.2 one of the requirements for a valid
ROC study is that detection must be moderately difficult, i.e. a detection
rate of approximately 50% is required24'140. In a plot series of 50 films we
altered the size of the nodules (10 films of 0.3 cm nodules, 10 films of 0.5
cm nodules, etc.) and discovered that the detection rate for nodules 0.7 cm
across was 40%. According to the literature*7"*13* these nodules are within
the range (0.5 to 1.0 cm) encountered in chest radiography.

In order to ascertain the location of the nodules, the outline of the phantom
lungs was drawn on a 40-cm square piece of perspex that was placed in
front of the phantom; a matrix was then made on the perspex with lead
markers at the corners.
The nodules were placed at random siss on the perspex, thus simulating a
realistic pattern indicative of pulmonary metatksis.

Teat series
Images of the phantom wltfi 50 dWerent nodule patterns were taken in the
PA projection with the different modaJMei.
For each image, 5-11 nodules (wNh a diameter of 0.7 cm) were
superimposed over the lungs and mediastinum. No nodules were placed
behind the heart For every nodule pattern the exact location of the nodules
Figure 11a: DrtaM of • nonmal phantom «m

M*0#* of a phantom Mm wNh a tknvtfA puknonaiy noduto. Th* noduto to

HMMaMM by an arrow.
was known because the position of the nodule in relation to the lead
markers was precisely determined.
All test films were judged to be of satisfactory diagnostic quality by one of
the radiologists.

Objective of the phantom model with pulmonary nodules

The imaging task discussed here is the detection of small tissue masses in
the lung, i.e. simulated metastasis.
The reasons for choosing lung nodules were:

1. Their presence is decisive for the prognosis for the patient

2. The artificial nodules closely simulate actual (clinical) nodules.
3. It was relatively easy to adjust the degree of detectablity of the simulated
nodules.
4. The detection task is of sufficient difficulty since pulmonary nodules are
tow-contrast objects and their detection is noise-Hmited. Furthermore,
nodules can be masked by normal thoracic anatomy.

We performed • PNO detection study using a 3M chest phantom.

The objectives of the phantom model study were two-fold:
A. To determine the diagnostic accuracy of 100 mm LFOV-II images (S-
II.LEF-M). This study fe oTecueied in chapter 5.
B. To determine the effect of rninelcatton on visual perception. This study is
discussed in chapters.

4.4 SIMULATION OF INTERSTITIAL PATTERN DISEASE

The 3M cheet phantom described in 42 we* used. Specialty prepared

plastic sheets described below, were pieced anterior to the phantom to
simulate diffuse MerattleJ pulmonary disease 0PD).
Each piettic sheet (36x43 cm x 1.5 mm thickness) contained approodmetely
350 radio-opaque objects (bird seeds), each 1-2 mm in diameter, distributed
homogeneously over the 337 cm3 bilateral lung field projection. The bird
seeds were held in place with adhesive.
By varying the number of plastic sheets superimposed on the chest
phantom, we could alter the extent of simulated pathology in a controlled
manner. A (schematic) representation of the IPD model is shown in figure
I2a,b.

S
12s.
Figure 12b: A photograph of tha phantom modal.

Aim of the phantom model with interstitial pattern disease

An enormous number of diseases can produce predominantly interstitial
involvement of the lungs. The chest radiograph is a very useful diagnostic
tool available to the radiologist. Confusion in the interpretation of diffuse
lung disease is not surprising since the patterns are numerous and
extremely varied42.
The detection of these subtle, predominantly diffuse, abnormalities is often
used as a criterion for the clinical adequacy of an imaging system4'*4.
The reasons for choosing simulated interstitial pattern disease are:
1. It is important for the initial diagnosis and subsequent follow-up of a
patient
2. Detection of the fins texture associated with interstitial pattern disease
tests the resolution characteristics of ths imaging system.
3. Interstitial pattern disease is tatty easly simulated.

eo
The objectives of this IPD phantom model were two-fold:
A. To compare the diagnostic accuracy of the detection of subtle interstitial
lung disease achieved by means of the modalities already described. This
study is presented in chapter 7.
B. To determine the role of radiological training in the detection of IPD
(chapter 8).

70
 CHAPTER 5

DIAGNOSTIC ACCURACY OF LFOV IMAGE INTENSIFIER CHEST

RONTGENOGRAMS

A Simulated Pulmonary Nodule Detection Study

Introduction
Two new LFOV-tl with a large imaging area which makes them suitable for
chest imaging have become available: LEF-triple mode II and S-ll (chapter
1.3 and 4.1).
The objective of this part of the study was to evaluate the diagnostic image
quality or accuracy of these two LFOV-II chest modalities with respect to
C-FS chest radiography for the detection of simulated nodules.
The reasons for choosing lung nodules were described in chapter 4.3.
This study is based on FROC methodology. This approach is an efficient
way to measure diagnostic accuracy since multiple lesions can be present
on each image and multiple detection responses are allowed for each
image. In addition, the location of each perceived nodule has to be
identified by the observer (chapter 3.3). An outline of this study is presented
in table 7.

MATERIALS AND METHODS

X-Ray parameters
The basic principles of the competing modalities were described in chapters
1.2 and 1.3. Technical data were presented in chapter 4.1.

Phantom films
A number of nodules (mixture of styrofoam and paraffin) were taped onto
the anthropomorphic 3M chest phantom described earlier (chapter 4.3).
Images of the phantom were obtained in the PA projection. For each image,
five to eleven nodules with a diameter of 0.7 cm were superimposed over
the lungs and mediastinum. No nodules were placed behind the heart.
In total 50 distinct and random nodule configurations, containing a total of
397 nodules, were identically imaged by means of each modality (C-FS, S-ll,
LEF-II with a 57-cm and a 47-cm entrance field). These 200 images made

72
 'GOLD' STANDARD (C-FS) LFOV II TECHNIQUES
X-ray tube

Object Phantom with Phantom with

Simulated Simulated
Nodules Nodules
Input X pattern

Image Generation Film - Screen LFOV- II

System
I

System Output Full Size 100 mm

Radiographic Image

Display System Viewing Box Viewing box

Display Image (masked)

Observer \
Search, Detection | Radiologists Radiologists
Interpret /

FINAL OUTPUT Diagnostic Diagnostic

DIAGNOSIS Accuracy Accuracy
(FROC) (FROC)

Tabte 7: Outiftw of tht study. Diagnostic Accuracy of LFOV-II Chsst radiographs using
simulatsd PND. The different Variablss' examined are printed in bold typt •<

73
 up the basic test set for this experiment. As described in chapter 4.3, the
actual locations of the nodules were known to us but not to the observers.
The large number of images and the random placement of the nodules were
needed to achieve good statistical results and minimize problems with the
inherent projection difference between the two II modalities (i.e. 2.0 m
source-to-image distance (SID) for C-FS and LEF-II, 1.20 m SID for S-ll)24.
The C-FS radiographs were 35x43 cm PA projections. The LFOV-II radio-
graphs were 100 mm PA projections.
More detailed technical data on the modalities were presented in chapter
4.1.

Prior to testing the diagnostic quality of the radiographs was judged

sufficient by a radiologist.
The 200 images were randomized and divided into sets of 10 images. Per
reading session 20 images were read.

Observers and film reading conditions

One group of 6 radiologists acted as observers in this study. The observers
knew that all images contained nodules but did not know the maximum
number on each image. They were instructed to view only one image at a
time in a darkened room with a low ambient light level. They were allowed
to vary the viewing distance for all images.
The same standard viewing box was used to read all films; for the 100 mm
films the viewing box was masked to minimize glare.

Before starting the study, each of the 6 observers read a protocol form
describing the experimental methodology (see appendix-1).
The observers were asked to detect and locate nodular lesions and indicate
the confidence level using a 4-point rating scale:

1 = nodule probably not present

2 - presence of nodule uncertain

74
 3 = nodule probably present
4 = nodule present

The category 'nodule not present' was not used, because all images
contained at least one nodule.
The observers indicated the location of and the confidence level for
perceived nodules on the film using a wax marker.
An indicated nodule location was considered to be a true positive (TP) if it
was within 1 cm of an actual nodule centre. The films were scored, cleaned
and reshuffled between readings. It was emphasized that test conditions
required the use of all categories of the rating scale.
The first viewing session was not scored but served to train the observers
by providing feedback10*.
The results of this reading were compared with the known nodule locations
and reviewed with the reader suggestions were made as to how the reader
might improve his or her accuracy.
No time restraints were placed on the observers, but reading time was
recorded.
Excluding the training Images, each observer read the basic image set
once.

Data analysis
The aim of the analysis was to extract an index of accuracy from the FROC
data for «ach observer and each modeJky and to estimate the statistical
significance of observed dMsrences between the modaJUas.

RESULTS

Dtaonoalic aocumcv
W^^^^^^B9 ^^^^^^^^^^r ^^^^^^^^^^V ^^^^F^B

The FROC data it tabuhisd In appendfcc-2. The total number of images and
nodules was 50 and 307, rwpadtoty, In each case. The data In thtat

76
tables were analyzed using the FROCFIT program22"23125. This produced
maximum likelihood estimates of A v the area under the Alternative Free
Response Receiver Operating Characteristic (AFROC) curve. This number
ranges from zero (chance accuracy) to 1 (perfect detection). A more
precise definition can be found in ref25; a physical interpretation is given in
ref23. Table 8 lists the A, score for each observer for each modality. The
table also presents the average score (for all readers) for each modality.

Reader C-FS LEF-II LEF-II S-ll

57cm 47cm

A 0.49 0.46 0.51 0.56

B 0.34 0.33 0.32 0.32
C 0.44 044 0.51 0.52
D 0.56 0.51 0.52 0.55
E 0.36 0.49 0.55 0.61
F 0.55 0.54 0.52 0.45

Average 0.46 0.46 0.40 0.50

(SD) (008) (006) (008) (010)

V H U M (MOJGK of sooufscy) for th# I W S M V for 1h# diHorant

A paired t-test w u applied to see If the numbers feted in this table differ
significantly. Tht results in Men cat* were expressed as a p-vafue.
A small p-vaJue implies a greater significance for observer difference*. By
convention, values of p below 0.05 are considered to be indicative of a
significant oUsnnoe between modaJfclti. In this study aN of tht p values for
tht differences between modaJUes fisted in the above table exceeded 0.2
and therefore none of tht differences was significant.
Reading time
Although reading time was not restricted, the time required to interpret the
series of test films was recorded (table 9).
The average reading time per film varied for the various modalities.
A paired t-test was used to analyze these reading times, whereby p > 0.08
indicated that the differences were not significant.

Reader C-FS LEF-II LEF-II S-ll

57cm 47cm

A 2.0 2.1 2.1 2.3

B 2.5 2.5 2.3 2.3
C 2.4 2.1 2.1 2.3
D 1.8 1.8 1.8 1.8
E 2.1 1.5 1.5 1.5
F 2.3 2.2 2.0 2.0

mean (mln) 2.2 2.0 2.0 2.0

(SO) (03) (0.3) (0.3) (03)

Tafctofc /W*ra<M>r—dino Mm* in trtnut* • matted to iMMDN

Diecueeton
It should be clear that lesion detection w i depend to a large extent on the
imaging system used (table 7 ) * .
Although our results demonstrate no eignMcance. It is interesting that the S-
II system produced a sNghtty higher accuracy- TNs Is party attributable to
lower scatter of the S-U images, as demonstrated by other
2 0
authors"***" -" '", ft Is also attributable to the fact that S-ll images are
produced by more X-ray photons than those of other modeJWet because

77
the latter uses a conventional grid whereas the S-ll essentially has an ideal
grid (slit). To illustrate this, we can use the measured exit doses (chapter 9)
to estimate the doses to the image receptor. From chapter 9 we measured
17.4 uGy for the LEF-II and 20.9 for the S-ll. Because the Bucky factor of a
typical grid is 2.7, the dose at the screen of the LEF-II is about 6.4 uGy, and
that for the S-ll is stW 20.9 uGy. Hence, we expect the image of the LEF-II to
be more noisy. These observations are consistent with the slightly lower
detectabNity of the nodules in our study found for the LEF-II technique.

Conclusion
This study presents the results of an observer performance experiment in
which FROC analysis was used to assess the detection of nodules
superimposed on the lungs of a 3M anthropomorphic chest phantom on
images acquired by means of two LFOV-II techniques and the C-FS
modality for chest radiography.
There was no significant difference in diagnostic accuracy for this particular
detection task.
As far as reading time is conoamsd. no significant differences were
observsd batwaan tha modaHtisr

71
 CHAPTERS

THE EFFECT OF MINIHCATION ON DIAGNOSTIC PERFORMANCE

A Simulated Pulmonary Nodute Datactkm Study

Introduction
The problem of optimum image display size is of great interest from the
point of view of both diagnostic accuracy and film consumption. In this
chapter we wiH consider the problem of the display size of the image. The
sizes of the displays differ: full size (30x40 cm) versus mini-size (100 mm or
10x10cm).
Tuddenham144 states that objects can arbitrarily be divided into two groups;
the first group consists of high contrast signals, for example bone trabecular
details. The detection of these signals is limited by the resolving power of
the eye, whle detection of the other group of signals, low contrast signals
such as pulmonary nodules and pleural plaques, is limited by the contrast
sensitivity of the eye. It has been suggested by Tuddenham mat low
contrast signals benefit from minMcation whle high contrast signals benefit
from magnification. The same can be expected for reading lenses and
viewing distance, because a minifying lens or increased reading distance
improves the detectabUy of low contrast signals whle a magnifying lens or
decreased reading distance Improves the detectablity of high contrast
signals. Objective evidence of this statement is derived from the results of
1625 observations143 of the effect of lensas on the frequency with which
readers perceived simulated nodules. In comparison to the unaided eye,
32.4% fewer lesions were dstactsd win a magnifying lens whle 45.4% more
lesions ware dtttctsd wfth a minifying ians.

Stark1*7 advocates tht us* of a minifying tans because k prompts a more

complete search of a l areas of the Urn. Stark1"7 and Tuddanham14* state
that the minifying lens also aids in perception of large shadows because a
complete contour is easier to perceive than a fragment of a shadow in a
single fixation.

Lenr at e l " nevertheieee obtained dMerant reeufts In a clinical study of the

effect of flm minMlcation on diagnostic accuracy. In contrast to the
experimental studies carried out by Tuddenham and the theoretical

so
considerations of Stark, a small negative effect on diagnostic accuracy was
found for minified films which possibly can be explained by the loss in
image quality of the film viewer system used in this study. Manninen93
performed a clinical study in which the diagnostic image quality of a LEF-II
tube was determined.
He states, without being supported by experimental results, that the visibility
of structures with W defined margins is significantly improved by minification.
In this chapter, the influence of minification on diagnostic accuracy was
assessed.
An outline of the study is presented in table 10.

MATERIALS AND METHODS

X-Ray
The basic principles of the C-FS Mm screen modality were described in
chapter 1.2. Technical detaJs were presented in chapter 4.1.

Phantom Mma
The effect of minification on the diagnostic accuracy of simulated PND
detection was investigated by means of FROC methodology.
A3M chest phantom was used wih superimposed wax nodules to simulate
PND. In total there were 50 conventional ful size (30x40 cm) PA
radiographs of 5-11 nodules positioned at random within the lung fields. No
nodules were placed behind the heart at mediastinum (to determine
whether there Is a dPsrsnce In detectabtty between central and peripheral
nodules, observer performance for nodules within 2 cm of the margin of the
peripheral long flakl was eve* talari separately). A more extensive description
of the nodules, the phantom mode) and the C-FS phantom radiographs was
given in chapter 4.3.
 'GOLD' STANDARD (C-FS)

X-ray tube
I
Object Phantom with
I Simulated
I Nodules
Input X pattern
I
Image Generation Full Size
System Flm-Screen

I
System Output FuHSfce
RadJographfc Image / \
COPIER COPIER
1 1
RILL SIZE MINIFIED
I copies copies
Display System viewing box viewing box
Display Image (masked)
I
Observer \
Search. Deletion | Radiologists Radiologists
Interpret /
I
FINAL OUTPUT Diagnostic Diagnostic
DIAGNOSIS Accuracy Accuracy
(FROO (FROQ

TaftfoiS: OutfMOftwtfejdy.
utino timuHMd nodulM. Th» Mriatet to to «c*i*Md an prfnlad In bold
Minification procedure
Two reproductions were made of each original full-size test film. An 100 mm
minified reproduction of each film was obtained with a high quality optical
minrfier (Delcomat, OMerft).
The second reproduction measured the same as the full-size original (30x40
cm); for this purpose a standard fMm copier (AGFA) was used.

Observers and film reading conditions

The entire set of images was viewed in randomized order by 6 radiologists.
Each of the observers received a protocol describing the experimental
methodology and reading procedure (appendix-1). Each observer marked
the location of perceived lesions with a wax pencl and indicated the
confidence level using a 4-point rating scale. Reading time was recorded for
each series of radiographs but no time limit was set

Data analysis
Two aspects of performance were determined: firstly, a FROC index was
generated for the full-size copy and the minified copy in order to compare
diagnostic accuracy. Secondly, performance was determined for peripheral
nodules on both the full-size and minified copies.

RESULTS

Diagnostic accuracy
The raw data are Hated in appcndk-3. From these data, the parameters of
FROC methodology (A,) can be derived, as described previously. For
example, the results obtained for reader AA (fcJ-sfee copy) are plotted in
graph 1. The A, values an* Nstsd In table 11.
The difference in diagnostic accuracy for si nodules betwasn the fuN-sizs
and minWad copies was estimated using a paired t4est The dffsrsnces in
area yielded no slgnMcanct at the 5% lava) <p« 0.26).

63
 AHnodulM: Peripheral Peripheral All nodules:
fug-size nodules: full- nodules: minified minified
coplei size coplet coplei coplst

R—dsr
AA 0.43 0.40 0.42 0.42
BB 0.37 0.38 0.36 0.40
CC 0.34 0.34 0.36 0.40
DD 0.41 0.40 0.45 0.47
EE 0.45 0.45 0.50 0.52
FF 0.47 0.42 0.54 0.49

AVERAGE 0.41 0.40 0.44 0.45

(SO) (0.04) (0.03) (0.07) (0.05)

Table 11: A, values for fuM aiz* and nWnified oopiet par reader for 'all nodules' and
'peripheral' nodule*. Readers AA-FF are listed.

10 TPF

08

06-

04-

02-

FPF

0 02 04 0.6 0.8 10
Mean number of false positives per image

drapf* 1: A raprwnUMw FR0C curve (reader AA,&FS). The vertoeJ axis repreesms Ihe
fraction of nodutea oomoMy looaejd, « M horizontal axis the mean number of FP
nodules per Imaae.

84
If we only consider the peripheral nodules, only a slight difference in the
average A1-values was found (0.40 and 0.45, respectively). A paired t-test
yielded p= 0.35, indicating that the difference was not significant.

Reading time
A large interobserver variation exists in reading time.
For example, reader EE took an average of 2.9 minutes to read a full size
copy while reader CC needed 6.0 minutes (table 12). A paired t-test yielded
p= 0.14, indicating that the differences were not significant.

R*-Ste CopiM M W M Copto*

AA 4.2 4.0
BB 4.0 2.6
CC 6.0 4.6
OD 4.3 3.4
EE 2.9 2.9
FF 3.9 4.4

4.2 3.6
(80) (1.0) (0.7)

Tabta 12: AraraQ* Km* in mfcwHw naadad to fntarprrtt a fuN^te* and minMad oopy par

Discussion
Hernmingson9' states that the smtfett vWbto photographic density
difference is a function of viewing distance and characteristics of the
object's bolder and adjacent structures. This implies, and others have
reported14*137, that viewing distance and flm size influence observer
performance.
Inconsistent findings for the effects of minification on the frequency with
which readers perceive simulated metastatic nodules have been
84 143 144
published ' - .
Analysis of eye movements during the search for faint lung nodules (1 cm
diameter) has revealed that 15 percent of all misses can be attributed to
incomplete scanning of the image by the central vision, about 30 percent
are failures of recognition and the remaining 55 percent are decision
errors73. The positive effects of minification on accuracy can be explained
by perceptual factors. In minification a complete contour is seen in a single
fixation and thus the problem of visual search is simplified143.
Nevertheless, our results demonstrate that the diagnostic accuracy for
minified images and full-size copies is about the same.
A limitation of the actual study is the use of full-size copies instead of the
original X-ray films. It is likely that image quality is decreased in going from
the original (chapter 5) to a copy (this chapter). Since the readers were
different, we had to use an unpaired t-test to compare the results obtained
for the two sets of full-size film. No significant difference was observed
(p= 0.71). Thus, wnle the conclusions could have been more definitive,
they at least appear to be consistent Note that the results for minified
copies were slightly superior to the results for full-size copies. Improving the
performance for the full-size copies could decrease the difference in
performance.

Conclusion
The effect of minification on the diagnostic accuracy for simulated PND was
investigated using FROC methodology. The phantom images were
displayed on full-size copies (30x40 cm) and minified copies (100 mm).
Statistical analysis of the FROC data faled to reveal a significant difference
in diagnostic accuracy between the two display sizes (5% level). Reading
time for viewing the test series was noted. No significance was found at the
5% level.
 CHAPTER 7

DIAGNOSTIC ACCURACY OF LFOV-II CHEST RONTGENOGRAMS

A Simulated Interstitial Pattern Disease Study

Introduction
In the previous two chapters we studied the detectability of nodular
abnormalities. Nodules are low-contrast localized structures and their
detection is influenced by the noise level of the image as well as the
observer's search efficiency80'103'1*1. It is natural to ask what happens when
the detection task is different.
The ability of an imaging system to resolve extremely small pathological
structures is used as a criterion for clinical adequacy4'94.
We choose to study interstitial pattern disease which is characterized by a
diffuse high spatial frequency abnormality.
The search efficiency is not a factor because the image can be viewed at a
glance.
The objective of this study was to compare the diagnostic accuracy of the
detection of subtle interstitial lung disease for the modalities under
consideration. An outline of the study is presented in table 13.

MATERIALS AND METHODS

X-Ray parameters
Basic principles of and technical data on the competing modalities were
described in chapters 1.2,1.3 and 4.1, respectively.

The Simulation of Diffuse Interstitial Pattern Disease

A chest phantom (3M Corp.) consisting of a human skeleton and the
inflated lungs of a dog was used. Diffuse IPD was simulated in bilateral lung
fields by superimposing specially prepared sheet(s) of plastic (35x43 cm,
1.5 mm thickness) on the chest phantom prior to radiological imaging.
Approximately 350 radio-opaque objects, 1-2 mm in diameter, were
homogeneously distributed, over the 337 cm2 lung field surface projection on
each plastic sheet and fixed In place.
 'GOLD' STANDARD (C-FS) LFOV-II TECHNIQUES
X-ray tube
I

Object Phantom with Phantom with

Simulated Simulated
IPD IPO
Input X pattern
1
1
Image Generation Film - Screen LFOV- II
System
1
1
System Output FuHStae 100 mm
Radtographic Image
1
1
Display System Viewing Box Viewing box
Display Image (masked)
1
1
Observer \
Search Detection | Radiologists Radiologists
Interpret /
1
1
FINAL OUTPUT Diagnostic Diagnostic
DIAGNOSIS Accuracy Accuracy
(BOC) (ROC)

TaM* 13: OuttVw of flM Aoouraoy of LF0V4 O w n r»dtograph< of

•imutatod IPO. TIM wtout to be «KMiinKf w» pffniad in bo4d«yp» «td «md««Md.
By varying the number of plastic sheets superimposed on the chest
phantom, we could alter the degree of simulated pathology in a graded and
controlled manner.
Per modality all films were produced during one day, using the daylight
processors described in Table 6. Detailed information on the phantom
model was given in chapter 4.

Film data
Ninety-six C-FS posterior-anterior (PA) chest radiographs were taken of the
chest phantom alone or with one to six plastic sheets. Table 14 gives the
distribution of normal and abnormal films. For the C-FS films, exposures
were taken with a Siemens biangulix tube with a nominal focal spot of 0.6
mm at i25kVp. The focus-to-film distance was 2 meters. Fast intensifying
screens (MR 400) were used with Agfa Curix film.
The 100 mm S-ll test images were made at 125 kVp. RP,S films were used.
The focus-to-film distance was 1.20 m. The 100 mm triple mode LEF-II
images were obtained at 125 kVp; a standard (12/40) grid and Agfa RP,S
films were used.
In this study only two modes were employed (57-cm and 47-cm). The third
mode (33-cm) is meant for children and therefore was not considered.

normal abnormal

0 sheets 48 0
1 sheet - 8
2 sheets - 8
3 sheets - 8
4 sheets - 8
5 sheets - 8
6 sheets 8

Tabto 14: Distribution of normal and abnormal films.

90
Viewing procedure
Seven experienced radiologists acted as independent observers in this
investigation. The observers were asked to comment upon the presence of
IPD on all C-FS, 100 mm LEF-II and S-ll images. The level of confidence for
the presence of interstitial disease was ranked on a 5-point rating scale:
1. disease not present
2. disease probably not present
3. presence uncertain
4. disease probably present
5. disease present.

The observers were encouraged to make full use of the entire rating sca'e.
The 96 fiims per modality wore randomized and divided into four sets of 24
test films each. Each film was numerically coded without correlation with
presence of simulated pathology. The sets of the different modalities were
alternated. For example, a particular reader evaluated 24 C-FS images first,
then 24 LEF-II images, etc.
Prior to the main experiment, each observer underwent a short training
session to become familiar with the chest phantom and the range of test
pathology. Immediate feedback was provided for both conventional and
100 mm images.
Each observer received a set of written instructions which explained the
method of viewing (appendix-4). The images were to be interpreted in a
quiet room with low ambient lighting.
The films were presented on a common viewing box. During viewing of the
images, the reading distance could be varied. The readers indicated their
rating on a sheet.
Images were studied one at a time and observers were not allowed to refer
to previous or subsequent images.
The observation time per image was not limited in this experiment but the
time requ'red to Interpret the sets of test films was recorded.

91
Data analysis
The primary objective of data analysis was to extract an index of
performance (AJ for the C-FS, 100 mm LEF-II and S-ll images. The ROCFIT
program 8898 was used to analyze the data and ROC curves were generated
for each observer on the basis of their certainty ratings.

RESULTS

Diagnostic accuracy
The raw data and scores are listed in appendix-5.
In table 15, the average A,, for all seven observers is listed per modality-
Graph 2 demonstrates ROC curves for the various modalities.

(SD)

C-FS 0.87 (0.10)

LEF-II, 57 cm mode 0.78 (0.06)
LEF-II, 47 cm mode 0.89 (0.06)
S-ll 0.75 (0.10)

Table 15: Diagnostic accuracy, expressed In A^ values for various modalities using
simulated IPD.

The relative ranking in terms of decreasing \ value is LEF-II 47-cm mod.*,

C-FS. LEF-II 57-cm mode and S-ll technique.
A paired t-test was performed. A p-vaiue of less than 0.05 means the
difference is significant at the 5% level.
A significant difference exists between LEF-II, 57-cm and 47-cm modes.
Furthermore a significant difference exists between the C-FS and S-ll (table
16).

92
i.u • i rr

•'f:i
0.8-
/

' * s s

0.6 -
i
/
i
p/
i / a Conv. Full Size
; // /
0.4- LEF-I 57 cm
/
d LEF-I 47 cm
o
/
z /
i i
A Slit II
0.2-
\ i
i

FPF
0 - 1 i i 1 i

0 0.2 0.4 0.6 0.8 1.0

Graph 2: ROC curves tot the various modalities. The vertical axis represents TPF, the
horizontal axis FPF 108 .

Significant p-values

LEF-II, 57-cm S-ll

C-FS 0.0140
LEF-ll,47-cm 0.0009 0.0017

Tsblo 16: Significant p-values

93
Rsading time
Although reading time was not restricted, the time required to interpret the
series of test films was noted (Table 17).
A large interobserver variation exists, especially for the C-FS radiographs
(12.6 versus 28.2 seconds).
The mean time needed to read the OFS films was highest (18 seconds)
while reading the S-ll films only took 14.4 seconds.

C-FS LEF-II.57 cm UEF-ll,47cm S-ll

Reader AAA 16.2 12.0 11.4 9.6

Reader BBB 16.2 15.0 15.0 15.0
Reader CCC 12.6 13.2 12.0 12.0
Reader DDD 12.6 14.4 10.8 12.0
Reader EEE 12.6 14.4 13.2 14.4
Reader FFF 24.6 21.6 21.6 21.6
Reader GGG 28.2 15.6 19.8 16.8

Mean 18.0 15.0 15.0 14.4

(SD) (4.2) (3.0) (3.7) (3.8)

T«b(« 17: Mean reading time in seconds per film.

These data were compared by means of a paired t-test; since p > 0.08
there were no significant differences.

Discussion
A disadvantage of PND studies is that it is time-consuming. While the
average reading time for an observer performance experiment using
simulated nodules is approximately 3 hours and 30 minutes, an experiment
involving simulated interstitial pattern disease can be completed in about 25

94
minutes. If one takes into account the number of signals that the readers
attempted to detect (48 in the IPD study versus approximately 400 in the
PND study), the viewing time was comparable for the two studies
The scoring of image data in the nodule detection study is also time-
consuming because all nodule locations have to be checked, while data
collection for a simulated IPD study is very easy.
Since phantom studies can ba repeated with high accuracy, this method
provides a means of comparing the effectiveness of various image
processing techniques. It is hoped that this phantom model of simulated
interstitial pattern disease will become the standard test procedure for
evaluating techniques4'153.
The relative ranking in terms of decreasing A^ values was LEF-II: 47-cm
mode, C-FS, LEF-II: 57-cm mode, and S-ll.
In chapter J it was noted that the performance of the S-ll could be
explained by the number of photons (slightly higher) and detected scatter
(slightly lower). The net result was that the S-ll was slightly superior (but not
sigr ificantly). The result of the IPD study (S-ll significantly inferior) can be
explained by the lower spatial resolution of this modality. We speculate that
the proximity focusing of the II of this device is not as optimal as the
focusing of the rr^re conventional LEF-II.

Conclusion
In this chapter the results are presented of a comparative study in which the
diagnostic accuracy of C-FS and two LFOV- II techniques was determined,
using a phantom model of simulated IPD. Tht rei iive ranking in terms of
decreasing A, values was: LEF-II: 47-cm mode, C-FS, LEF-II: 57-cm mode
and S-ll.
The results of the latter modality differ from those of the diagnostic accuracy
study of simulated pulmonary nodules (chapter 5). A possible explanation
for the difference in performance is given.
 CHAPTER 8

INFLUENCE OF RADIOLOGICAL TRAINING ON DIAGNOSTIC

PERFORMANCE

A Phantom Study
Introduction
Studies of film reader accuracy conducted over the last 20 years have
consistently shown high reader variability. Error rates are alarmingly high;
FN rates of 20-30%, interobserver variations of 10-20% and intraobserver
variations of 5-10% have been found for chest film reading16'56115.
The data indicate that the radiologist fails to use a lot of the information
routinely recorded on radiographs16173'77'13714211'13.
The detection of a pulmonary nodule, or any other faint abnormality with a
complex background, depends on the successful operation of at least three
components of perception: scanning, pattern recognition and decision-
making. On the basis of these components, KundeJ73i7S divided FN errors
into three classes: scanning errors (15%), recognition errors (30%) and
decision-making errors (55%).
For years there has been considerable interest in factors that affect the
detection and diagnosis of chest lesions.
Some of the variables that influence accuracy, such as clinical history and
eye movement?, have been studied11l12ill79'B31Z9'147.
Only a few studies have focussed on the influence of experience and
radiological training on diagnostic accuracy.

For such studies the detection tasks can be divided into unfamiliar
structured noise71115, clinical cases5378 and phantoms of simulated
47 67
pulmonary nodular disease ' .
In all three types of study significant individual differences in diagnostic
accuracy were found. It is suggested that talent is more important than
training in detection tasks74'115.

More experienced observers appear to use their low resolving peripheral

vision more effectively than the inexperienced7176. One of the most
consistent differences between experienced and inexperienced observers is
the number of foveaJ fixations required to centre the lesion: the more

98
experienced the viewer, the fewer fixations are required to read a chest
film16'72.
According to Rackow et al.115 no significant advantage can be attributed to
radiological training for the detection of low contrast signals in an unfamiliar
structured noise background. Herman et al.56 performed a study in which
100 clinical chest rontgenograms were read by 8 radiologists at 4 different
levels of training and experience. There was no consistent pattern with
respect to the duration of training beyond the first year of residency. These
findings are in agreement with those of Sheft et al.131 and Berbaum et al.13
who reported little difference in the interpretation of chest radiographs
between senior residents and staff radiologists.

Kelsey et al.87 state that the diagnostic accuracy found for simulated
pulmonary nodules was about the same for radiologists, residents and
technicians. However, in their study the nodules were produced by the
mask technique, which is not realistic for reasons already discussed136.
Furthermore, in their study, the sample size was too small for statistically
valid conclusions.
The experiment described in this chapter was designed to evaluate the
influence of radiological training on the ability to detect simulated IPD
against a structured noise background. We used the chest phantom model
described earlier with simulated diffuse IPD for our comparative study.
An outline of the study is presented in table 18.

MATERIALS AND METHODS

Phantom model
The set-up of this study differs from the experiment described in chapter 7.
The same 3M anthropomorphic chest phantom is used. Instead of 96 test
films, 68 test radiographs of the phantom model were taken.

99
 'GOLD' STANDARD (C-FS)

X-ray tube

Object Phantom with

Simulated IPD

Input X pattern

Image Generation Film-Screen

System

System Output Full Size

Radiographfc Image

Display System Viewing Box

Display Image

Observer \
Search Detection | Radiologists Medical Students
Interpretation /

FINAL OUTPUT Diagnostic Diagnostic

DIAGNOSIS Accuracy Accuracy
(ROC) (ROC)

Tabto Outftne erf tho study, tnflusneo of radiological training on the detection of
simulated IPD. The variables ars underlined and printed in boldtyps.

100
Twenty-eight were normal and forty were radiographs showing varying
degrees of abnormality.
IPD was simulated over the lung fields by superimposing specially prepared
sheet(s) of plastic (35x43cm, 1.5mm thickness) on the chest phantom prior
to radiologic imaging. Instead of 350 small-sized (1-2 mm in diameter) radio-
opaque objects, 700 small objects were homogeneously distributed over the
337 cm z lung field surface on each plastic sheet.
By varying the number of plastic sheets superimposed on the chest
phantom, we could alter the degree of simulated pathology in a graded and
controlled manner.

Experiments! films
Sixty-eight conventional posterior-anterior (PA) chest radiographs were
taken with a Siemens Biangulix tube with a nominal focal spot of 0.6 mm at
125 kVp. The focus-to-film distance was 2 meters. Fast intensifying screens
(Agfa MR 400) were used wrth Agfa Curix film. The 28 normal radiographs
were taken of the chest phantom alone. The 40 abnormal radiographs were
taken of the chest phantom with one to five plastic sheets.

Observers and film reading conditions

Of the 10 observers who participated, 5 were board certified radiologists
and 5 were senior medical students. The average age of the radiologists
was 33 years; they all had recently finished their residencies. The average
age of the medical students was 26 years; they all were about to finish
medical school.
The 68 cases were divided into 4 sets of 17 films arranged in random
sequence. The observers studied each image separately and were
instructed not to refer to prior or subsequent radiographs.
The films were viewed on a standard viewing box under low ambient lighting
conditions in a quiet room. The viewing distance was not constant. Each
observer was asked to assess the presence of simulated IPD on each image
with the level of confidence given by a 5-polnt rating scale:

101
1. disease not present
2. disease probably not present
3. disease unsure
4. disease probably present
5. disease present.

It was emphasized that the ROC analysis required full use of the rating
scale. No time restraints were placed on the observers as they read the
individual studies but the reading time was recorded for every session.

Training of observers
The first viewing session was not scored but was used to train the
observers by providing feedback information; after viewing each image, the
observers were told the 'truth1 (normal or abnormal) so that they could
assess the visibility levels of the disease and adjust their ratings. The
radiologists and medical students received the same training. Not counting
the training images, each observer read the image set once.

Data analysis
Data were analysed by using the ROCFIT program9868. ROC curves for each
observer were estimated from the rating data by means of a maximum
likelihood algorithm.

RESULTS

Diagnostic accuracy
The raw data and scores are listed In appendbc-6.
A representative ROC curve (reader 1, untrained) is shown in graph 3.
TaWe 19 lists the ROC parameters (AJ for both groups of observers. The
individual readers, both medical students and radiologists, exWibit a large
interobserver variability.

102
 CHAPTER 8

INFLUENCE OF RADIOLOGICAL TRAINING ON DIAGNOSTIC

PERFORMANCE

A Phantom Study
Introduction
Studies of film reader accuracy conducted over the last 20 years have
consistently shown high reader variability. Error rates are alarmingly high;
FN rates of 20-30%, interobserver variations of 10-20% and intraobserver
variations of 5-10% have been found for chest film reading1856115.
The data indicate that the radiologist fails to use a lot of the information
routinely recorded on radiographs16'73l77l137>1421143.
The detection of a pulmonary nodule, or any other faint abnormality with a
complex background, depends on the successful operation of at least three
components of perception: scanning, pattern recognition and decision-
making. On the basis of these components, Kundel73'78 divided FN errors
into three classes: scanning errors (15%), recognition errors (30%) and
decision-making errors (55%).
For years there has been considerable interest in factors that affect the
detection and diagnosis of chest lesions.
Some of the variables that influence accuracy, such as clinical history and
eye movements, have been studied1 W f l
* T
Only a few studies have focussed on the influence of experience and
radiological training on diagnostic accuracy.

For such studies the detection tasks can be divided into unfamiliar
structured noise71 "11S, clinical cases5878 and phantoms of simulated
pulmonary nodular disease47'67.
In all three types of study significant individual differences in diagnostic
accuracy were found. It is suggested that talent is more important than
training in detection tasks7411S.

More experienced observers appear to use their low resolving peripheral

vision more effectively than the Inexperienced7176. One of the most
consistent differences between experienced and inexperienced observers is
the number of foveal fixations required to centre the lesion: the more

98
experienced the viewer, the fewer fixations are required to read a chest
film18'72.
According to Rackow et al.11fi no significant advantage can be attributed to
radiological training for the detection of low contrast signals in an unfamiliar
structured noise background. Herman et al.56 performed a study in which
100 clinical chest rdntgenograms were read by 8 radiologists at 4 different
levels of training and experience. There was no consistent pattern with
respect to the duration of training beyond the first year of residency. These
findings are in agreement with those of Sheft et al.131 and Berbaum et al.13
who reported little difference in the interpretation of chest radiographs
between senior residents and staff radiologists.

Kelsey et al.67 state that the diagnostic accuracy found for simulated
pulmonary nodules was about the same for radiologists, residents and
technicians. However, in their study the nodules were produced by the
mask technique, which is not realistic for reasons already discussed136.
Furthermore, in their study, the sample size was too small for statistically
valid conclusions.
The experiment described in this chapter was designed to evaluate the
influence of radiological training on the ability to detect simulated IPD
against a structured noise background. We used the chest phantom model
described earlier with simulated diffuse IPD for our comparative study.
An outline of the study is presented in table 18.

MATERIALS AND METHODS

Phantom model
The set-up of this study differs from the experiment described in chapter 7.
The same 3M anthropomorphic chest phantom is used. Instead of 96 test
films, 68 test radiographs of the phantom model were taken.

99
 'GOLD' STANDARD (C-FS)

X-ray tube

Object Phantom with

Simulated IPD

Input X pattern
1
1
Image Generation Film-Screen
System
1
1
System Output Full Size
Radiographic Image
1
1
Display System Viewing Box
Display Image
1
1
Observer \
Search Detection | Radiologists Medical Students
Interpretation /
i
1
FINAL OUTPUT Diagnostic Diagnostic
DIAGNOSIS Accuracy Accuracy
(ROC) (ROC)

Table IB: Outline of the study. Influence of radiological training on the detection of
simulated IPD. The variables are underlined and printed in boidtype.

100
Twenty-eight were normal and forty were radiographs showing varying
degrees of abnormality.
IPD was simulated over the lung fields by superimposing specially prepared
sheet(s) of plastic (35x43cm, 1.5mm thickness) on the chest phantom prior
to radiologic imaging. Instead of 350 small-sized (1-2 mm in diameter) radio-
opaque objects, 700 small objects were homogeneously distributed over the
337 cm 2 lung field surface on each plastic sheet.
By varying the number of plastic sheets superimposed on the chest
phantom, we could alter the degree of simulated pathology in a graded and
controlled manner.

Experimental films
Sixty-eight conventional posterior-anterior (PA) chest radiographs were
token with a Siemens Biangulix tube with a nominal focal spot of 0.6 mm at
125 kVp. The focus-to-film distance was 2 meters. Fast intensifying screens
(Agfa MR 400) were used with Agfa Curix film. The 28 normal radiographs
were taken of the chest phantom alone. The 40 abnormal radiographs were
taken of the chest phantom with one to five plastic sheets.

Observers and film reading conditions

Jf the 10 observers who participated, 5 were board certified radiologists
and 5 were senior medical students. The average age of the radiologists
was 33 years; they all had recently finished their residencies. The average
age of the medical students was 26 years; they all were about to finish
medical school.
The 68 cases were divided into 4 sets of 17 films arranged in random
sequence. The observers studied each image separately and were
instructed not to refer to prior or subsequent radiographs.
The films were viewed on a standard viewing box under low ambient lighting
conditions in a quiet room. The viewing distance was not constant. Each
observer was asked to assess the presence of simulated IPD on each image
with the level of confidence given by a 5-point rating scale:

101
1. disease not present
2. disease probably not present
3. disease unsure
4. disease probably present
5. disease present.

It was emphasized that the ROC analysis required full use of the rating
scale. No time restraints were placed on the observers as they read the
individual studies b'jt the reading time was recorded for every session.

Training of observers
The first viewing session was not scored but was used to train the
observers by providing feedback information; after viewing each image, the
observers were told the 'truth' (normal or abnormal) so that they could
assess the visibility levels of the disease and adjust their ratings. The
radiologists and medical students received the same training. Not counting
the training images, each observer read the image set once.

Data analysis
Data were analysed by using the ROCFIT program9898. ROC curves for each
observer were estimated from the rating data by means of a maximum
likelihood algorithm.

RESULTS

Diagnostic accuracy
The raw data and scores are listed in appendix-6.
A representative ROC curve (reader 1, untrained) is shown in graph 3.
Table 19 lists the ROC parameters (AJ for both groups of observers. The
individual readers, both medical students and radiologists, exhibit a large
interobserver variability.

102
A t-test (unpaired) yielded p= 0.17, demonstrating that no significant
difference existed between the two observer groups at the 5% level.

1.0 n TPF

0.8-

I
I
0.6- I
I
I
I
I

0.4-

0.2-

FPF

0 0.2 0.4 0.6 0.8 1.0

Graph 3: A representative ROC curve (reader 1, untrained). The vertical axis represents
TPF, the horizontal axis FPF.

Reading time
Each observer noted the reading time needed to interpret the 68 phantom
films (Table 20). The mean reading time for the unexperienced readers was
approximately 25% longer than the reading time for the radiologists
(students 32.4 seconds, radiologists 24.0 seconds).

103
 medical students radiolog

1 0.89 0.90
2 0.98 0.98
3 0.99 0.86
4 0.94 C.bo
5 0.99 0.93
Average 0.96 0.91
(SD) (0.04) (0.05)

Table 19: Diagnostic accuracy for medical students and radiologists expressed as Az.

medical students radiolog

1 29.4 22.8
2 35.4 16.8
3 41.4 22.8
4 22.8 32.4
5 33.6 24.6

Mean 32.4 24.0

(SD) (6.9) (5.6)

Table 20: Individual and mean reading time per film for both groups of observer* (in
seconds).

These data were analyzed by means of an unpaired Mest; since p= 0.069,

there was no significant difference at the 5% level.

104
Discussion
In accordance with the literature, there were large differences in the
detection accuracies of individual readers (both medical students and
radiologists, table 19).
Our results showed no influence of radiological training on diagnostic
accuracy. These results suggest that talent is more important than
radiological training. However, the results could be influenced by the fact
that the medical students are more likely to be motivated by the novelty of
the experiment and secondly spent more time participating in the
experiment. Another result of this experiment is the discovery that this
phantom model provides insight into visual perceptual capabilities and thus
can be used as an aptitude test for applicants for diagnostic radiological
training programs.
Uewellyn87 states that experienced radiologists perceive most important
abnormalities within the first few seconds of viewing, a single display of less
than 300 msec, duration may be sufficient for identification of the major
features of a lesion; moreover rapid localization of abnormalities increases
with experience.

Oestmann et al.108 correlated viewing time and detection of lung cancer

among experienced radiologists. They too concluded that a large proportion
of obvious lung cancers are detected by 'flash' viewing. According to Gray
et al.47, our finding implies that if viewing time is unlimited it should be
possible to use individuals who are not radiologists for performance studies
in the future. The detection task must then be well defined, involving only
the detection of a limited specific pathological condition.

Conclusion
This study presents the results of an observer performance experiment
based on the detection of simulated IPD in order to evaluate the influence of
radiology training.
Our results support literature that there Is no influence of radiology training

106
on diagnostic accuracy although a high interobserver variability exists for
both the trained and untrained observers. These variations are known to
accompany all types of responses from human observers.
Providing the detection task is well defined and involves only the detection
of a limited, specified pathologic condition, then the novel technique of
superimposing simulated interstitial patterns on a 3M chest phantom makes
it possible to evaluate interobserver and intraobserver accuracy in an
accurate and rapid way.
Our findings imply that in the future it would be possible to use non-
radiologists in such studies.

106
 PART II

THE COST-DIAGNOSTIC BENEFIT ANALYSIS

PART II B THE COSTS

 CHAPTER 9

MEASUREMENT OF RADIATION DOSE

Introduction
Although the radiation dose to the patient is not a primary image quality
parameter, it is an important factor in choosing a chest X-ray technique40.
Measurement of the radiation dose absorbed by the patient (in situ) is
impossible because of the inhomogeneous radiation fields involved (dose
distribution inside the patient cannot be measured). A useful alternative,
especially for comparative studies, is to measure the entrance and exit
doses (expressed in Gy) at the patient surfaces by placing an ionization
chamber or Thermoluminescent Dosimeter (TLD) in the X-ray field.

Chest radiography is, or should be, a low radiation dose procedure. An

entrance dose of 0.2-0.3 mGy (PA projection) is typical while, in
comparison, an abdominal radiograph needs 5.0-9.0 mGy18'80'118.
Radiation doses may vary by as much as a factor 10 from one institute to
another as found in the USA19119.
US government guidelines suggest chest radiographs should not exceed
0.25 mGy. However, with 65-80 million chest radiographs (USA) yearly the
total dose to the population should not be ignored. Therefore, radiation
dose deserves to be considered when comparing various techniques for
chest radiography103.

The purpose of this study is to compare the radiation dose produced by

three chest imaging modalities: conventional full-size (C-FS) chest
radiography and two LFOV Image Intenslfier techniques (LEF-II, 57-cm and
47-cm modes, and S-ll).

9.1 DOSIMETRY

Materials and methods

Comparison of the radiation exposure of imaging modalities requires a test
object. Exposure of patients is not chosen because of the potential harmful

110
effects of radiation145148'148. Jn this study two phantoms were used: a 3M
chest phantom (pilot phase) and a homogeneous Polymethylmeta-acrytste
(PMMA or perspex) phantom.
For a method to be suitable for dose measurements, several requirements
have to be fulfilled. The device used has to be easy to handle, accuracy
must be high and the size and price of the device have to be acceptable.
Two types of radiation measurement device or dosimeter are available:
ionization chambers and thermoiuminescent dosimeters (TLD).
The working principles of these dosimeters are based on the interactions of
radiation with matter148.
An ionization chamber uses the principle cf ionization in air, the number of
ionizations being dependent on the number, energy and interaction
probability of X-ray photons148.

TL dosimetry, which was introduced in diagnostic radiology in the early

60's, provides a useful alternative to the widely used ionization
chamber32'"7'128-130'141'1481132. In TLD, exposure to the ionizing radiation will
cause excitation of electrons in the crystal structure of the detector used.
These electrons are 'trapped' in a metastable state due to the physical
properties of the crystal. As the detector Is heated (200-350°C), the
electrons are released from their traps and regain their original energy-level
while emitting thermoiuminescent light photons (TL).

The amount of light emitted depends on the number of electrons originally

trapped and is related linearly to the radiation dose. With the aid of a
photomuitiplier tube the emitted light can be measured quantitatively.
TL detectors are available In small-size extruded chips.
Various materials are used, UF being one of the most popular because of
its low effective atomic number.
The advantages of TLD are numerous: the dosimeters are smaH, they are
cheap because they are re-usable, the influence of fading or mechanical

111
factors is negligible and a wide range o* exposure-levels can be measured
accuratel/0"1*. TLD obviously fulfills the necessary criteria.

imaging modalities
In a comparative study, the exposure produced by two LFOV-JI techniques
and C-FS chest radiography was measured using TLD.
All chest radiography equipment is maintained and serviced by the
manufacturer.
A detailed description of the technical characteristics and parameters of the
modalities Is provided in chapter 4.1; a summary is given below:
1. Standard Conventional Full-Size Film-Screen (C-FS: Siemens Vertfc 2E,
125 kVp, Agfa MR 400 screens, Agfa Curtx films. SID=2.0 m).
2. 100 mm Large Entrance Field Triple Mode Image Intenslfier (LEF-II:
Siemens TS 57,125 kVp, 12/40 grid, Agfa RP,S films. SID=2.0 m).
In this study only two modes are used (57-cm and 47-cm entrance
field).
The third mode (33-cm entrance field) is, according to factory
guidelines, for the imaging of chMren and was therefore not
considered.
3. 100 mm Slit Image Intensifier (S-ll: Phlips, 125 kVp, no grid, Agfa RP,S
films. SID=1.2 m).

9.2 DOSE MEASUREMENTS

In this Investigation we used TLD's made avalable by the Radiological

Service, part of the Organization for Applied Scientific Research (TNO). For
each measurement two UF (TLD-100) chips were used.
Two types of measurement were made (only in the PA projection):
a. For the plot study a 3M chest phantom was used. Two TLD's were
placed on the anterior and posterior sides of the phantom in the centre

112
 of the incident X-ray beam (figure 13). Per test series 20 exposures
were made,
b. Use of a homogeneous PMMA phantom (30x30x10cm).
Twenty TLD's were distributed equally over the anterior and posterior
surfaces of the phantom. Per test series 50 exposures were made
(figure 14).

Results
The entrance and exit doses (PA projection) found for each of the three
chest techniques are listed In tables 21 and 22.
In both phantom studies the II techniques produced less radiation exposure
than the C-FS technique.
Comparison of the LEF-II 57-cm mode and S-ll techniques reveals that the
entrance dose of the S-ll is slightly lower while the exit dose is slightly
higher. An explanation for this finding could be a difference in beam quality
between the machines as well as the difference in geometry (SID).
In both phantom studies, higher entrance and exit exposures were found for
the 47-cm mode of the LEF-II.

Figure 13: Radiation dot* msasurwntnts using a 3M d M t t phantom (pilot study)

113
Figure 14: Radiation dos* m«uur«m#nts using a Itomogwwou* PMMA phantom

This finding is a consequence of the zoomed 47-cm entrance field and is in

accordance with expectations.
For ail modalities, the ratio of entrance to exit values found during the 3M
chest phantom study was comparable to that for the PMMA phantom study.
It should be noted that measurements were only made within the direct X-
ray beam. Therefore, scattered radiation was not considered.

Discussion
Patients can undoubtiy derive enormous diagnostic benefits from chest X-
rays, although the ionizing nature of the X-rays means that their use is not
entirely without risks132.
It is assumed that the main risk of chest X-rays wS! be the induction of
malignancies7'00.
According to Beentjes et al.7, this risk can be expressed in terms of a single
dose parameter, the somatteally effective dose (SED).
The SED parameter is defined as that uniformly absorbed whole body dose
resulting in the same risk of lethal cancer as that produced by the actual set
of nonuniform doses absorbed by individual organs and tissues"3. Alter
calculating the SED, the collective effective dose equivalent (CED) can be

114
 3M CHEST PHANTOM
Posterior (Entrance) Anterior (Exit)
range average range average

1. C-FS (175.3- 180.5} 177.9 (13.9-17.4) 15.7

2a. LEF-II, 57 cm mode (82.8- 88.9) 86.3 (7.0- 7.8) 7.4
2b. LEF-II, 47 cm mode (120.3- 125.6) 122.9 (10.5-10.8) 10.5
3. SI! ( 78.5- 82.0) 80.2 (8.3- 9.0) 8.6

T*b*e 2 1 . Rkrt study. Dose measurements in uGy (PA projection) at 125 Wp using a 3M
chest phantom to compare threw chest modaMtfes. Values in pa/*nttiM*f
the rang*; nrwan valutt • / • pfinttd in botd typ*.

PMMA PHANTOM
Posterior (Entrance) Anterior (Exit)
range average range average

1. C-FS (393.3- 524.0) 478.7 (29.6-64 5) 48.8

2a. LEF-II, 57cm (135.2- 185.7) 167.4 (10.5-23.5) 17.4
2b. LEF-II, 47cm (205.8- 240.7) 225.8 (23.5-31.4) 26.2
3. S-li (104.6- 161.3) 138.6 (11.3-26.2) 20.9

Tabto 22. A comparatr."« study of thre* chest imaging tachniquM. Dose measurements in
uGy at 125 kVp using a homogeneous PMMA phantom. Values in parentheses
indicate the range; mean values are printed in bold type.

assessed. This dose parameter expresses the collective risk of inducing fatal
malignancies due to X-ray examinations.
A summary of the theoretical model of Beentjes et al.7 and the calculations
is given below.

115
Somatically Effective Dose (SED)
The theoretical model of Beentjes et al.7 Is based on several assumptions:
there is a linear dose-effect relationship; the effect, which is an average for
the whole body, is the risk of inducing lethal cancer; all risks are additive in
the case of repetitive exposures; and summation of individual risks leads to
a collective risk estimation.
The various risk factors for the induction of fatal malignancies are derived
from UNSCEAR 1988 and ICRP 199081'148 (table 23,1).
The mean organ dose can be approximated from the entrance dose, using
conversion factors described in the literature (table 23,1V*)63'124.
If an organ is only partially located within the volume of interest, the mean
organ dose is obtained by multiplying the estimated average dose in that
organ by the fraction of the organ that is irradiated (table 23,1V**). The
relevant fractions are estimated from the organ images on the radiographic
films.

If we consider the organs located in the direct beam, the products of the
mean organ doses and the mortality risk factors together represent the
mortality risk for each organ, (table 23,V). The mortality risk for partially
radiated organs is also listed in table 23,V.
On the basis of these assumptions, the individual total mortality risk
attributable to a standard diagnostic examination of the chest with an
arbitrarily chosen entrance dose of 1 mGy was calculated: 10.46 x 10"6
(table 23,V).

For the risk estimation in our study an additional assumption has to be

made. Suppose that the radiation exposure produced by the C-FS
determined in our 3M phantom studies (PA projection) Is comparable to that
of the standard chest techniques proposed by Beentjes but equals 0.2 mGy
(20 mrad)7. The corresponding individual risk per film (PA) becomes 2.09 x
10* (table 24). Since the average entrance doses of the LFOV-II techniques

116
 I II III IV V
ORGAN OR TISSUE UNSCEAR FRACTION OF AVERAGE DOSE MEAN ORGAN MORTALITY RISK
1988 THE ORGAN FOR THE PART DOSE FOR EACH ORGAN
ICRP 1990 EXPOSED OF THE ORGAN (mGy) DUE TO THE
(lO^/Gy) (mGy) MEAN ORGAN
DOSE (10")

Red Bone 45 0.33 (0.45) 0.15* 0.67

Thyroid 8 0.50 (0.30) 0.15* 0.12
Breast (av. pop.) 25 1.00 (0.20) 0.20* 0.50
Lung 90 1.00 (0.60) 0.60* 5.40
Bone Lining Cells 5 0.20 0.40 0.08** 0.04
Stomach 110 0.33 0.40 0.13** 1.43
Liver 20 0.66 0.40 0.26** 0.52
Esophagus 35 1.00 0.40 0.40** 1.40
Skin 2 ant. 0.08 0.10 \ 0.09** 0.02
post.0.08 1.00/
Remainder 45 0.20 0.40 0.08** 0.36

Total mortality-risk Total mortality risk

factor (all organs): 10x10*. Calculated
2
5xiO' /man Gy after UNSCEAR
1988, ICRP
19go ei.i46.

Table 23: Mortality risk from a standard full size' radkxJiagnostic examination of the chest for an
entrance dose of 1 mGy (100 mrad)7.

Dose response relationships for the radiation induction of fatal malignancies. Mortality risk
factor per unit of absorbed dose (10~*/Gy). The mortality risk factors per organ gray,
presented in UNSCEAR 1968 and ICRP 199001'140 are used.
Fraction of the organ exposed.
Estimated from the known dose in adjacent organs; the values in parentheses are calculated
from columns IV and II.
IV Mean organ dose relative to entrance dose in full size' radiography (120-140 kVp, 4mm Al
filtration). Baud on data of Bengtsaon*8 and oompleted by multiplication of the average
dose (III) with the fraction exposed** (il).
The mortality risk per organ (V) is calculated from the mortality risk factor per unit of
absorbed dose (I) multiplied with the mean organ dose (TV).

117
are known with respect to that of the C-FS, in percentages, the total
mortality risk per modality can be calculated.

3M Phantom Total Mortality Risk

1. C-FS 100% 2.09 X10"8

2a. LEF-II, 57 cm mode 48.5% 0.96 x 10*
2b. LEF-II, 47 cm mode 69.1 % 1.44 x 10*
3. S-IS 45.1% 0.94 x 10*6

Table 24. Estimation of total mortality risk on the basis of the 3M phantom studies (not
the PMMA phantom study). It is assumed that the average entrance dose of the
C-FS equipment used is in accordance with Beentjes et al/(0.2 mGy). The total
mortality risk per film per modality is expressed in Iff 6 .

As mentioned earlier, the risk can be expressed as a somatically effective

dose (SED, table 25,l)7, being the total individual mortality risk per film per
modality (mentioned In table 24) divided by the total mortality risk factor
(cancer death per man gray, see table 23,1).

CtUective Somatic Effective Dose Equivalent (CED)

The collective risk of induced fatal malignancies (CED) is obtained by
multiplying SED by the number of radiographs made per year. Suppose that
in the Netherlands 4.8 x108 chest radiographs are made (2.5x10°
examinations); the corresponding CED can then be calculated (Table
25.il)6'7.
If we know the extra risk of fatal cancer per chest film and the number of
chest films made annually, the number of induced fatal malignancies can be
estimated (table 25.III).
If we compare both radiation exposure and the estimated number of
induced malignancies due to the S-ll and C-FS chest techniques, a large

118
 difference in exposure exists whereas only a very limited reduction in the
number of induced fatal malignancies can be obtained. Moreover, it has to
be stressed that this is a strictly hypothetical situation in which a large
number of chest radiographs was taken with the S-ll modality only.

1 II III
SEO CED Estimated Number of
in manGy/film in manGy Induced Fatal
Malignancies

1. C-FS 0.42X10" 201 10.0

2a. LEF-II, 57cm 0.19X10" 91 4.5
2b. LEF-II, 47cm 0.29x10" 139 6.9
3. S-ll 0.19x10" 91 4.5

Table 25:
I SED: Calculated SED values expressed in man-gray/film for various modalities.
For example: SED C-FS= (2.09 x lO^/film)/ 500 x 10*4 man-gray = 0.42 x 10"* man-
gray/film.
II CEO: The following equation was used to calculate CED (in man-gray):
CED modality « number radiographs/year x SED modality
For example: C-FS: 4.8 x 10* x 0.42 x10"* = 201 man-gray
III Estimated number of induced malignancies.
The following equation was used to estimate the number of induced malignancies:
Malignancies per modality: CED modality x total mortality risk factor.
For example: C-FS: 201 x 500 x 10^/man-gray * 10.0.

119
Conclusion
The results show a marked difference in entrance dose between the C-FS
phantom radiographs and both the LFOV-II techniques. In particular, the
radiation dose of the S-ll technique is low.
A rough estimation of the strictly hypothetical situation in which all C-FS
units are replaced by S-ll equipment yields only a limited reduction in the
number of calculated induced fatal malignancies. If we consider the value of
the parameter 'image quality* versus radiation dose, it is apparent that any
attempt to reduce the number of induced malignancies must be
accompanied by maintenance of the image quality whiie the costs involved
should be considered.

120
 CHAPTER 10

A COST ANALYSIS
Introduction
Economic interests have always been an important factor in diagnostic
radiology. For every new modality introduced, costs should be analyzed
because the continuing increase in the costs of medical care is a major
problem, also in Dutch society37'38'58.
The goal of this study is to determine the best chest radiography system,
purely on the basis of costs and user intensity. The model only applies to
general hospitals and not to university hospitals since the Dutch budgeting
system has different regulations for the latter28. The hospital either has no
equipment (new hospital), or entirely depreciated chest equipment is
present (existing hospital)08.

Dutch Situation
To manage costs, the Dutch government passed a regulation (1988) that
resulted in three measures: treatment capacity reduction28, investment
regulation and reduction of exploitation costs20. The reduction in treatment
capacity was achieved by decreasing the number of hospital beds available.
Investment regulation was enforced by introducing the 'Hospital Supply' law
(Wet Ziekenhuis Voorzieningen). In particular, regulations 6, building
permission, and 18, acquisition of exceptional facilities such as CT scanners
and lithotriptors, were aimed at management of costs.
To get a grip on the exploitation costs of individual hospitals, a system of
'functional' budgeting was introduced in 1968. In this system, a budget is
set for a certain forthcoming period of time for individual hospitals, whereby
financial revenue is (merely) based on a number of functions such as:
number of beds, number of patient admissions, number of specialists,
number of outpatient visits, etc.29.
In fact, the Dutch budgeting system is a compromise between the
government's obligation to support health care and the need to keep costs
within acceptable limits.

122
Chest radiography systems
Three competing chest X-ray modalities are considered:
a. Conventional full-size (C-FS) bucky film-intensifying screen
radiographs. For film processing, a generally available multi-purpose
daylight processor is used.
b. Dedicated chest equipment. This modality uses a full-size (Ded-FS)
film-intensifying screen combination but differs from the bucky
system in two respects:
1. A receiver cassette in which 50 films can be stored is used.
2. The processor is attached directly ('dedicated') to the imaging
equipment.
c. Large Field of View Chest Image Intensifiers (LFOV-II). These
equipments yield a 100 mm image which are stored in a receiver
cassette (50 films). After processing in a separate 100 mm daylight
processor, the films are placed in specially prepared paper files
(Cadrix).

Because the Dutch market is dominated by Philips and Siemens, we

investigated the abovementioned equipment offered by these two
companies (C-FS; Ded-FS; LFOV-il).

10.1 COST MODEL

Costs, their relevancy and presumptions to be made

An important requirement for a cost model is to specify who is responsible
for the costs. For example: a cost model for chest X-ray radiography can be
performed on different levels: the government, an insurance company or an
individual hospital.
In this study the cost model is performed on the hospital level.

123
Costs directly related to making a chest X-radiograph are called direct costs
(for example: depreciation of an X-ray apparatus). Indirect costs are also
listed in a different budget (for example: overhead). Furthermore, costs can
be divided into variable, semtvariable and fixed costs. These costs are
dependent, gradually dependent and independent of user intensity,
respectively.
Thus, various costs have to be considered; direct variable, direct
semivariable, direct fixed, indirect variable, indirect semivariable and indirect
fixed.
Indirect costs will not be considered because these costs fail under other
budgets and will therefore not influence the decision to buy this particular
piece of equipment. Therefore, only direct costs will be evaluated.
Furthermore the financial revenues of chest radiography are not considered
because, in the Dutch budget-financing system, these revenues are
independent of the type of equipment used in the individual hospital and
therefore do not influence a decision.
In the next paragraph the following cost factors are considered: direct
variable, direct semi-variable and direct fixed (in appendix 7 the costs in Dfl
per modality are listed according to category).

Direct Variable Costs

With the C-FS film-screen and Ded-FS equipment, the male chest is imaged
on 35x43 cm film and the female chest on 35x35 cm film. AH LFOV-II
radiographs are imaged on 10x10 cm film. There is a marked price
difference between these two formats of film.

According to HaH, Allen and Mazzaferro et al. %4M6 , the incidence of

repeated chest radiographs is 5%, mainly due to exposure errors (47%),
positioning errors (25%) or equipment errors (11%). In this analysis, aft
calculations are related to the number of successful radiographs (i.e. 95% of
the total number of radiographs).

124
Developer and fixative represent direct variable costs which are related to
film size. According to the manufacturer, the requirements are;

developeriin ml) fixative(in ml)

10 x 10 cm (100 mm) film 4.9 7.6
35 x 35 cm film 55.0 85.0
35 x 43 cm film 67.6 104.4

In histogram 1 the direct variable costs are listed for the modalities under
consideration for a 10-year period, assuming 30,000 exposures per year
(raw data are presented in appendix-7).

Direct Variable Costs/10 years

*10 6 (FI)

modalities
Histogram 1: Direct variable costs (in DF1) par 10 years, assuming 30,000 successful
exposures per year. The horizontal axis represents the various Imaging
modalities offered by two companies.
1: LFOV-H;S-H (Philips) 2: LFOV-II;LEFN (Siemens) 3: Oed-FS (Philips)
4: Ded-FS (Siemens) 5: C-FS (Philips) 6: C-FS (Siemens)

12S
Direct Semlvariabl* Costs
The number of repeated radiographs Influences the life span of major spare
parts such as X-ray tube, Image Intensffier tube and Intensifying screen;
replacement of these parts Is dependent on the number of radiographs
made (X-ray tube 50,000, II tube 200,000, screen 50,000, according to the
manufacturer).
In histogram 2 the direct semivariabte costs are listed for the modalities
under consideration for a 10-year period, assuming 30,000 exposures per
year (raw data are presented in appendtx-7).

Direct Semivariable Costs/10 years

*106 (Fl)

0.7-

0.6-

0.5

0.4-

0.3-

0.2-

modalities
Histogram 2: Direct temivariaWe costs Cm DFI) per 10 years, assuming 30,000 successful
exposures per year. The horizontal axis represents the various imaging
modalities offered by two companies.
1: LFOV-II;S-II (Philips) 2: LFOV-II.LEF-II (Siemens) 3: Ded-FS (Philips)
4: Ded-FS (Siemens) 5: C-FS (Philips) 6: C-FS (Siemens)

126
Direct Fixed Cost*
In histogram 3 the direct fixed costs are listed for the modalities under
consideration for a 10-year period (raw data are presented in appendix-7).

Depreciation of X-ray equipment Is, according to government nies, linear

over a 10-year period2*. The residual value is nl.

Maintenance will be performed partly by department personnel (cleaning);

major maintenance Is covered by a contract with the manufacturer, the cost
of which depends on the purchase price. The contracts for the modalities

Direct Fixed Costs/10 years

*106(FI)

1.0-

modalities
Histogram 3: Direct fixed cost* (in DF1) per 10 years. The horizontal axis represents the
various imaging modalities offered by two companies.
1: LFOV-II; S-ll (Philips) 2: LFOV-II; LEF-II (Siemens) 3: Ded-FS (Philips)
4: Ded-FS (Siemens) 5: C-FS (Philips) 6: C- FS (Siemens)

127
under consideration are based on equal replacement Major spare parts are
paid for by the hospital {X-tubes, il tubes and screens) while all other parts
are paid for by the manufacturer.

According to the Dutch budgeting system, the difference between paid and
budgeted interest is not paid by the hospital but Is included In the annual
appraisal.

Although the LFOV-II techniques would seem to be more efficient, due to

the receiver cassette which holds 50 films, In practice It does not yiefd a
decrease In manpower; therefore, the salaries of the technicians need not
be considered.

The Cost Modal

A BASIC computer program was written to evaluate the costs described in
the text and listed in the appendix; the results are presented in table 26 and
graph 4.
A detailed description of the model has been presented by v.d.Kaaden"; It
is based on equation I.
The total costs for the various imaging systems (TC) are calculated for
different user intensities over a 10-year period on the basis of the
considerations described in the text.
n
DSVCi mod
Equation I : T O Sum DVC • 10 * (X+0.05X)) +Y. * m / ( * > 0 . 0 5 X ) ] + Sum DFC
1*1

TC ; Total oocts per imaging system psr 10 years at a certain user intensity (successful
films)
DVO ; Direct variable costs per radiograph for imaging system.
10 ; M is assumed that the life span of the equipment is 10 years
X ; Number of successful radiographs per year
DSVCi; Direct semivariable costs of spare-part i. The following spare-parts are considered:
X-ray tube, image intensrfier tube and intensifying screen).
Ls ; LJfeepan of the spare-parts expressed In number of radiographs
DFO ; Direct fixed costs for Imaging system per 10 years (mainly purchase price)

128
Results and Discussion
Table 26 presents the numerical data for the cost analysis. Graph 4
illustrates cost lines for the competing modalities at various user intensities.
At the intersection of two lines (break-even point), the costs for the relevant
modalities are equal at this particular user intensity.
The 'steps' in the cost lines are attributable to the replacement of spare
parts of the imaging system after a certain number of exposures. The
'height' of the 'steps' differs between modalities because the prices of these
spare parts are different.

It can be seen that the LFOV-II techniques are cheaper, especially when a
targe number of chest examinations are performed. Although the TC at zero
examinations per year, consisting of the purchase price plus major
maintenance costs (which are related to the former), is higher for the LFOV-
II techniques (histogram 3), the difference is rapidly abolished by the lower
variable costs, mainly due to the price of 100 mm film (histogram 1).

For all three imaging modalities (C-FS, Ded-FS, LFOV-II), the PhBips Imaging
systems are cheaper than comparable Siemens equipment.

Graph 4 and table 26 also show the savings to t> obtained by using the
LFOV-II techniques.
For example: if instead of a Siemens Ded-FS system a Philips LFOV-li is
used, the savings for 10,000 exposures per year w i l be Dfl. 617,085= (in 10
years) while for 60,000 exposures per year Dfl. 2,868,235= w i l be saved in
10 years.

120
NUMBER OF
SUCCESSFUL
RADIOGRAPHS/
YEAR x10 3 MODALITIES

0 857.834 1.059.434 652.957 968.457 501.162 599.602

10 1.075.686 1.290.774 1.363.783 1.692.771 1.175.581 1.287.509
20 1.377.538 1.726.114 2.074.609 2.417.085 1.850.905 1.976.321
30 1.592.710 1.954.774 2.773.035 3.128.999 2.515.586 2.654.490
40 1.893.222 2.388.774 3.477.661 3.847.113 3.184.155 3.336.547
50 2.120.454 2.629.494 4.231.887 4.614.827 3.901.486 4.067.366
60 2.408.906 3.051.434 4.880.713 5.277.141 4.518.310 4.697.678

Table 26:
Total costs (TC) expressed in OR for general hospitals at different user intensities (vertical
axis) for a period of 10 years. This situation is calculated for placement of equipment in a
hospital with no or fully depreciated equipment. The horizontal axis represents the various
imaging modalities offered by two companies.
1: LFOV-II; S-ll (Philips) 2: LFOV-II; LEF-II (Siemens) 3: Ded-FS (Philips)
4: Ded-FS (Siemens) 5: C-FS (Philips) 6: C- FS (Siemens)

Several analysis techniques can be used for a cost evaluation of new

modalities.
In a cost-effectiveness analysis not only the financial costs but also the
immaterial effects are considered3*'"
Morbidity and mortality are frequently used as measures of the effects33'90.
For Imaging equipment, a measure of effect is diagnostic image quality.
Patton108 recently introduced a model for diagnostic radiology in which the
parameters diagnostic Image quality, morbidity and mortality are related to
costs.

130
Total Costs/10 years

*106 (Fl)

5.0-

10 20 30 40 50 60
successful radiographs per year (* 1.000)

(1): LFOV-II: S-ll (Philips)

(2): LFOV-II: LEF-II (Siemens)
(3): Ded-FS system (Philips)
(4): Ded-FS system (Siemens)
(5): C-FS system (Philips)
(6): C-FS system (Siemens)

Graph 4 Co«t model. Cost analysis for the modalities under consideration.
The horizontal axis represents the number of successful chest radiographs per
year, the vertical axis the total costs (TC) per 10 years in mln DFI.

The difficulty encountered in this type of study is to relate these nonuniform

measures of effect to a single value3.
In a cost-benefit analysis all advantages and disadvantages are expressed
in terms of money. This type of analysis is not suitable for evaluating
medical technology because health quality and health improvement cannot
be expressed in terms of money20.

131
In a cost analysis, the costs of different techniques can be compared but
the medical effects are not taken into account26.

Because we determined both diagnostic image quality (Chapter 5,7) and

radiation dose (chapter 9) for the modalities under consideration a cost-
effectiveness analysis that relates these parameters could be the subject of
a future study.

Conclusion
For every new modality introduced, the costs have to be analyzed. A cost
analysis of three different chest modalities (LFOV-II techniques, Ded-FS and
C-FS bucky film-screen systems) offered by two companies has been
performed, taking the specific Dutch budgeting system into account.
The situation considered was a new hospital which required new chest X-ray
equipment or an existing hospital, in which the present equipment had
depreciated. Both LFOV-II techniques are cheaper with low break-even
points (mainly because of lower film costs). If the choice has to be made
between Philips and Siemens equipment, then on the basis of costs Philips
has to be preferred.

132
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145
 SUMMARY and GENERAL CONCLUSIONS

PART 1 INTRODUCTION

Although plain chest radiography is one of the most useful diagnostic tools
available to the physician, this procedure has not evolved into a consistent
method. Two Large Field of View Image Intensifies (LFOV-II) became
available; the large imaging area makes them suitable for chest imaging.
Both modalities supply 100 mm images to the radiologist.
In this thesis the 'diagnostic benefits' and 'costs' of these modalities are
evaluated and related to the 'gold' standard (conventional full-size).
The emphasis is on diagnostic image quality using phantoms for observer
performance experiments.

Chapter 1 covers commonly used chest rdntgenographic techniques. The

basic principles of the LFOV-II are described and illustrated.
In Chapter 2 the literature is reviewed. Only a limited number of
publications is available. From these, only few reliable conclusions can be
drawn about 'diagnostic benefits' and 'costs', mainly because of lack of
comparison with a 'gold'standard. In other studies, comparative clinical trials
were carried out but because of marked Intraobserver and interobserver
variability, this type of study is inconclusive. Furthermore, few of the studies
have included statistical analysis.
Chapter three focusses on the basic questions about diagnostic image
quality: How do we define and how do we determine it?
The most important facet of diagnostic image quality is image
informativeness or diagnostic accuracy which refers to the transmission of
diagnostic Information.
For determination of diagnostic accuracy, clinical trials or phantoms with
simulated pathology can be used. For this thesis.the phantom methodology
was chosen for various reasons.

146
Most important is the fact that there is no doubt about the 'truth', i.e. no
invasive procedures or patient radiation dose is required to prove a
diagnosis as in clinical studies. Furthermore, the degree and location of the
pathology can be manipulated by the investigator.
As a consequence, the statistical validity of observer performance phantom-
based experiments is high.
A review of the advantages and limitations of the various techniques used
for statistical analysis to assess diagnostic accuracy suggests that ROC
analysis provides the most meaningful results in studies focusing on one
diffuse abnormality, while the recently introduced FROC methodology is
more appropriate for studies in which multiple abnormalities are present and
localization is required.

PART II A THE DIAGNOSTIC BENEFITS

In Chapter 4 the technical factors and the phantom model are described.
Two kinds of pathology were simulated:
subtle diffuse interstitial pattern disease (one abnormality, ROC) and
multiple pulmonary nodular disease simulating metastasis (multiple
abnormalities, FROC).
Both pathologies are Important in clinical practice and could be simulated
reliably.
In Chapter 5, the diagnostic accuracy of the new modalities are determined
using the metastasis detection task. For this particular task, the diagnostic
accuracy of the 'gold' standard and 100 mm LFOV-II techniques proved to
be equal.
In Chapter 6 the influence on diagnostic accuracy of various image display
sizes (30x40 cm versus 10x10 cm) is examined. For this study, too, the
metastasis detection task was used. The two display sizes did not influence
the diagnostic accuracy.
Chapter 7. In this study diagnostic accuracy was determined using
simulation of interstitial pattern disease.

147
The results of the experiment show a significant difference between the
'gold' standard and the Slrt-ll (LFOV) technique.
This result differs from those of the study in which pulmonary nodules were
simulated (chapter 5). A possible explanation for the difference in
performance is given.
In Chapter 8, we examined the influence of radiological training on the
detection of simulated interstitial pattern disease. A group of board-certified
radiologists and senior medical students without radiological training
participated in the experiment. A <arge interobserver variation exists and no
difference in diagnostic accuracy wa? found between the two groups. It
seems likely that (for this particular detection task) talent is more important
than radiological training. These results support current views in the
literature that it should be possible to use individuals who are not
radiologists in observer performance experiments with phantoms. In our
opinion this methodology could also be used to select residents for
diagnostic radiological training programs.

PART II B THE'COSTS'

Chapter 9. Although patient radiation dose is not a primary parameter of

image quality, it Is an important factor in choosing a chest technique. It is
assumed that the main risk of chest X-rays wM be the induction of
malignancies. In this study, a markedly lower entrance dose was found for
both LFOV-II modalities. A hypothetical situation Is considered in which all
conventional chest radiographs are taken with low dose (LFOV-II) units: it
appears that only a very limited number of induced malignancies can be
prevented.
Chapter 10. For every new modality introduced, the costs should be
analyzed. It is demonstrated that cost savings can be achieved with the
LFOV-II techniques.

148
SAMENVATTING EN CONCLUSIES

DEEL 1 INTRODUCTIE

Hoewel de thoraxopname het meest frequent verrichte onderzoek is, heeft

deze modaliteit zich nog niet ontwikkeld tot een consistente methode.
Thans zijn er twee beeldversterkersystemen beschikbaar waarvan het
Ingangsformaat groot genoeg is voor afbeelding van de thorax. Beide
systemen genereren 100 mm (10x10 cm) röntgenfflms.
In dit proefschrift worden diagnostische baten en kosten van deze
röntgensystemen geëvalueerd in vergelijking met de gouden standaard:
convertïionele hoog kVp groot formaat techniek. Speciale aandacht is
gericht op de diagnostische beeldkwaliteit waarbij gebruik gemaakt is van
fantoombeelden.

In Hoofdstuk 1 is een overzicht gegeven van gangbare thoraxsystemen.

Verder worden basisprincipes van de beeldversterker systemen beschreven
en geWustreerd.
In Hoofdttuk 2 Is de literatuur beschouwd. Uit het beperkte aantal
publikaties dat verschenen is, kan geen conclusie getrokken worden over
de diagnostische baten en kosten.
In het merendeel van de publikaties is geen vergelijking gemaakt met een
gouden standaard. In andere studies blijken inter- en Intra- beoordelaars-
variatie te groot om betrouwbare conclusies te trekken. Overigens is in geen
van de gepubliceerde studies betrouwbare statistische analyse verricht
In Hoofdstuk 3 wordt het basisvraagstuk beschreven: Hoe diagnostische
beeldkwaliteit te dsflnürsn sn te bspaton ?
Het belangrijkste f a c t van diagnostische batJdkwaNteit is de diagnostische
InforrriÄieKJverdfacht of dlagrostlstto accuratesse.
Bij het bepalen van diagnostische accuratesse kan gebruik gemaakt worden
van klinische beelden of van een fantoornmotM met nagebootste
pathologie.

140
In dit proefschrift is gekozen voor de fantoombenadering om verschillende
redenen.
De belangrijkste reden is het feit dat er geen twijfel is over de waarheid. Er
is geen invasieve diagnostiek of stralenbelasting nodig voor bevestiging van
de diagnose.
Een bijkomend voordeel is dat de mate van pathologie alsook de locatie
exact gesimuleerd kunnen worden door de onderzoeker.
Daardoor is de statistische betrouwbaarheid van fantoom studies hoog.
Een overzicht van de voordelen en beperkingen van de verscheidene
beschikbare statistische methoden laat zien dat de ROC-analyse de meest
betrouwbare methodiek is in het geval slechts een (diffuse) afwijking
aanwezig is, terwijl de recent geïntroduceerde FROC-methodologie meer
geschikt is indien multipele afwijkingen aanwezig zijn en het lokaliseren
hiervan (door de beoordelaar) vereist is.

DEEL II A DE DIAGNOSTISCHE BATEN

In Hoofdstuk 4 worden de technische specificaties en het fantoommodel

beschreven. Twee aandoeningen zijn nagebootst: een subtiel diffuus
interstWeel afwijkend beeld en metastasen.
Beide afwijkingen zijn belangrijk in de dagelijkse praktijk en bleken
betrouwbaar na te bootsen.
In Hoofdstuk 5 is de diagnostische accuratesse bepaald, met gebruik-
making van de métastase nagebootste beelden. Voor deze diagnostische
taak bleek de accuratesse van de nieuwe beekfversterkersystemen gelijk
aan die van de gouden standaard.
In Hoofdstuk 6 is de invloed van accuratesse op beekjformaat (30x40 cm
versus lOxiOcm) bepaald. Ook voor dit doel zijn de métastase fantoom-
beelden gebruikt. Er bleek geen veracM in diagnostische accuratesse
tussen de twee formaten van afbaskUng.
In Hoofdstuk 7 is de diagnostische accuratesse bepaald van de
beeWversterkersystêmen, gebruik makend van de nagebootste InterstfcMHe

150
afwijkingen. Het resultaat van deze studie laat een significant verschil zien in
accuratesse tussen de gouden standaard en één van de nieuwe beeld-
versterkersystemen (Slit BV). Mogelijke verklaringen zijn gegeven voor de
genoemde bevinding.
In Hoofdstuk 8 hebben wij de invloed onderzocht van opleiding in de
radiodiagnostiek op de detectie van nagebootste interstitiêle afwijkingen.
Een groep radiologen en medische studenten hebben meegewerkt aan het
experiment. Alhoewel een grote interbeoordelaarsvariatie bestaat is er geen
significant verschil tussen beide groepen. Het lijkt redelijk te veronderstellen
dat talent belangrijker is dan opleiding.
De resultaten ondersteunen de literatuur en suggereren dat het mogelijk is
om niet-radiologen voor observer-performance experimenten te gebruiken.
Ook zou deze methode gebruikt kunnen worden bij de selectie van arts-
assistenten in opleiding tot radkxtiagnost.

DEEL II B DE 'KOSTEN'

Hoofdstuk 9. Hoewel stralendosis geen primaire parameter van

beeldkwaliteit is, is deze toch belangrijk bij de keuze van een röntgen
thoraxsysteem. Uit de literatuur Wijkt het belangrijkste risico van
thoraxopnamen de inductie van maligniteiten. In deze studie blijken de
nieuwe beeldversterker-systamen een duidelijk lagere benodigde dosis te
hebben. Voorts is een strikt hypothetische situatie beschouwd waarbij
conventionele thorax units vervangen zijn door een van de nieuwe beeld-
versterkersystemen. Er blijkt slechts een gering aantal maligniteiten
voorkomen te kunnen worden.
Hoofdstuk 10. Bij de introductie van een nieuwe modaliteit dienen de
kosten geëvalueerd te worden. UK deze studie bNjkt duidelijk dat er
belangrijke kostenbesparingen gerealiseerd kunnen worden bij de
beeldversterkersystemen.

151 ƒ
/ l/5JL
APPENDICES

INDEX

1 : Viewing instructions for pulmonary nodule detection studies.

2 : Scores and raw data chapter 5.
Diagnostic accuracy of LFOV-II chest rontgenograms of a phantom
model with simulated pulmonary nodules.
3 : Scores and raw data: chapter 6.
The effect on diagnostic accuracy of minification using a phantom
model with simulated nodules.
4 : Viewing instructions for interstitial pattern disease detection studies
5 : Scores and raw data: Chapter 7.
Diagnostic accuracy of LFOV-II chest rontgenograms of a phantom
model with simulated interstitial pattern disease.
6 : Scores and raw data: Chapter 8.
Influence of radiological training on diagnostic accuracy assessed
by means of a phantom model with simulated interstitial pattern
disease.
7 : Raw data Chapter 10.
A cost analysis.

153
APPENDIX-1

VIEWING INSTRUCTIONS FOR Pulmonary Nodule Detectton STUDY

View in a dark room and view only one image at a time. Only one
viewbox should be switched on.

Indicate the presence of a nodule on the film and give the confidence
level using the following rating scale.

1 = Nodule probably not present

2 = Presence uncertain
3 = Nodule probably present
4 = Nodule present

For the FROC analysis it is VERY IMPORTANT that the entire range of
the rating scale is used.

Viewing distance may be varied at all times.

Note the time before and after reading aM films in one envelope.

154
APPENDIX-2,a-d

Scores and raw data: chapter 5.

Diagnostic accuracy of LFOV-II chest rdntgenograms using a phantom
model with simulated pulmonary nodules.

155
APPENDIX-2*

Conventiorjil Full Size

Reader Confidence True False A,
Level Positive Positive

A 1 7 13 0.4875
2 15 18
3 25 16
4 160 8
B 1 16 59 0.3448
2 44 52
3 43 24
4 85 3
C 1 15 18 0.4412
2 46 31
3 52 4
4 78 1
D 1 2 6 0.5585
2 9 17
3 55 11
4 158 4
E 1 33 36 0.3607
2 41 14
3 53
4 26
F 1 2 15 0.5493
2 19 19
3 54 11
4 155 5

APPENDK-2a. Chapter 5. Diagnostic accuracy of C-FS modality assessed in a comparative

study using simulated pulmonary nodules. Readers A-F are listed.

156
APPENDIX-2b

Large Entrance Field image Intentifier, 57-cm mode

Reader Confidence True False A,
Level Positive Positive

1 5 17 0.4632
2 13 15
3 30 15
4 155 14
B 1 14 34 0.3285
2 30 50
3 48 23
4 78 3
1 15 11 0.4430
2 47 12
3 42 3
4 57 1
1 2 11 0.5128
2 16 14
3 42 13
4 150 5
1 27 26 0.4942
2 39 10
3 49 1
4 83 1
1 5 23 0.5379
2 30 31
3 53 18
4 155 5

APPENDM-2b. Chapter 5. Diagnostic accuracy of LEF-II, 57-cm mod*, in a

corRparativ* study using simulated pulmonary nodules. Rsadsre A-F art listed

157
APPENDIX-2C

Large Entrance Field Image Intensifier, 47-cm mode

Reader Confidence True False A1
Level Positive Positive

^ 1 77 23
23 0.5130
2 8 20
3 21 19
4 193 23
B 1 9
9 46
46 0.3175
2 21 47
3 69 32
4 81 10
C 1 19
19 13
13 0.5150
2 35 8
3 52 3
4 83 1
D 1 2
2 7
7 0.5214
2 8 23
3 30 22
4 183 12
E 1 36
36 20
20 0.5520
2 35 8
3 45 1
4 98 -
F 1 3
3 23
23 0.5190
2 16 27
3 40 17
4 161 2

APPENDDC-2C. Chapter 5. Diagnostic accuracy of LEF-II, 47-cm mode, assessed in a

comparative study using simulated pulmonary nodules. Readers A-F are listed.

158
APPENDIX2d

Slit Image Intensifier

Reader Confidence True False A1
Level Positive Positive

1 6 20 0.5561
2 13 14
3 18 13
4 209 24
B 1 17 59 0.3230
2 33 61
3 49 26
4 74 1
1 24 14 0.5208
2 45 5
3 46
4 78
1 1 7 0.5508
2 10 17
3 38 14
4 176 6
1 27 14 0.6101
2 44 5
3 51
4 106
1 1 9 0.4664
2 15 13
3 42 9
4 127 5

APPENDD(-2d. Chapter 5. Diagnostic aocuracy of S-ll assssssd in a comparative study using

simulatsd nodulss. Raadars A-F ara Hstad.

150
APPENDIX-3,a-d

Scores and raw data: chapter 6.

The effect of minification on diagnostic accuracy using a phantom
model with simulated nodules.

161
APPENDIX-3*

Full-size copies
Reader Confidence True False A1
Level Positive Positive

AA 1 17 245 0.433
2 36 84
3 32 22
4 140 4
BB 1 6 201 0.367
2 32 80
3 53 39
4 113 8
CC 1 15 150 0.338
2 49 258
3 43 111
4 128 27
00 1 11 130 0.411
2 45 130
3 40 25
4 132 9
EE 1 11 44 0.455
2 20 16
3 27 7
4 147 11
FF 1 17 45 0.473
2 41 20
3 79 3
4 66 -

APKNOIX-aa. Chap** 6. Oao/loaHc aoouraoy of fuM-aiza ooplM of rOntoanograma of

•
aknutattd oulmonarv nodular AM nodulaaara
i oonaiditfVO.

162
APPENDIX-3D

Minified copies
Reader Confidence True False A1
Level Positive Positive

AA 1 9 181 0.398
2 30 75
3 28 29
4 143 18
BB 1 10 214 0.380
2 19 43
3 47 25
4 120 7
CC 1 5 149 0.341
2 45 260
3 67 130
4 127 32
DD 1 11 98 0.405
2 51 81
3 56 24
4 106 4
EE 1 15 35 0.454
2 17 14
3 26 10
4 142 8
FF 1 7 37 0.425
2 52 51
3 64 3
4 55 1

r
r9b. Chapter 6. nagnoatte aoouraoy of mfeiMad oopiaa of rfirrtganogramc of
oodutei. All nodutes a n oonaWarad.

163
 APPENDIX-3C

Full-size copies
Header Confidence Tme False A1
Level Positive Positive

AA 1 6 47 0.4222
2 13 25
3 16 9
4 54 2
BB 1 23 0.3641
2 15 28
3 20 21
4 44 3
CC 1 4 40 0.3611
2 20 99
3 18 27
4 52 9
DD 1 2 34 0.4528
2 18 41
3 16 8
59 2
EE 1 3 10 0.4964
2 6 5
3 11 1
4 64 6
FF 1 7 17 0.5371
2 19 11
3 36 2
4 34

APPENOOMe. Chapter 6. Dtagnorffc aoouraoy of fuN-aiza oopiaa of r&rtganogramc of

simulated pulmonary nodol—. Only paripnaral nodutes ar» oorMktorcd.

164
APPENDiX-3d

Minified copies
Reader Confidence True False A1
Level Positive Positive

AA 1 3 39 0.4237
2 10 31
3 15 6
4 60 5
BB 1 3 23 0.4004
2 7 15
3 18 18
4 55 7
CC 1 5 58 0.3973
2 24 96
3 27 48
4 61 17
DD 1 5 28 0.4711
2 15 27
3 7
4 49
EE 1 7 9 0.5194
2 7 4
3 7 2
4 66 2
FF 1 5 19 0.4944
2 17 24
3 41 3
4 32

APPENDDC-Sd. Chapter 6. Oagnoatlc aoouracy of minified ooptes of rontgenograms of

simulated pulmonary nodul—. Only peripheral nodulM are oonaidered.

166
APPENDIX-4

VIEWING INSTRUCTIONS FOR Interstitial Pattern Detection HUMS

View in a dark room and view only one image at a time.

Only one viewbox should be switched on.

Write down your diagnosis, using the confidence levels for interstitial
pattern disease listed below.

1 - Interstitial pattern disease not present

2 = Interstitial pattern disease probably not present
3 = interstitial pattern disease unsure present
4 - Interstitial pattern disease probably present
5 = interstitial pattern disease present

For the ROC ansJysis it is VERY IMPORTANT that the entire range of
the rating scale is used.

Viewing distance can be varied for all images.

186
APPENDIX-M-d

Scores and raw data: chapter 7.

Diagnostic accuracy of LFOV-II chest rontgenograms using a phantom
model with simulated interstitial pattern disease.

167
APPENDIX-58
Conventional Full-size

RATING SCALE RATING SCALE RATING SCALE

observer AAA observer BBB observer CCC
11 21 3! 4i 5! tot. 11 2| 3 4 EJ lj tot. 1 2 3| 4j 5| tot. I
i 48 j
0 Layers of IPD (normal) 1j19jI7j 48 | 3 8 3| 48 16J19 7j 6|
1 4|
1 Layer IPD 2} 1 8 | 1j 1! 1 1 4j 8 3 2| 1j 2| 8 j
2 Layers 2j 3j 3| 8
! 3j ij 1 1 2| 8 1j 1j 6j 8 !
2| ij 1 1 2! 3} 1j 8 |
4
3 Layers 2| 2| •I 8 | •I 8
i i 7| 1 i j 1 7| 8 i
4 Layers 8 | 1! 7| 8 |
5 Layers 1] 2| 5] O | i ij

| j
n 8 4 i
*i 3| 8 !
6 Layers (strong abnormal) 1! 1! 5! 1 8 i 8j 8 J
2| 6! 8 !
Az 0.6752 Az 0.8260 Az 0.9096

RATING SCALE RATING SCALE RATING SCALE

observer DDD observer EEE observer FFF
Ij 2} 3! 4! 5! tot.! 1! 2! 3! 4i 5! tot.! 1! 2! 3! 4l 5i tot.!
0 Layers of IPD (normal) 48j | j | 1 48 ! 11 23> 6 : 8' 1 48 12J21 10; 5| j 48
1 Layer IPD 7' 1'j j 1 8 !i 1 1 3 3j 8 41
1
1 J 2! 2| 3| 8
1 1 8 2j 1 3j 2| 1 8
2 Layers I j i
1 4j 3| 8
1| 1 1 4{ 2| 1| 5| 1j 8
4
3 Layers 6| 1|i 1 8| 8
4 Layers i1 !1 | 6j 8| 2 2' 4j 8
a
1j 1! 6! 8
5 Layers 2| ij 5j 8i 2| 6j 1j •I 3| 8
6 Layers (strong abnormal) 3{ 2j ! 1! 2! 8 ! ! 3! 5! 8 1 2! 3! 2! 8
Az 1.000 (degenerate) Az 0.9113 Az 0.8502

RATING SCALE
observer GGG
1! 2! 3! 41 5! tot.i
0 Layers of IPD (normal) 7|27j 8j 6| 1 48
1
2
Layer IPD
Layers
1 1

1 I!
6j 2{
2j4j 1;
i 8
8
3 Layers i 1!1j4j 2j
1 1 8
8i
4 Layers :: ! 8|
5 Layers. :i 1j 4j 3| 8 j
6 Layers (strong abnormal) > •
i ?!3! 8
Az 0.9274

APPENDM-Sa. CHAPTER 7. Diagnostic accuracy of conventional full-siz* rdntganogram* of simulatad

inrnvttHial pattern diaaat*.

168
APPENDIX-5b
Large Entrance Field Image Intentifier, 57-cm mode

RATING SCALE RATING SCALE RATING SCALE

observer AAA observer BBB observer CCC
11 2! 31 41 51 tot.i 11 21 31 4! 51 tot.i 11 21 3i 415i tot..1
0 Layers of IPO (normal) 48 11J10J 2J13J12J 48 9J14J 48 j
1 Layer IPO 5| 8 3! 8 8i
2 Layers A 8 8 i t
3| 8 !
3 Layers 3! 1| 8 1 4|3| 8 2| 8 i
4 Layers 2| 6} 8 i Si 8 8! 8 !
5 Layers 5{ 3| 8 8 6| 8 i
6 Layers (strong abnormal) 21 61 8 i l l s ! 8 ol
Oi 8i
Az 0.7850 Az 0.7925 Az 0.8411

RATING SCALE RATING SCALE RATING SCALE

observer 000 observer EEE observer FFF
1i 2i 3i 4l 51 tot..1 1! 2i 3! 4i 5! tot.! 11 2i 3! 4! 5! tot.!
0 Layers of IPO (normal) 46} 2j i 48 I 9 8i 9|16J 6| 48 8! 8j 1i 48 |
8
1 Layer IPD 8 i 4 j 1 j3! i 8 2J2| 3| 1! |
2 Layers 8 J 1} 2| 8
*i 2| 2| 2| 2| 8 !
3 Layers 8 i 1 2.21 1| 8 3|
i 8
j
4 Layers 8 { i j 8j 8 8
2| 1! 1! 1! 3 !
5 Layers 8 | i 3| 5j 8 j 4| 3 8 i
6 Layers (strong abnormal) i 7! 8 i i 1! 7! 8 I i 4! 4! 82
Az 0.8125 Az 0.7509 Az 0.6558

RATING SCALE
observer GGG
11 21 3! 4i 5! tot.i
0 Layers of IPO (normal) 7J24J11J 6 | | 48
1 Layer IPD 1|4|3| | ! 8
2 Layers 1| 1 | 1 | 5 | | 8
3 Layers 1j 2| 2j 3j | 8
4 Layers i ! !2|6J 8
5 Layers I i 1|2{5{ 8
6 Layers (strong abnormal) 8 I } 5{ 3} 8
Az 0.8110

APPENDK-5b. CHAPTER 7. Diagnostic accuracy of LEF-II, 57-cm mod*, rdntgenogram* of simulctad

intarstitial pattern dii

169
APPENDIX-5C
Large Entrance Field Image Intensifier, 47-cm mode

RATING SCALE RATING SCALE RATING SCALE

observer AAA observer BBB observer CCC
11 2! 3i 4! Sj tot.l 1! 2i 3! 4i 5i tot.I 11 2i 3! 41 51 tot.I
0 Layers of IPO (normal) 1|16|i2ji9j ij 48 j 12|16| 6j 6j 8| 48 | 17J16 8! 7! 48
1 Layer IPD I °i 2i 4{ 2> 8 i I3j4j 8 i i 1] 6! 8
i |
2 Layers 1| 4j 8 ! I ! 8{ 8 3j 8
3
4
Layers
Layers
3} 4! 1! 8 I
4j 3! 8 I
i 11 71 8
1 1} 7J 8 i i •] 1]
3[
°! 8
8
5 Layers 8 8 11 7! 8
6 Layers (strong abnormal) i i
i :«!
8 i
6! 8 8! 8 !
Az 0.8547 I
Az 0.9291 I 8! Az 0.9528

RATING SCALE RATING SCALE RATING SCALE

observer ODD observer EEE observer FFF
11 21 3! 41 5itot. 1! 2! 3i 4i 5l tot.l 1! 2! 3! 4l 5l tot.I
0 Layers of IPO (normal) 47} j 1} 48 7J19J 9J12{ 1j 48 20)16! 6j 5| 48
1 Layer IPD 3{ 8 2{4! j 8 2} 2j 3| 1} 8
2 Layers 1! 8 11 i 7} 8 11 1! 2j { 8
3 Layers 11 3j 3{ 8 3! 4j i 3 2! 3! 2!11 8
4 Layers 2! 8 ! i 3j 4! 8 5i ! 3 ! 1 8
5 Layers 7! 8 I Si i 8i 8I I I 2| 3} 31 8
6 Layers (strong abnormal) _8]_ 8 i i 8! 8 i i ! 4! 8
Az 0.9860 Az 0.8762 Az 0.8184

RATING SCALE
observer GGG
1! 2l 3! 48 5! tot.l
0 Layers of IPD (normal) 6! 48}
1 Layer IPO 2J2J 8!
2 Layers i i 7J 8!
3 Layers 2J2{ 81
4 Layers 8 !
5 Layers Ml ! 4 J 3| 8;
6 Layers (strong abnormal) I I ; ii 71 8 !
Az 0.8418

APPEND0C-5C CHAPTER 7. Diagnostic accuracy of LEF-II, 47-cm mod*, rorrtgenograms of simulated

interstitial pattern disease.

170
APPENDIX-5d
Slit I m a g e Intensifier

RATING SCALE RATING SCALE RAT INC; SCALE

observer AAA observer BBB observer CCC
1
1! 2! 3! 4! 5| tot.! 1! 2i 3! 4 ! 5! tot. 1{ 2 u-3 ' 4' 5 tot.J
6 18|10j14j
0 1
0 Layers of IPD (normal) ! 5|14|25J 4 ! 48 ! i 48 9 8{ 48
1 Layer IPD 2
! ! 1 •I 1! 8 i ! 2 |3 3' 8 i 3 4 1' 8j
2 Layers i 3| 4 11 ! 8 2j 1 I 3 !2| 8 1
2 1 1' 8j
3 Layers
4 Layers i
2\ 2
i
si2| 61!! 8i
8
1! 1 i 2 4'
i
i i 8J
8
8
1j 2 3' 2 8 i
2| 6 i 8 !
5 Layers !i 3] 5! 8 ii i
i
i
I 8| 8 |8 8:
I I8
6 Layers (strong abnormal) • |
1 j 7! 8I i • 8| 8 8i
Az 0 .6475 Az (1.7664 Az (1.8422

RATING SCALE RATINCi SCALE RATINCi SCALE

observer DDD observer EEE observer FFF
1j 2| 3J 4| 5 tot. 1! 2! 3 ! 4 5| tot.. 1! 2! 3 *i5 tot. I
0 Layers of IPD (normal) 44 j | I i 4 48 j 4|17| 5J15 7\ 48, ^I
15}12|15 48
1 Layer IPD 8j j 8 ! 2j3j 3| . ii 8
ii !i 1
2 Layers 5J3J 8 i 1! 1! 3J 1| 2| 8i
1|3
1 1
3J
2| • i 1
8 j
8i
3 Layers 7j | i i 1 8 ! i i! 5 3| 8i 2 | 2 | 1 3| 8!
4 5| Oj 0| 2| 1 1j 1{ 4 2| i 8
Layers 8 8 ! : i 5|: 2! i
5 Layers 3| 1| ! 1 i3 8 i 11 3 | 4', j
II
8| 3
! ! i
3| 2| 8
i
6 1! 1! 1! 1! 4 1 1
-2J 5! lj 8
Layers (strong abnormal) 8 J j ! 3! 8! '
Az 0.9167 Az 0.6113 Az 0 .7270

RATING SCALE
observer GGG
1! 2! 3! 4j 5| tot.
0 Layers of IPD (normal) 1OJ16{12J1OJ i 48
1 Layer IPD 1J2J 2|2J 1 8
2 Layers !4! 1|3J i 8
3 Layers S21 i 4| 3| ii 8
4 Layers S i 2| 4| 8
5 Layers S 2{ 1j 5J 8
6 Layers (strong abnormal) j | 1! 5{ 2| 8 j
Az 0.7407

APPENDD(-5d. CHAPTER 7. Diagnostic accuracy of S-ll rdntgenograms of simulated interstitial pattern disease.

171
APPENDIX-6,a-b

Scores and raw data: chapter 8.

The influence of radiological training on diagnostic accuracy assessed by means of a
phantom model with simulated interstitial pattern disease.

173
APPEMDIX-6a
Untrained observers

RATING SCALE RATING SCALE RAT INC> SCALE

observer 1/untrained observer 2/untrained observer 3/untrainec
1! 2 ! 3| 4|5j tot.j 1j 2j 3! 4! 5 tot. | 1j 2 3j 4 5 j tot.
0 Layers of IPD (normal) 8| 6 4*4' 6| 28! 15iHi 2! ! 28! 10j 9 7| 2 i 28
1 Layer IPD 1| : 2i ii 4! 8i | 2j 6' ' 8! 1 A a
1 1
1| ! ii i 6J 1 a

oo"

co"
2 Layers ! 1! 3! 4j A
i i
3 Layers i 1 1 : : 7j 8! 3j4j 1 8! 1
A 8
4 Layers i
i ii ii 8! 8! i i
|7i 1 8| A 8
i i
5 Layers (strong abnormal) 8! • 8 iJ
8! 8! 8
Az: 0.8850 Az: I).9825 Az:(),9891

RATINli SCALE RATING SCALE

observer 4/untrained observer 5/untrained
1j 2 3! 4! 5j tot.} i! 2] 5|: 4j >!! tot.}
0 Layers of IPD (normal) 8J10 6 J 2 J 2j 28{ 8J14J 6' ' 28!
i i i i
1 Layer IPD 1|2! 5! 8j i 2| 5j 1j 8!
i ii
2 Layers ! ! 1! 7j ai ! 2! 8!
3 Layers \2 1| 2} 3! 8! ij 2' 5' 8!
4 Layers 1 1 4 1 7j i I
5 Layers (strong abnormal)
1 '1
1 1
8| i
1|7J 8!
1 8j 8! • • | 8| 8j
Az:C1.9388 Az:0.9857

APPENDIX-ea. CHAPTER 8. The influence of radiological training on diagnostic accuracy found fc

simulated interstitial pattern disease. Readers 1-5 (unUained) are listed.

174
APPENDIX-6b
Trained observers

RATING SCALE RATING SCALI RATING SCALI

observer 1/trained observer 2/trained observer 3/trained
1} 2! 3} 4 ! s;tot.; 1! 2 • 3 5j tot.J 1 2! 3! 4 5! tot.!
9 1 1
0 Layers of IPO (normal) 14{ ! 3j 2 1 1 28! 24} 3 , 1 i
281, 10| 4j 4j 6 *l 28!
1 Layer IPO i
3} | 2{ ' 1 2' 8j 1| 2 1
5! 8| i ,8{ 8i
2 Layers
3 Layers
1| 1 j
i !ii 1 6'
i*i
8'
8
i ii
!2 2 3
i 1
1j
8!
•1
i
I
I
2 6j
8!
8!
8|
4 Layers 7 i
i i 1
i i i 8! i 8! 8!
8
i 8! 8!
5 Layers (strong abnormal) i I | ! ?! 8! i 8! ! 8! 8l
Az:0.8989 Az:().9841 Az:0.8571

RATING SCALI RAT INC; SCALE

observer 4/trained observer 5/trained
1! 2! 3! 4 ?! 'j o t T ! 1! 2 3' 4 5| tot.J
0 Layers of IPD (normal) 3|10| 9\ 5 1! 28! 14J10 *l II i 28j
1 Layer 1 PD !3 1!3 1{ 8! 1| 2 5! i 8!
i 9l
2 Layers 2!* *| 8! 1 j j 3! 2! 2! 8i
1
3 Layers ! ! 2 5J 8! i 2{ 3! 3! 8|
i
4 Layers 1i 7! 8! 1! i 3! 4j 8!
5 Layers (strong abnormal) ^^^^^ 1
•1
1 8! i 1 1 fli 8'
1
Az:0.8802 Az: 0.9339

APPENOOMb. CHAPTER •- Tha inAuanoa of radfotogioaj training on dtognoaUc aoouracy found for
MM*. R M d m 1-6 pnkmd) tn Naiad.

7/
APPENDIX-7

Raw data: Chapter 10

A Cost analysis.

177
Slit Image Intensifier (Philips LFOV-II)

DIRECT VARIABLE (per successful exposure)

- Film costs 1.05
- Developer and fixative 0.03
- Paper costs 0.26
TOTAL 1.34
DIRECT SEMIVARIABLE (per unit)
- Image intensifier tube 84,000
- SRO X-ray tube 41,256
DIRECT FIXED (10 years)
- Philips Piimodlagnost, including support and lead screen 201,600
- Medio 50 CP Pulmogenerator 160.800
- HS cables 5.544
- Scopix 12 Daylight processor 36,950
- 10 x 10 cm flm fssdsr 6.500
- General Bsctric 100 mm viewer 36.000
- Odelca Delcadro mapping machine 11.760
TOTAL 459,154
DIRECT FIXED (3yeers)
- Cadrix plastic holders for mapping machine 0.816
DIRECT FIXED (1 year)
- Manufacturer maintenance: imaging equipment 20,400
- Manufacturer maintenance: viewing equipment 0.720
- Manufacturer maintenance: daylight proceseor 3.046
Manufacturer maintenance: mapping machine 0.900
TOTAL 25,086
DIRECT FIXED (1 week)
- Department maintenance of daylight proceseor
1.5 hours a DR. 25 37.50

Tabtot. in OR for (LFOV) 8-* teohniqu* when no •q/utptmt* or a

178
Large Entrance Field Image Intensifier (Siemens LFOV-II)

DIRECT VARIABLE (per successful exposure)

- FMm costs 1.05
- Developer and fixative 0.03
- Paper costs 0.26
TOTAL 1.34
DIRECT SEMIVARIABLE (per unit)
- Image intensifler tube 204,000
- X-ray tube 48,000
DIRECT FIXED (10 years)
- Siemens TS 5 7 I I , including lead screen 117,600
- 3D support 104.400
- Poiyphoe 50 generator 192,000
- HS cables 6,000
- Scopbc 12 daylight processor 36.950
- 1 0 x 1 0 cm feeder 6,500
- General Electric 100 mm vlewsr 36,000
- Odeica Deicadro mapping machine 11,760
TOTAL 511.210
DIRECT FIXED ( 3 y w n )
- Cadrix plastic holder* for mapping machine 0,816
DIRECT FIXED (1 year)
- Manufacturer maintenance equipment 22,680
- Manufacturer msJntsnance viewing equipment 0,720
- Manufacturer 3.046
Manufacturer maintenance mapping machine 0,900
TOTAL- 27,346
DIRECT FIXED (1 week)
Department maintenance of daylight processor
1.5 hours a D R 25 37.50
Tafete N. DWhwtttattd oaato in OH for (UQV) LEF-* (Stomom) •MnnK|Uv wiwn no
opuipmont or • dopwotatod systMi to O J M M I in a QMwral hotpKii

179
Dedicated Full-size film-screen (Philips)

DIRECT VARIABLE (per successful exposure)

- Film costs 5.81
- Developer and fbcatsvd 0.39
TOTAL: 6.20
DIRECT SEMIVARIABLE (per unit)
- SRO X-ray tube 41,256
- 35 x 43 cm intensifier screens 1,057
DIRECT FIXED (10 years)
- Philips dedicated system Dettnorax,
including support and lead screen 182,400
- Medio SO CP Puimogenerator 160,800
- HS cables 5,544
- Cronex T6 daylight processor 38,400
TOTAL 387,144
DIRECT FIXED (1 year)
Ubunrfartmw maintananrar krmnlnn Anninrrmnt

including daylight processor 20,400

DIRECT FIXED (1 wsafc)
- Department maintenance of daylight processor
1.5 hours a ML 25 37.50

com in On for DMJ-FS (PMIpt) when no «quipmMt or •

dspnotated sydMn ispnwnt in CQMMftl hospMsl

180
Dedicated Full-size film-screen (Siemens)

DIRECT VARIABLE (per successful exposure)

- Film costs 5.81
- Developer and fixative 0.39
TOTAL: 6.20
DIRECT SEMIVARIABLE (per unit)
- X-ray tube 48,000
- 35 x 43 cm intensifying screens 1,057
DIRECT FIXED (10 years)
- Siemens dedicated system Thoramat, including
lead screen 131,900
- 3 D support 104,400
- Polyphos 50 generator 192,000
- HS cables 6,000
- Cronex T6 daylight processor 38,400
TOTAL: 472,700
DIRECT FIXED (1 ytsf)
- Manufacturer maintenance: imaging equipment
including daylight processor 42,720
DIRECT FIXED (1 WNk)
- Department maintenance daylight processor
1.5 hours a DR 25 37.50

Table IV. Dlfferentlaled ooeto In DO for Dad-PS (Stamen*) when no equipment or «

oepreoiMM eyewm w pf###nt n • o*nerai notpmi.

181
Conventional Full-size film-screen (Philips)

DIRECT VARIABLE (per successful exposure)

- Film costs 5.48
- Developer and fixative 0.37
TOTAL: 5.85
DIRECT SEMIVARIABLE (per unit)
- SRO X-ray tube 41,256
- 35 x 43 cm intensifying screen 1,057
- 35 x 35 cm intensifying screen 0,905
DIRECT FIXED (10 years)
- PhNips Diagnost 2 bucky system, including
lead screen 31,200
- CS 62 ceiling construction 68,400
- Medfo 50 CP generator 160,800
• HS cables 5,544
TOTAL- 265,944
DIRECT FIXED (1 year)
- Manufacturer maintenance imaging equipment 19,200

FsM# V. DiffMvnlislod ooMs in DR. for C*FS (Philips) when no cQuipfrwnt Of •

QspreoMMO lyHMn m

182
Conventional Full-size film-screen (Siemens)

DIRECT VARIABLE (per successful exposure)

- Film costs 5.48
- Developer and fixative 0.37
TOTAL: 5.85
DIRECT SEMIVARIABLE (per unit)
- X-ray tube 48,000
- 35 x 43 cm intensifying screen 1,057
- 35 x 35 cm intensifying screen 0,905
DIRECT FIXED (10 years)
- Siemens Vertix 2E bucky system 40,840
- 3D2 manual support 78,000
- Polyphos 50 generator 192,000
- HS cables 6,000
- lead screen 7,800
TOTAL 324,640
DIRECT FIXED (1 year)
- Manufacturer maintenance imaging equipment 22,500

Table VI. in DR for C-FS (Siemens) system when no equipment or

TI is present m a general noepnej.

"/in
UST OF ABBREVIATIONS

CED = Collective Effective Dose

C-FS = Conventional Full-Size Film-Screen Radiography
COTG = Centraal Orgaan Tarieven Gezondheidszorg,
Central Organ Charges Health Care
DA = Diagnostic Accuracy
Ded-FS = Dedicated Full-Size Film-Screen Radiography
FN(F) = False Negative (Fraction)
FP(F) = False Positive (Fraction)
FROC = Free Response Receiver Operating Characteristic
II = Image Intensifier
IPD = Interstitial Pattern Disease
LEF-II = Large Entrance Field Image Intensifier
LFOV = Large Field of View
PA = Posterior-Anterior
PU = Proximity-focused Linear Image Intensifier
PND = Pulmonary Nodular Disease
ROC = Receiver Operating Characteristic
RP = Rdntgen Photofluorography
SD = Standard Deviation
SED = SomatteaHy Effective Dose
SID = Source to Image receptor Distance
S-ll = Slit Image Intensifier
TL(D) = Thermoluminescence (Doslmetry)
TN(F) = True Negative (Fraction)
TP(F) * True Positive (Fraction)

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UST OF PUBLICATIONS AND PRESENTATIONS

In the course of the studies, the following publications and lectures were
presented.

11-12-1987 : Presentation: 100 mm chest X-rays. Course chest radiology.

Dutch association of radiology. Utrecht.
16-04-1988 : Presentation: New future for 100 mm chest X-ray?
Dutch association of pulmonoiogists. Utrecht.
26-04-1988 : Presentation: Digital and conventional chest imaging; an
observer performance study using simulated interstitial
pattern disease. Europacs. Leiden.
26-09-1988 : Scientific poster: Image quality and radiation dose of 100
mm image intensifier chest rontgenographs. Workshop
image quaiity and radiation exposure in diagnostic radiology.
Commission of the European communities. Oxford, England.
05-10-1968 : Presentation: Digitale und Konventtonelle Thoraxaufnahmen:
eine ROC-Studie unter Verwendung eines PACS Subsystem.
3. Frankfurter Gesprach uber Digitale Radiographie. Bad
Neunekn, Germany.
29-11-1988 : Presentation: Large Field of View Image Intensifiers versus
conventional chest radiography: A ROC study with simulated
interstitial disease. Look H.L Winter, Dev.P. Chakraborty,
Paul F.G.M. van Waes. RSNA, Chicago, USA.
11-1988 : Abstract: Large Field image Intensifiers versus conventional
chest radiography: ROC study with simulated interstitial
disease. Loek H.L Winter, Dev.P. Chakraborty, Paul F.G.M.
van Waes. Radiology 1988; 169(P): 159
29-01-1969 : Presentation: Diagnostic quality of digitized versus analog
phantom chest rontgenograms. Medical Imaging III.
Newport Beach, USA.

185
 03-1989 : Publication: Diagnostic image quality of video-digitized chest
images: a phantom study. Loek H.L Winter, Rhett B. Butler,
Walter B. Becking et al. J.Med. Imaging 1989; 3: 61-67.
1989 : Publication: Diagnostic evaluation of a PAC subsystem using
phantom ches! rontgenograms: An observer performance
study. Loek H.L Winter, B.M. ter Haar Romeny, F.H.
Barneveld Binkhuysen et al. SPIE vol. 1989; 1093: 418-422.
1989 : Publication: Diagnostic image quality evaluation chain:
applications of the package in practice. F.P. Ottes, J.P.J. de
Valk, LH.L Winter et al. SPIE vol. 1989; 1093: 2-9.
25-10-1989 : Presentation: 100 mm chest X-rays. Course radiation
physics. Dutch association of radiology. Utrecht.
17-11-1969 : Presentation: Study of two novel Large Field of View Image
Intensifiers versus conventional chest radiography with use
of FROC methods and simulated pulmonary nodules. Loek
H.L Winter, Dev.P. Chakraborty, Paul F.G.M. van Waes, Carl
B A J . Puylaert. RSNA, Chicago, U.SA
11-1989 : Abstract: Study of two novel Large-Field of-View Image
Intensifiers versus conventional chest radiography with use
of FROC method and simulated pulmonary nodules. Loek
H.L Winter, Dev.P. Chakraborty, Paul F.G.M. van Waes, Carl
B A J . Puylaert. Radiology 1989; 173(P): 91
09-12-1989 : Presentation: Diagnostic image quality of digital and
conventional chest radiography. A phantom study. Dutch
association of radiology. Utrecht.
1990 : Publication: Free-response methodology: alternate analysis
and a new observer performance experiment. Dev. P.
Chakraborty, Loek H.L Winter. Radiology 1990; 174:873-881
1990 : Publication: Diagnostic image quality and patient exposure
of phototpot image Intensifier chest radiographs. BIR report
1980; 20:129-130.

187
CURRICULUM VITAE

De schrijver van dit proefschrift werd op 30 november 1959 geboren te

Voerendaal (Z-L).
In 1978 behaalde hij het eindexamen Atheneum B aan het Coriovallum
College te Heerlen.
De studie geneeskunde aan de Rijksuniversiteit Umburg werd in 1984
besloten met het arts-examen.
Vervolgens is hij werkzaam geweest als 'flying-docter' bij de alarmcentrale
S.O.S. international te Amsterdam.
Van maart 1985 tot maart 1987 heeft hij de B-opleiding radiologie gevolgd te
Almelo (opleider: J.W. Rethmeier). De hierop volgende A-opleiding (1 maart
1987 - 1 maart 1989) werd genoten in het Academisch Ziekenhuis te Utrecht
(opleider: Prof.dr. P.F.G.M. van Waes). Na een waarneming van 1 maand ín
het LBJ Hospital (American Samoa) maakt hij vanaf 1 mei 1989 deel uit van
de röntgenmaatschap van het Reinier de Graaf Gasthuis te Delft.

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ISBN 90 900 4625 9