Are exposure index values consistent in clinical practice? A multi-manufacturer investigation

The advent of digital radiography poses the risk of unnoticed increases in patient dose. Manufacturers have responded to this by offering an exposure index (EI) value to the clinician. Whilst the EI value is a measure of the air kerma at the detector surface, it has been recommended by international agencies as a method of monitoring radiation dose to the patient. Recent studies by the group have shown that EI values are being used in clinical practice to monitor radiation dose and assess image quality. This study aims to compare the clinical consistency of the EI value in computed radiography (CR) and direct digital radiography (DR) systems. An anthropormorphic phantom was used to simulate four common radiographic examinations: skull, pelvis, chest and hand. These examinations were chosen as they provide contrasting exposure parameters, image detail and radiation dose measurements. Four manufacturers were used for comparison: Agfa Gaevert CR, Carestream CR, Philips Digital Diagnost DR and Siemens DR. For each examination, the phantom was placed in the optimal position and exposure parameters were chosen in accordance with European guidelines and clinical practice. Multiple exposures were taken and the EI recorded. All exposure parameters and clinical conditions remained constant throughout. For both DR systems, the EI values remained consistent throughout. No significant change was noted in any examination. In both CR systems, there were noteworthy fluctuations in the EI values for all examinations. The largest for the Agfa system was a variation of 1.88-2.21 for the skull examination. This represents to the clinician a doubling of detector dose, despite all exposure parameters remaining constant. In the Kodak system, the largest fluctuation was seen for the chest examination where the EI ranged from 2560 to 2660, representing approximately an increase of 30 % in radiation dose, despite consistent parameters. The fluctuations seen with the CR systems are most likely due to image processing delay, replacing of the imaging plate and calibration factors. Fluctuations in EI values may result in confusion to the clinician and unnecessary repeat examinations. The reliability of EI values as a feedback mechanism for CR is also questionable.