Economic Evaluation of Conventional Radiography with Film and Computed Radiography: Applied at BMC

Advances in Computed Tomography, 2012, 1, 23-29

http://dx.doi.org/10.4236/act.2012.13006 Published Online December 2012 (http://www.SciRP.org/journal/act)

Economic Evaluation of Conventional Radiography with

Film and Computed Radiography: Applied at BMC

Usama Ali Rahoma, Pavan Kumar Chundi

Department of Radiology, Faculty of Medical Technology, Omar Al-Mukthar University, Tobruk, Libya

Email: UsamaAliRahoma@yahoo.com, pavan9000@yahoo.com

Received September 16, 2012; revised October 26, 2012; accepted November 7, 2012

ABSTRACT

Conventional radiography with film (CRF) has been in use for diagnostic purposes for a long time now. It has proved to

be a great assert for the radiographers in assessing various abnormalities. With recent advances in technology it is now

possible to have digital solutions for radiography problems at a very cost effective, environment friendly and also with

better image quality in certain applications when compared to CRF. Rather than using a CRF a computed radiography

(CR) uses imaging plates to capture the image. The imaging plate contains photosensitive phosphors which contain the

latent image. Later this plate is introduced into a reader which is then converted into a digital image. The major advan-

tage and the cost effective element of this system is the ability to reuse the imaging plates unlike the photographic film

where in only a single image can be captured and cannot be reused. The computed radiography drastically reduces the

cost by eliminating the use of chemicals like film developers and fixers and also the need for a storage room. It also

helps to reduce the costs that are involved in the disposal of wastes due to conventional radiography. This paper inves-

tigates whether it is cost effective to use computed radiography over film based system at Al-Batnan Medical Center

(BMC), Tobruk, Libya by using Cost Benefit Analysis (CBA). Apart from the initial cost of the CR System, based on

the data collected from the center, from the year 2008 to 2012 (until June 2012) a total of 581,566 images were pro-

duced with the total cost incurred using film based system being USD 4,652,528. If the same number of images were

produced using a CR system the total cost incurred would have been USD 82,600. Taking into consideration the cost of

a new CR system to be USD 120,000 the overall cost of producing these images is USD 202,600. It is observed that an

amount of USD 4,449,928 could have been saved over the period of 5 years starting from 2008 to 2012 by using the CR

system at BMC. Using Cost Benefit Analysis, the average value of the net difference between the costs and benefits for

the conventional film based system is −83.38 where as for the Computed System it is 22.06. Based on the principles of

Cost Benefit Analysis it can be concluded that the system with a net positive difference is more cost beneficial than the

other. With the help of the above two analysis it can be concluded that the use of computed radiography is definitely

more cost effective for use at BMC, when compared to the conventional x-ray radiography.

Keywords: Radiographic Film; X-Ray Radiography; Computed Radiography; Cost Benefit Analysis

1. Introduction

Computed radiography (CR) is a digital imaging tech-

nology and digital x-ray image management system that

has been used in human and veterinary medicine since

the 1980s. CR helps eliminate many of the disadvantages

of traditional radiography. A storage phosphor plate col-

lects the pattern of x-ray attenuation that is extracted by a

reader, which converts the data into a digital signal. The

image is stored like any computer file and can be viewed

on a computer screen, transmitted electronically, or

printed out on paper or transparent film, similar to x-ray

film [1-3]. Computer software allows manipulation of the

digital image to enhance viewing. Rather than utilizing

conventional x-ray film to capture an image, computed

radiography uses an imaging plate. This plate contains

photo sensitive storage phosphors which retain the latent

image. When the imaging plate is scanned with a laser

beam in the digitizer, the latent image information is re-

leased as visible light [1,4,5]. The imaging plate is a

flexible image sensor in which bunches of very small

crystals (grain size about 5 μm to 25 microns) of photo-

stimulable phosphor [5]. The first step involved in this

process is the exposure of the phosphor plate to record an

image. The image thus recorded here is an invisible la-

tent image. Now the phosphor plate is made to pass

through a reader and processing unit. In this unit the

screen is scanned by a very small laser beam. When the

laser beam strikes a screen it causes light to be produced.

The light that is produced is proportional to the x-ray

exposure. The result is that an image in the form of light

is produced on the surface of the phosphor screen. As the

U. A. RAHOMA, P. K. CHUNDI

surface of the phosphor screen is scanned by the laser

beam, the analog data representing the brightness of the

light is converted into digital values for each pixel and

stored in the computer memory as a digital image [6-8].

The CR system also eliminates the need of a dark room

and also the disposal of the chemical wastes that are

produced during the development of the film [9,10].

1.1. Cost Benefit Analysis

Cost benefit analysis is a basic tool that can be utilized to

improve the decision making process in the allocation of

funds to health and other. It is a method of comparing

costs and benefits of alternative programs which are

competing for funds and resources. It is recommended

that cost-benefit analysis be used as a mechanism to

evaluate innovative health programs. This may be the

sole mechanism that will enable health practitioners to

cost-justify their innovative services to the federal gov-

ernment and other third-party payers [11]. There are spe-

cific measurements for the viability of health services in

treating diseases and illness which is called economic

evaluation. These are important techniques and tools for

health economics to evaluate the health outcomes by

studying the medical cost, profit and benefits taken from

the patients’ health. There are four (4) forms of economic

evaluation which are used predominately in public health;

these are Cost Analysis (CA), Cost Effective Analysis

(CEA), Cost Utility Analysis (CUA) and Cost Benefit

Analysis (CBA). This is to ensure the economic feasibi-

lity, acceptability or viability in deciding to implement a

specific health program whether it is in public sector or

private sector. It should be noted that the most common

profitability indicators being used to come up with feasi-

bility study of the private sector in the establishment of

hospitals, clinics and medical centers is the Cost Benefit

Analysis. This is to ensure that their investments (cost of

doing the project) are highly feasible. The return of in-

vestments are sustained at given supply price such as the

user rate of hospital services, laboratory examinations,

professional fees of health personnel and other hospital

charges. The economic evaluations on cost utility analy-

sis are being used to decide the economic acceptability of

the project to support the prevention, promotion and re-

habilitation of particular illnesses or diseases for social

welfare. The health services and programs are imple-

mented to purchase the needed medical supplies, equip-

ment and facilities including the professional fees of

health personnel to specific target clients. The public

health sector has to implement health services and pro-

grams such as vaccines for communicable and non-

communicable diseases, the use of contraceptives for the

reproductive health, cancer screening, spray of DDT and

etc. These examples on the implementation of health pro-

grams have direct, indirect and intangible benefits such as

reduction in health risk, pain and suffering which cannot

be estimated from market data.

1.2. Advantages

Many studies have stated numerous advantages of using

a CR system with respect to image quality and also

eliminating the need for retakes that result from over and

under exposure [2,4,6,7,12]. Because x-ray film has a

limited linear response, a relatively small, under or over

exposure may result in an unacceptable image [8]. With

the help of CR system images that are too dark or light

can be adjusted with the image management software

thus eliminating the need for a retake. The other distinct

advantage of the CR system is the possibility to view

bone-only and soft-tissue only images from a single ex-

posure [13]. In conventional x-ray film radiography, a

numbers of images have to be taken to see both soft tis-

sue and bone in detail. This can be done in a single image

with the help of a CR system.

1.3. Disadvantages

The major disadvantages of using CR system include the

initial cost, need for training and making the necessary

changes for the new system. One important aspect that

has to be taken into account before purchase is the ease

of use of the new system. Depending on the user’s com-

puter skills, manipulation of images and use of other

software can be a time consuming process [1]. The prices

of CR systems are falling consistently and they are rec-

ommended for use in high volume practices. The initial

cost of the CR system must be weighed against the bene-

fits of using less film. Digital manipulation cannot make

all images useful. Like other computer systems the im-

ages must be backed up. Another disadvantage can be the

over processing of the image which can create artifacts.

Optimal viewing of the digital images depends on the

quality of the monitors being used and also the quality of

the paper used to take print out. These can increase the

cost of the CR system. Improper labeling or misidentifi-

cation of the patient can make the image retrieval diffi-

cult. CR system cannot compensate for improper use of

the system or poor staff training. This paper investigates

whether the Economic Evaluation of conventional radi-

ography with film and computed radiography: applied

using cost benefit analysis (CBA).

2. Material and Method

Al-Batnan Medical Center in Tobruk, Libya is a multis-

pecialty hospital catering to the needs of the people in

and around Tobruk. The center’s Radiology department

provides various diagnostic services using conventional

x-ray film techniques, computed tomography, NMR-Mag-

netic Resonance Imaging, Ultrasound scanning. From the

U. A. RAHOMA, P. K. CHUNDI 25

data collected for the year 2008 there were a total of

100,160 cases that used various diagnostic techniques

and in the year 2012 (until June) there were about

160,740 cases. Taking into account the increase in the

number of cases using the various diagnostic techniques,

the cost of developing films with conventional x-ray film

radiography also increases. The Radiology Department at

Al-Batnan Medical Center s equipped with a Konica

Regius Nano CR system which is a single bay reader

capable of processing 76 plates (14 × 17") per hour [14].

The center has also a PCR-Eleva reader system which

uses the Eleva work spot technology to give a clear and

excellent image quality. A cost benefit analysis has been

done with data collected from Al-Batnan Medical Center.

The analysis is based on a model that was used to deter-

mine the cost benefit analysis of automated testing with

IBM Rational Robot [15].

A key consideration in the use of flexible storage pho-

sphor plates and CR systems is that any exposure source

that can be used with conventional x-ray films can also

be used with this filmless technology. Also the flexible

storage phosphor imaging plates can be directly substi-

tuted for film. This compatibility with existing sources

and cassettes makes a transition from conventional film

radiography to CR a fairly uncomplicated and inexpen-

sive proposition. The most important aspect of the use of

imaging plates is the ability to reuse them. Theoretically

each imaging plate can be used thousands of times [16].

But keeping in view the improper handling of imaging

plates can cause damage to the plates. Hence for the

study, it is assumed that each imaging plate can be reused

up to 5000 times. Thus the recurring costs can be drasti-

cally reduced by using the imaging plates. This also

eliminates the need of chemicals like developer and fixer

that are used in order to produce an image with conven-

tional film radiography. Performing a cost benefit analy-

sis involves the following steps i.e. identifying the costs

and benefits. For the study the following costs for con-

ventional and computed radiography systems were iden-

tified.

1) film (total cost for the no. of films used);

2) developer chemical costs;

3) silver recovery system;

4) chemical waste disposal;

5) film archiving (space + labour);

6) administration (film indexing);

7) Software + back-up system;

8) Cost of imaging plates;

9) Consumables (DVDs).

Benefits:

1) Image quality;

2) View bone-only and soft tissue only images;

3) No retakes (over and under exposure);

4) Artifacts (over processing);

5) Compatibility to PACS;

6) Ease of producing images.

After the benefits have been identified, we have to

establish performance measures for each benefit and esti-

mate the value of the benefit. If a benefit can’t reason-

ably be assigned a monetary value, it should be valued

using a more subjective, qualitative rating system (which

assigns relative numerical values). Table 1 has been used

to rate the benefits [15]. When intangible benefits are

significant factors in the analysis, the dollar values of the

tangible benefits can be converted to the same rating scale

as used to arrive at the relative values of the intangible

benefits. This is be done by dividing all dollar values by

some arbitrary number, such as 10,000, that will give

values lower than the highest value on the “Level of

Benefit” scale [15]. The costs involved in each system

have been calculated in the following way. All the data

that was collected is in Libyan Dinars (LYD). A con-

version rate of 1 USD = 1.26 LYD has been used to

change the data in term of USD ($).

1) film (total cost for the no. of films used ) $8 per

film;

2) developer chemical costs $50 per unit per week.

units per week are 52;

3) silver recovery system $40 × 10 hrs per week;

4) chemical waste disposal $60 × 60 per week;

5) film archiving (space + labour) $15,375 per year;

6) administration (film indexing, 17 staff) $40 × 17

per week;

7) administration (on pc, 10 staff) $40 × 10 per

week;

8) Cost of imaging plates $700 per plate;

9) Consumables (DVDs) 0.25 LYD per DVD equi-

valent to $0.19.

3. Results

The data pertaining to the number of films that were used

was collected from the Emergency and Radiology depart-

ment for the years starting from 2008 to June 2012. Cost

for 100 films is 1000 Libyan Dinars (LYD) equivalent to

793 US Dollars. The conversion used here for the calcu-

lation is 1 USD = 1.26 LYD. Approximately 1 film costs

8 USD. Cost for 100,160 films is 801,280 USD for the

Table 1. Level of Benefits scale.

Level of benefit Value

Very high 5

High 4

Medium 3

Low 2

Very low 1

U. A. RAHOMA, P. K. CHUNDI

year 2008 (Table 2). Cost of one imaging plate is 700

USD which can be used for 5000 times. So for 100,160

images the number of imaging plates required is 20. The

total cost involved for 100,160 images is 14,000 USD

(Table 2). From Tables 2 and 3, for the year 2008, it can

be seen that the use of imaging plates and computed radio-

graphy system is more cost effective when compared to

the conventional x-ray film radiography. Similar conclu-

sions can be stated from Tables 2 and 3, that for the

years 2009-2012 respectively, the computed radiography

system is cost effective for use at Al-Batnan Medical

Center, Tobruk, Libya. Table 4, shows the total costs

involved in developing the images for the years from

2008 to 2012 by conventional film radiography and com-

puted radiography. Table 5 shows, the benefits on a

relative scale. From Table 6, based on cost benefit ana-

lysis it is seen that the net benefit value is positive for

Computed Radiography when compared to conventional

x-ray system. As discussed earlier a system which has a

positive net benefit value is considered to cost beneficial

over the other. Based on the above two analysis the com-

puted radiography system is cost effective for use at

Al-Batnan Medical Center. However it should be noted

that the benefits were evaluated on a scale which is sub-

jective.

4. Discussion

If the study is extended to BMC in Libya it can be stated

that huge amount money can be saved by using CR

systems over a period of time. However this study has

not taken into consideration the initial cost of equipment.

The initial cost of a CR system (approximately 120,000

USD) is much higher than that of conventional x-ray film

radiography (approximately 20,000 USD). It is important

to note that the cost of CR systems is reducing and also

the availability of the films has become less. Many

studies have stated that apart from the recurring costs, the

use of CR system can reduce the radiation dose, reduces

the number of retakes, and eliminates the need for the use

of chemicals and their disposal. Total No. of films used

around 2008-2012 (up to June) are 581566 with total cost

incurred using film based system is USD 4,652,528

where as the total cost incurred with a CR system is USD

82,600. We found that the film based system when used

has cost BMC more money when compared to the CR

system.

Table 4 shows the total costs involved in producing

images by both film based system and computed radio-

graphy system. Starting from 2008 to 2012 for each year

all the costs have been calculated based on the data that

was collected at BMC. It is observed that the costs

Table 2. Total cost and the No. of films used in the Emergency and Radiology Department for the year starting from 2008 to

June 2012.

Year No. of films used Total cost USD

2008 100160 801,280

2009 101346 810,768

2010 102580 820,640

2011 116740 933,920

2012 (up to June) 160740 1,285,920

Total 581566 4,652,528

Cost of 1 film = 8 USD.

Table 3. Estimated cost by using imaging plates. Calculations are base d on the No. films used in the Emergency and Radiol-

ogy Department for the year starting from 2008 to June 2012.

Year No. of films used to develop images Total no. of imag i n g plates required Total cost (in USD)

2008 100160 20 14,000

2009 101346 21 14,700

2010 102580 21 14,700

2011 116740 24 16,800

2012 (up to June) 160740 32 22,400

Total 581566 118 82,600

Cost of 1 imaging plate = 700 USD.

U. A. RAHOMA, P. K. CHUNDI 27

Table 4. Indicating the total costs involved in developing the images for the years from 2008 to 2012 by conventional film ra-

diography and computed radiography.

2008 2009 2010 2011 2012

Cost (in USD)

FR CR FR CR FR CR FR CR FR CR

Total cost for films 801,280 0 810,7680 820,6400 933,920 0 1,285,9200

Developer chemical costs 2600 0 2600 0 2600 0 2600 0 2600 0

Silver recovery system 20,800 0 20,8000 20,8000 20,800 0 20,800 0

Chemical waste disposal 3600 0 3600 o 3600 0 3600 0 3600 0

Film archiving (space + labour) 15,375 0 15,375 0 15,375 0 15,375 0 15,375 0

Administration (film indexing) 35,360 20,800 35,360 20,800 35,360 20,80035,360 20,800 35,360 20,800

Software + back-up system 0 25,000 0 2000 0 2000 0 2000 0 2000

Cost of imaging plates 0 14,000 0 14,7000 14,7000 16,800 0 22,400

Consumables (DVDs) 0 19,873 0 20,108 0 20,3530 23,162 0 31,892

Total cost (USD) 879,015 79,673 888,53057,608898,37557,8531,011,655 62,762 1,363,65577,092

Film radiography = FR, Computed radiography = CR.

Table 5. Indicating the benefits on a relative scale.

Benefits Film radiography Computed radiography

Image quality 2 5

View bone-only and soft only images 1 4

No retakes (over and under exposure) 1 4

Artifacts (over processing) 4 2

Compatibility to PACS 1 5

Ease of producing images 2 4

Electronic archiving for future reference 1 5

Lower dosage of x-rays to achieve the same quality 2 4

Eliminating the use of chemicals 1 4

Eliminating the need for chemical waste disposal 1 4

Reduction of storage space and manual labour 1 4

Total benefits 17 45

Table 6. Converting cost into equivalent numbers (cost/

10,000).

Year Film based radiographyComputed radiography

2008 87.9 7.9

2009 88.8 5.7

2010 89.8 5.7

2011 101.1 6.2

2012 136.3 7.7

involved in producing images by film based system are

much higher when compared to the costs involved using

computed system. Over the years the number of images

taken has increased and thereby the operational costs

involved have also increased. The high operational costs

involved in the film based system are due to the cost of

the films, use of chemicals to develop the images, dis-

posal of chemicals, cost of administration staff for film

indexing and storage. All these costs over a period of

time have the film based system a costly affair. While

coming to the computed radiography system, in the year

2008, the operational costs are high due to initial cost

U. A. RAHOMA, P. K. CHUNDI

involved in purchasing scanner and recovery software. In

the following years the CR system has seen low opera-

tional costs when compared to the film based system. All

the costs involving chemicals and disposal, use of addi-

tional administrative staff for film indexing and storage

have been completely eliminated. Instead of using a 17

member team for film indexing a CR system uses just 10

staff for administration on PC thereby reducing the

operational costs.

Keeping in view the use of film based system and

computed system the general benefits have been listed in

Table 5. A relative measure on a scale of 1 - 5 has been

given to each benefit and the total obtained for each sys-

tem has been calculated. The above benefits are called as

intangible benefits where we cannot assign a monetary

value for these benefits. But these benefits play a sig-

nificant role in the economic evaluation of the systems.

Based on the previous studies involving film based sys-

tem and CR system the above benefits are listed to be the

most significant ones that play a key role in making a

decision. From the above table it can be seen that for the

benefit eliminating the use of chemicals, under film

based system it has value of 1 where as under CR system

it has 4. This is because in film based system we cannot

eliminate the use of chemicals but in case of CR system

this possible so value of 4 has been assigned under it.

Similarly for the benefit artifacts (over processing) it can

be seen that the under film based system it has a value of

4 where as under CR system it is 2. This is because of the

possibility of over processing and manipulation of the

image with the CR system which can produce artifacts

there by creating undesirable images which can lead to

wrong diagnosis. But this is not possible with a film

based system as it doesn’t involve any software to de-

velop the images. So a value of 4 has been assigned un-

der it. Similarly, each benefit has been valuated with ref-

erence to both the system and a relative reference value

has been assigned under each system.

Cost benefit analysis is being used in this study to

evaluate the two systems. As seen before we need to

have a comparable scale to compare the costs and bene-

fits. It is seen that the costs involved in the study are in

term of dollars where as the benefits have been assigned

a relative numerical value based on the level of benefits

scale. In order to compare the costs and benefits and to

arrive to a conclusion it is highly desirable to have the

costs and benefits on the same scale i.e. either have both

costs and benefits in terms of dollars or both expressed

on a relative scale. Since the benefits in this study are

intangible benefits it is very difficult to assign a dollar

value to each benefit. Hence the costs have been con-

verted to a relative scale in order to compare with the

benefits. To achieve this, the total costs involved in each

year for the two systems have been divided by an arbi-

trary number 10,000, that gave values lower than the

highest value on the “Level of Benefit” scale. Now the

costs and benefits are on a comparable scale and a cost

benefit analysis can be performed to evaluate each system.

Tables 6 and 7 show the results obtained after converting

the costs for each year for both the system involved in the

study and cost benefit difference. A system that has a net

positive difference is considered to be cost beneficial

over the other. For the year 2008 the film based system

has a difference of −70.9 and the CR system −43.8. The

negative difference for the CR system is due to initial

cost of the scanner and software backup system. In the

year 2009 the difference for a film based system is −71

and the CR system is 39. This trend is observed for all

the years from 2009 to 2012. The CR system has a net

positive difference indicating that the system has an

overall net cost benefit when compared to the film based

system. This analysis can be useful tool for decision

making whether to go for the new system or not. Based

on the results seen above we can find that the use of CR

system at BMC is cost beneficial when compared to the

film based system.

Over the years it can be observed that the net dif-

ference value which is negative for film based system has

increased from −70.9 in the year 2008 to −119 in the year

2012. This increase in difference is due to the increase in

the number of images taken and thereby an overall

increase in the cost to produce and store such images.

The cost benefit analysis has been a useful tool in the

field of medicine and healthcare especially in designing

and implementing healthcare programs which involve

high costs. The important factor to be noted while

performing a cost benefit analysis is that the measure of

level of benefits in highly subjective and may vary from

person to person. However based on the data and

previous studies involving CR system and film based

Table 7. Cost benefit difference table.

2008 2009 2010 2011 2012

System

C B D C B D C B D C B D C BD

FB 87.9 17 −70.9 88.8 17 −71 89.817 −72 101 17 −84 136 17−119

Com 88.8 45 −43.8 5.7 45 39 5.7 45 39 6.2 45 38.8 7.7 4537.3

B = Film based, Com = computed, C = cost, B = Benefit, D = Diff.

U. A. RAHOMA, P. K. CHUNDI 29

system, it can be concluded that the use of CR system is

cost beneficial when compared to film based system.

5. Conclusion

For the years starting from 2008 to 2012, the average

value of the net difference between the costs and benefits

for the conventional film based system is −83.38 where

as for the CR System it is 22.06. Based on the principles

of Cost Benefit Analysis it can be concluded that the

system with a net positive difference is more cost benefi-

cial than the other. Apart from the initial cost of the CR

System, based on the data collected from the center a

total of 581566 images were produced with the total cost

incurred using film based system being USD 4,652,528.

If the same number of images were produced using a CR

system the total cost incurred would have been USD

82,600. Taking into consideration the cost of a new CR

system to be USD 120,000, the overall cost for producing

the images is USD 202,600. It is observed that an amount

of USD 4,449,928 could have been saved over the period

of 5 years starting from 2008 to 2012 (up to June) by

using the CR system at BMC. With the help of the above

two analysis it can be concluded that the use of computed

radiography is definitely more cost effective for use at

BMC, when compared to the conventional x-ray radio-

graphy. Considering the fact that center’s staff is well

trained in using the CR system, it is economical to use

this system with respect to the operational and recurring

costs when compared to the conventional x-ray film ra-

diography.

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