SURVEY OF IMAGING TECHNOLOGY AND PATIENT DOSE RECORDING PRACTICE IN DEVELOPING COUNTRIES

SURVEY OF IMAGING TECHNOLOGY AND PATIENT DOSE RECORDING PRACTICE IN DEVELOPING COUNTRIES ABSTRACT A survey was conducted through the International Atomic Energy Agency (IAEA) to assess the use of older imaging technologies and availability of dose information in radiography, computed tomography (CT), mammography and interventional machines. Responses from 55 countries indicated 55.8% having non-digital radiography systems, only 9.1% having all systems that are digital (CR and DR), nearly one-third (36.4%) still use calcium tungstate screens in radiography cassettes and only 16.9% having all mammography systems as digital. On the dose features, not all CT machines provide CTDI, DLP values directly as only about half (50.6%) stated all machines having CTDI and DLP display, nearly half (46.8%) indicated the absence of KAP meters in radiography systems. Only 53.2% stated all angiography machines having DAP/KAP display. Only about a quarter (23.4%) having picture archiving and communication system in all hospitals in the country. Nearly one-third (36.4%) have no difficulty in maintaining patient identification number while sending dose data. INTRODUCTION Imaging technology has been advancing at a fast pace and there has been great momentum on monitoring radiation dose of patients in recent years, and using this information for improving patient safety. In the absence of published information, normally one makes assumptions about the state of imaging technology in developing countries. Professionals from advanced countries may not think that older technology of screen-film radiography is in use and that too with old time calcium tungstate screens which are not at all seen in developed countries as they were replaced in almost 1990s or even earlier by rare earth screens. Similar questions and anticipation arise about the availability of digital technology and dose monitoring features in radiography, computed tomography (CT) and in interventional radiology equipment as also the availability of picture archiving and communication system (PACS). Realizing the need to have a better picture about the extent of use of old imaging technology and availability of dose monitoring features in the imaging equipment, a survey was conducted through the International Atomic Energy Agency (IAEA) and this article presents finding of this survey. MATERIAL and METHODS A Google forms based survey was prepared that consisted of 11 questions besides the demographic information about the respondent and an open question for remarks. The link for the survey was sent to collaborators of existing IAEA project on radiation protection of patients and protection in medical exposure. The link was also sent to those in the network from the previous IAEA projects on medical exposure control. All these countries are recipients of the Technical cooperation program of the IAEA. The collaborators and members in the network consist of medical physicists, radiation protection experts, regulators, radiologists and radiographers. The results automatically provided by the Google system as a spreadsheet were transferred to a Microsoft Excel spreadsheet and used for further analyses. The survey was sent out on 16 May 2016 and responses received till 24 May 2016 were collated. RESULTS Overall, 77 responses were obtained from 55 countries (Table 1). Not all countries who responded fall in the category of developing economies as some got graduated to developed economies and thus they were classified in three levels in Table 1 based on the recent UN classification: developed economies, economies in transition and developing economies.(1) There was more than one response from some countries, but in view of nature of questions that can allow different judgment about the situation, all responses were counted individually. The distributions of respondents were: medical physicists (31.2%), radiologist or nuclear medicine physicians (24.7%), regulators (14.3%), radiation protection experts (14.3%), radiographers (5.2%) and others (10.4%). The choice of profession was as selected by the respondent from the options provided and only a single selection was possible. Table 1. Participating countries grouped according to the UN classification.(1) Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia View Large Table 1. Participating countries grouped according to the UN classification.(1) Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia View Large The response to 11 questions is presented in tables below. The information about use of non-digital systems is presented in Table 2. Table 2. What fraction of radiography systems in country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) View Large Table 2. What fraction of radiography systems in country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) View Large If one combines ‘About 50%’, ‘More than 50%’ and ‘Almost all’, it gives a figure of 55.8% with having non-digital radiography systems and only 2.6% having all systems that are digital (CR/DR). Further, there are only two countries, both in higher level of economies, (last two columns) with all digital systems. The next question asked information on the type of screen-film radiography systems and results are presented in Table 3. Table 3. For screen-film radiography systems. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) View Large Table 3. For screen-film radiography systems. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) View Large It is interesting to note that 36.4% stated that some still use calcium tungstate screens that most developed countries had abandoned in 1980s or 1990s. Mainly about half (51.9%) stated use of only rare earth screens. The situation of dose assessment systems in radiography is presented in Table 4. Table 4. What fraction of radiography systems in your country have DAP/KAP meter to measure patient dose attached in actual practice? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) View Large Table 4. What fraction of radiography systems in your country have DAP/KAP meter to measure patient dose attached in actual practice? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) View Large It can be seen that nearly half (46.8%) indicated absence of KAP meters in radiography systems and only 5.2% indicated all radiography equipment having KAP meter, mostly in developed economies of Europe. Table 5 presents the data on mammography technology. Table 5. What fraction of mammography systems in your country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) View Large Table 5. What fraction of mammography systems in your country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) View Large As shown in Table 5, only 16.9% indicated that all mammography systems are digital and rest have screen-film systems. Once again, large number (9 out of 13) of those with all mammography systems as digital fall in developing economies. The situation on CT technology is presented below in Table 6. Table 6. What fraction of CT machines in your country do not provide dose indices CTDI and DLP values directly? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 View Large Table 6. What fraction of CT machines in your country do not provide dose indices CTDI and DLP values directly? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 View Large It was interesting to note that not all CT machines provide CTDI, DLP values directly as only about half (50.6%) stated all machines having CTDI and DLP display and rest all giving some fraction of machine having CTDI, DLP display. As anticipated, the fraction of CT equipment without CTDI/DLP display is lowest in developed economies as most have CTDI/DLP displays. The fraction of angiography equipment used for interventional procedures displaying DAP/KAP values was surveyed and results were as below in Table 7. Table 7. What fraction of angiography equipment used for interventional procedures in your country displays DAP/KAP values? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 View Large Table 7. What fraction of angiography equipment used for interventional procedures in your country displays DAP/KAP values? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 View Large With angiography equipment used for interventional procedures, only 53.2% respondents stated all machines having DAP/KAP display and rest falling in group with different extent of machines having dose display. In the 13 developed economies 100% responded (16 responses) that almost all systems have dose displays. Question 7 pertained to possibility to provide CTDI and DLP values of all patients done in his/her hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in his/her country. Table 8 presents the results on this question. Table 8. Responses on possibility to provide data on CTDI and DLP. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) View Large Table 8. Responses on possibility to provide data on CTDI and DLP. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) View Large A large number (55.8%) indicated difficulty in providing this information as records are not kept, only 40.3% indicated that they can and 3.9% stated that they have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year. Slightly larger number (59.7%) indicated difficulty in providing data on DAP/KAP or patient entrance reference point (Table 9) as records are not kept, only 11.7% stated that they have regular record of these dosimetric quantities of most patients in major hospitals in country and can provide data for last 1 year, whereas 28.6% can provide DAP/KAP and kerma at patient entrance reference point for most patients done in his/her hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in his/her country. Table 9. Mark all those which are true in your country (interventional radiology and fluoroscopy). Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) View Large Table 9. Mark all those which are true in your country (interventional radiology and fluoroscopy). Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) View Large Table 10 below presents data on verification of CTDI and DAP/KAP using dosemeter and phantom. It is seen that only 49.4% are verifying whereas 40.3% stated that they have not verified CTDI values and 39% for DAP/KAP values. Table 10. Verification of dose displays and calibration of dosemeters. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) View Large Table 10. Verification of dose displays and calibration of dosemeters. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) View Large The data on availability of PACS is presented in Table 11 which indicates that only about a quarter (23.4%) hospitals in country having PACS in almost all and nearly half (46.8%) stating that most hospitals in the country do not have PACS. The fraction of countries with PACS is higher in the group of developed economies. Table 11. Fraction of hospitals in country have PACS? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) View Large Table 11. Fraction of hospitals in country have PACS? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) View Large Nearly one-third (36.4%) have no difficulty in maintaining patient identification number while sending dose data and two-third (63.6%) have. This highlights the need for making patient dose data unidentifiable when it comes to the patient to whom it belongs and thus the culture of confidentiality needs to be maintained even for radiation dose. DISCUSSION This survey provides insight into the imaging technology and patient dose recording practices that can help decision making bodies in planning strategies as there seems to be much lag both in technology and dose monitoring. Previous studies by the IAEA had sensitized and motivated developing countries to get on the path of dose assessment and dose management(2–6) but the need for assessing ground realities in 2016 was felt for strategic planning. There have been interesting findings. Changing to newer technology and availability of dose monitoring features is always a difficult aspect as it involves financial resources but actions on dose recording are a matter of skill development and enthusiasm. It is clear that there is rampant use of old technology in many developing economies. Only 9.1% having all digital radiography (CR/DR) is a fairly small component in the group. Obviously, there is a long road for many countries to get to fully digital and thus any radiation dose assessment and management program has to consider these countries and develop solutions that help these countries. If dose monitoring and radiation protection programs are directed at only digital systems, one will miss the real world and the opportunities to improve patient safety in a large part of the world. Further, some countries had adopted the method to stop use of technologies that impart higher patient dose. Good examples are replacing dark room type fluoroscopy with image intensified fluoroscopy in 1990s and 2000s, encouraging switch over to rare earth screens in 1990s, just to name a few. Subsequently, movement to modern technology of flat panel did not require specific regulatory actions. On the issue of dose monitoring feature availability, there has been a common trend in Europe for radiography machines to have DAP/KAP meters installed whereas outside Europe it is rare to find this even though DAP/KAP is common in fluoroscopy machines universally. Even in Eastern Europe, there are only three countries who responded, ‘Almost all’ radiography machines having DAP/KAP. That implies that any action on dose assessment must be based on measurement/ calculation of entrance surface air kerma, normally by a medical physicist, which creates the issue of human resource. Future continuation of the international actions to raise the awareness of the need of medical physicists and improve their education and training are critical for success of dose monitoring program and optimization of patient protection. The mammography systems are largely non-digital where again availability of dose monitoring has been uncommon and thus the need for a medical physicist to measure incident air kerma and calculate average glandular dose. This again goes in line with human resource creation as above. One can normally expect CT machines to have CTDI and DLP display capability and thus the actions on dose management in CT should become simpler. But with 50.6% stating that all CT machines have CTDI/DLP display and rest stating smaller fraction, it again creates necessity of emphasizing regular calibration of machine for dose and dose assessment by medical physicist, which leads to human resource requirement. The situation with angiography machines is somewhat similar to CT and similar conclusions apply. From technology and features of dose display in machine, the authors wanted to assess practice of dose recording. It is unfortunate to see that only 40.3% stated that, if needed, he/she can provide CTDI and DLP values of all patients done in his/her hospital for the past 1 year, or if not working in a hospital, can get from several hospitals in his/her country. Rather 55.8% indicated difficulty in providing data as records are not kept. This requires creating momentum on dose monitoring and recording. Understandably the situation with dose records is somewhat more difficult for angiography machines than CT with 59.7% indicating difficulty in providing data as records are not kept. The solution of creating momentum on dose monitoring and recording is valid here also in addition to requiring new machines to have DAP/KAP and cumulative air kerma display. PACS seems to be penetrating much slowly than one can anticipate as only about a quarter (23.4%) stated that almost all hospital in country have PACS and nearly half (46.8%) stating that most hospitals in the country do not have PACS. Obviously, there is no point of talking about PACS when there is lack of digital imaging but keeping PACS part of upgradation to digital imaging seems wise step to propagate. Despite limitations in technology and availability of features for dose monitoring, there has been substantial momentum in recent years on patient dose management and a recent paper reviews the situation in Africa(7). Eighteen countries provided more than one answer. No serious discrepancies have been observed between the answers of different individuals from the same country. There were few differences in answers, for example, the estimates of the percentage of use of rare earth screens or screen-film systems, but this can be expected, as the answers in most cases are not based on an accurate statistics. Some of the answers of clinical specialists may be based on their local practices. In such cases, email clarification was resorted to arrive at common figure. Another observation stems from use of classification system for countries. The UN system used in this report(1,) classifies countries like Singapore and Saudi Arabia as developing economies. These countries are high income economies by per capita gross national income(1). They have wider use of better imaging technology with features of monitoring patient dose indices included. This skews the results in favor of developing economies having better technology. ACKNOWLEDGEMENT This article is based on survey request sent through email and electronic online system for response. It was conducted through the International Atomic Energy Agency (IAEA), Vienna, Austria. There is no financial disclosure or conflict of interest. REFERENCES 1 United Nations . World Economic Situation and Prospects 2018 . Statistical Annex: Country Classification. https://www.un.org/development/desa/dpad/wp-content/uploads/sites/45/publication/WESP2018_Full_Web-1.pdf. 2 Vassileva , J. et al. . A study to establish international diagnostic reference levels for paediatric computed tomography . Radiat. Prot. Dosim. 165 ( 1–4 ), 70 – 80 ( 2015 ). Google Scholar CrossRef Search ADS 3 Rehani , M. M. Multi-national findings on radiation protection of children . Pediatr. Radiol. 44 ( Suppl 3 ), 475 – 478 ( 2014 ). Google Scholar CrossRef Search ADS PubMed 4 Vassileva , J. et al. . IAEA survey of pediatric CT practice in 40 countries in Asia, Europe, Latin America, and Africa: procedure and protocols . Eur. Radiol. 23 ( 3 ), 623 – 631 ( 2013 ). Google Scholar CrossRef Search ADS PubMed 5 Rehani , M. M. et al. . Radiation protection of patients in diagnostic and interventional radiology in Asian countries: impact of an IAEA project . Eur. J. Radiol. 81 ( 10 ), e982 – e989 ( 2012 ). Google Scholar CrossRef Search ADS PubMed 6 Muhogora , W. E. et al. . Patient doses in radiographic examinations in 12 countries of Asia, Africa and Eastern Europe: initial results from IAEA projects . Am. J. Roentgenol. 190 , 1453 – 1461 ( 2008 ). Google Scholar CrossRef Search ADS 7 Muhogora , W. and Rehani , M. M. Current status of radiation protection in diagnostic radiology in Africa . J. Med. Imaging (Bellingham) 4 ( 3 ), 031202 ( 2017 ). Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Radiation Protection Dosimetry Oxford University Press

SURVEY OF IMAGING TECHNOLOGY AND PATIENT DOSE RECORDING PRACTICE IN DEVELOPING COUNTRIES

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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0144-8420
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1742-3406
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10.1093/rpd/ncy019
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Abstract

ABSTRACT A survey was conducted through the International Atomic Energy Agency (IAEA) to assess the use of older imaging technologies and availability of dose information in radiography, computed tomography (CT), mammography and interventional machines. Responses from 55 countries indicated 55.8% having non-digital radiography systems, only 9.1% having all systems that are digital (CR and DR), nearly one-third (36.4%) still use calcium tungstate screens in radiography cassettes and only 16.9% having all mammography systems as digital. On the dose features, not all CT machines provide CTDI, DLP values directly as only about half (50.6%) stated all machines having CTDI and DLP display, nearly half (46.8%) indicated the absence of KAP meters in radiography systems. Only 53.2% stated all angiography machines having DAP/KAP display. Only about a quarter (23.4%) having picture archiving and communication system in all hospitals in the country. Nearly one-third (36.4%) have no difficulty in maintaining patient identification number while sending dose data. INTRODUCTION Imaging technology has been advancing at a fast pace and there has been great momentum on monitoring radiation dose of patients in recent years, and using this information for improving patient safety. In the absence of published information, normally one makes assumptions about the state of imaging technology in developing countries. Professionals from advanced countries may not think that older technology of screen-film radiography is in use and that too with old time calcium tungstate screens which are not at all seen in developed countries as they were replaced in almost 1990s or even earlier by rare earth screens. Similar questions and anticipation arise about the availability of digital technology and dose monitoring features in radiography, computed tomography (CT) and in interventional radiology equipment as also the availability of picture archiving and communication system (PACS). Realizing the need to have a better picture about the extent of use of old imaging technology and availability of dose monitoring features in the imaging equipment, a survey was conducted through the International Atomic Energy Agency (IAEA) and this article presents finding of this survey. MATERIAL and METHODS A Google forms based survey was prepared that consisted of 11 questions besides the demographic information about the respondent and an open question for remarks. The link for the survey was sent to collaborators of existing IAEA project on radiation protection of patients and protection in medical exposure. The link was also sent to those in the network from the previous IAEA projects on medical exposure control. All these countries are recipients of the Technical cooperation program of the IAEA. The collaborators and members in the network consist of medical physicists, radiation protection experts, regulators, radiologists and radiographers. The results automatically provided by the Google system as a spreadsheet were transferred to a Microsoft Excel spreadsheet and used for further analyses. The survey was sent out on 16 May 2016 and responses received till 24 May 2016 were collated. RESULTS Overall, 77 responses were obtained from 55 countries (Table 1). Not all countries who responded fall in the category of developing economies as some got graduated to developed economies and thus they were classified in three levels in Table 1 based on the recent UN classification: developed economies, economies in transition and developing economies.(1) There was more than one response from some countries, but in view of nature of questions that can allow different judgment about the situation, all responses were counted individually. The distributions of respondents were: medical physicists (31.2%), radiologist or nuclear medicine physicians (24.7%), regulators (14.3%), radiation protection experts (14.3%), radiographers (5.2%) and others (10.4%). The choice of profession was as selected by the respondent from the options provided and only a single selection was possible. Table 1. Participating countries grouped according to the UN classification.(1) Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia View Large Table 1. Participating countries grouped according to the UN classification.(1) Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia Developing economies (32 countries, 46 answers) Economies in transition (10 countries, 15 answers) Developed economies (13 countries, 16 answers) Afghanistan Algeria (2) Argentina (2) Bangladesh (2) Benin Botswana Brazil Cote d’Ivoire Costa Rica Dominican Ecuador Egypt (2) Ghana Guatemala India Kenya (2) Malaysia (2) Mexico (3) Nicaragua Niger (2) Pakistan Panama Peru (2) Saudi Arabia Singapore Sri Lanka Thailand Tunisia (2) Uganda Uruguay (3) Vietnam (2) Zambia Albania Armenia Azerbaijan Kazakhstan (3) Macedonia (Former Yugoslav Rep) Moldova (2) Montenegro (2) Russian Federation (2) Serbia Ukraine Bulgaria Croatia Cyprus Czech Republic Estonia Greece Hungary (2) Lithuania Malta Poland Romania (3) Slovakia Slovenia View Large The response to 11 questions is presented in tables below. The information about use of non-digital systems is presented in Table 2. Table 2. What fraction of radiography systems in country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) View Large Table 2. What fraction of radiography systems in country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 1 (1.2) 0 1 (6.7) 0 More than 50% are screen-film 32 (41.6) 19 (41.3) 10 (66.7) 3 (18.7) About 50% are screen-film 10 (13.0) 9 (19.6) 1 (6.7) 0 About one-third are screen-film 27 (35.1) 13 (28.2) 3 (20) 11 (68.8) All are digital (CR or DR) 2 (2.6) 0 0 2 (12.5) View Large If one combines ‘About 50%’, ‘More than 50%’ and ‘Almost all’, it gives a figure of 55.8% with having non-digital radiography systems and only 2.6% having all systems that are digital (CR/DR). Further, there are only two countries, both in higher level of economies, (last two columns) with all digital systems. The next question asked information on the type of screen-film radiography systems and results are presented in Table 3. Table 3. For screen-film radiography systems. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) View Large Table 3. For screen-film radiography systems. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Some still use calcium tungstate screens 33 (42.9) 24 (52.2) 8 (53.3) 1 (6.2) All use rare earth screen 42 (54.6) 22 (47.8) 7 (46.7) 13 (81.2) Not applicable as we have only digital radiography systems 2 (2.6) 0 0 2 (12.5) View Large It is interesting to note that 36.4% stated that some still use calcium tungstate screens that most developed countries had abandoned in 1980s or 1990s. Mainly about half (51.9%) stated use of only rare earth screens. The situation of dose assessment systems in radiography is presented in Table 4. Table 4. What fraction of radiography systems in your country have DAP/KAP meter to measure patient dose attached in actual practice? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) View Large Table 4. What fraction of radiography systems in your country have DAP/KAP meter to measure patient dose attached in actual practice? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Mostly not 36 (46.8%) 27 (58.7) 7 (46.7) 2 (12.5) About one-third 23 (29.9) 13 (28.3) 6 (40.0) 4 (25%) About half 14 (18.2) 5 (10.9) 2 (13.3) 7 (43.8) Almost all 4 (5.2) 1 (2.2) 0 3 (18.7) View Large It can be seen that nearly half (46.8%) indicated absence of KAP meters in radiography systems and only 5.2% indicated all radiography equipment having KAP meter, mostly in developed economies of Europe. Table 5 presents the data on mammography technology. Table 5. What fraction of mammography systems in your country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) View Large Table 5. What fraction of mammography systems in your country are non-digital using screen-film? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all as we do not have CR/DR digital systems 2 (2.5) 1 (2.2) 1 (6.7) More than 50% are screen-film 24 (31.2) 15 (32.6) 6 (40) 3 (18.7) About 50% are screen-film 16 (20.8) 11 (23.9) 3 (20.0) 2(12.5) About one-third are screen-film 22 (28.6) 10 (21.7) 5 (33.3) 7 (43.8) All are digital (CR or DR) 13 (16.9) 9 (19.6) 0 4 (25%) View Large As shown in Table 5, only 16.9% indicated that all mammography systems are digital and rest have screen-film systems. Once again, large number (9 out of 13) of those with all mammography systems as digital fall in developing economies. The situation on CT technology is presented below in Table 6. Table 6. What fraction of CT machines in your country do not provide dose indices CTDI and DLP values directly? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 View Large Table 6. What fraction of CT machines in your country do not provide dose indices CTDI and DLP values directly? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) They all have CTDI and DLP display 39 (50.6) 18 (39.1) 8 (53.3) 13 (81.3) About one-third 13 (16.9) 7 (15.2) 3 (20.0) 3 (18.7) About half 6 (7.8) 5 (10.9) 1 (6.7) 0 More than 50% 9 (11.7) 7 (15.2) 2 (13.3) 0 Don’t have this information 10 (13.0) 9 (19.6) 1 (6.7) 0 View Large It was interesting to note that not all CT machines provide CTDI, DLP values directly as only about half (50.6%) stated all machines having CTDI and DLP display and rest all giving some fraction of machine having CTDI, DLP display. As anticipated, the fraction of CT equipment without CTDI/DLP display is lowest in developed economies as most have CTDI/DLP displays. The fraction of angiography equipment used for interventional procedures displaying DAP/KAP values was surveyed and results were as below in Table 7. Table 7. What fraction of angiography equipment used for interventional procedures in your country displays DAP/KAP values? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 View Large Table 7. What fraction of angiography equipment used for interventional procedures in your country displays DAP/KAP values? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 41 (53.2) 16 (34.8) 9 (60) 16 (100) About half 12 (15.6) 8 (17.4) 4 (26.7) 0 About one-third 4 (5.2) 4 (8.7) 0 0 Mostly not 5 (6.5) 4 (8.7) 1 (6.7) 0 Don’t have this information 15 (19.5) 14 (30.4) 1 (6.7) 0 View Large With angiography equipment used for interventional procedures, only 53.2% respondents stated all machines having DAP/KAP display and rest falling in group with different extent of machines having dose display. In the 13 developed economies 100% responded (16 responses) that almost all systems have dose displays. Question 7 pertained to possibility to provide CTDI and DLP values of all patients done in his/her hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in his/her country. Table 8 presents the results on this question. Table 8. Responses on possibility to provide data on CTDI and DLP. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) View Large Table 8. Responses on possibility to provide data on CTDI and DLP. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide CTDI and DLP values of all patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 31 (40.3) 15 (32.6) 6 (40.0) 10 (62.5) We have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year 3 (3.9) 1 (2.2) 1 (6.7) 1 (6.3) It is very difficult to provide data as records are not kept 43 (55.8) 30 (65.2) 8 (53.3) 5 (31.2) View Large A large number (55.8%) indicated difficulty in providing this information as records are not kept, only 40.3% indicated that they can and 3.9% stated that they have regular record of CTDI and DLP of most patients in major hospitals in country and can provide data for last 1 year. Slightly larger number (59.7%) indicated difficulty in providing data on DAP/KAP or patient entrance reference point (Table 9) as records are not kept, only 11.7% stated that they have regular record of these dosimetric quantities of most patients in major hospitals in country and can provide data for last 1 year, whereas 28.6% can provide DAP/KAP and kerma at patient entrance reference point for most patients done in his/her hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in his/her country. Table 9. Mark all those which are true in your country (interventional radiology and fluoroscopy). Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) View Large Table 9. Mark all those which are true in your country (interventional radiology and fluoroscopy). Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) If needed I can provide DAP/KAP and kerma at patient entrance reference point for most patients done in my hospital for the past 1 year, or if not working in a hospital, can get from a number of hospitals in my country 22 (28.6) 10 (21.7) 4 (26.7) 8 (50) We have regular record of DAP/KAP and kerma of most patients in major hospitals in country and can provide data for last 1 year 9 (11.7) 3 (6.5) 3 (20.0) 3 (18.8) It is very difficult to provide data as records are not kept 46 (59.7) 33 (71.7) 8 (53.3) 5 (31.2) View Large Table 10 below presents data on verification of CTDI and DAP/KAP using dosemeter and phantom. It is seen that only 49.4% are verifying whereas 40.3% stated that they have not verified CTDI values and 39% for DAP/KAP values. Table 10. Verification of dose displays and calibration of dosemeters. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) View Large Table 10. Verification of dose displays and calibration of dosemeters. Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) We are verifying CT and DAP/KAP dose displays by measurements 38 (49.4) 18 (39.1) 9 (60.0) 11 (68.8) We have not verified CTDI values using dosemeter and CT phantom 31 (40.3) 23 (50.0) 4 (26.7) 4 (25.0) We have not tested accuracy of DAP/KAP meters by making measurements ourselves using calibrated dosemeter 30 (39.0) 20 (43.5) 5 (33.3) 5 (31.3) View Large The data on availability of PACS is presented in Table 11 which indicates that only about a quarter (23.4%) hospitals in country having PACS in almost all and nearly half (46.8%) stating that most hospitals in the country do not have PACS. The fraction of countries with PACS is higher in the group of developed economies. Table 11. Fraction of hospitals in country have PACS? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) View Large Table 11. Fraction of hospitals in country have PACS? Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) Response options All countries: Answers (%) Developing economises: Answers (%) Economies in transition: Answers (%) Developed economies: Answers (%) Almost all 18 (23.4) 10 (21.7) 0 8 (50) About half 7 (9.1) 1 (2.2) 1 (6.7) 5 (31.3) About one-third 16 (20.7) 11 (23.9) 4 (26.7) 1 (6.2) Mostly not 36 (46.8) 24 (52.2) 10 (66.7) 2 (12.5) View Large Nearly one-third (36.4%) have no difficulty in maintaining patient identification number while sending dose data and two-third (63.6%) have. This highlights the need for making patient dose data unidentifiable when it comes to the patient to whom it belongs and thus the culture of confidentiality needs to be maintained even for radiation dose. DISCUSSION This survey provides insight into the imaging technology and patient dose recording practices that can help decision making bodies in planning strategies as there seems to be much lag both in technology and dose monitoring. Previous studies by the IAEA had sensitized and motivated developing countries to get on the path of dose assessment and dose management(2–6) but the need for assessing ground realities in 2016 was felt for strategic planning. There have been interesting findings. Changing to newer technology and availability of dose monitoring features is always a difficult aspect as it involves financial resources but actions on dose recording are a matter of skill development and enthusiasm. It is clear that there is rampant use of old technology in many developing economies. Only 9.1% having all digital radiography (CR/DR) is a fairly small component in the group. Obviously, there is a long road for many countries to get to fully digital and thus any radiation dose assessment and management program has to consider these countries and develop solutions that help these countries. If dose monitoring and radiation protection programs are directed at only digital systems, one will miss the real world and the opportunities to improve patient safety in a large part of the world. Further, some countries had adopted the method to stop use of technologies that impart higher patient dose. Good examples are replacing dark room type fluoroscopy with image intensified fluoroscopy in 1990s and 2000s, encouraging switch over to rare earth screens in 1990s, just to name a few. Subsequently, movement to modern technology of flat panel did not require specific regulatory actions. On the issue of dose monitoring feature availability, there has been a common trend in Europe for radiography machines to have DAP/KAP meters installed whereas outside Europe it is rare to find this even though DAP/KAP is common in fluoroscopy machines universally. Even in Eastern Europe, there are only three countries who responded, ‘Almost all’ radiography machines having DAP/KAP. That implies that any action on dose assessment must be based on measurement/ calculation of entrance surface air kerma, normally by a medical physicist, which creates the issue of human resource. Future continuation of the international actions to raise the awareness of the need of medical physicists and improve their education and training are critical for success of dose monitoring program and optimization of patient protection. The mammography systems are largely non-digital where again availability of dose monitoring has been uncommon and thus the need for a medical physicist to measure incident air kerma and calculate average glandular dose. This again goes in line with human resource creation as above. One can normally expect CT machines to have CTDI and DLP display capability and thus the actions on dose management in CT should become simpler. But with 50.6% stating that all CT machines have CTDI/DLP display and rest stating smaller fraction, it again creates necessity of emphasizing regular calibration of machine for dose and dose assessment by medical physicist, which leads to human resource requirement. The situation with angiography machines is somewhat similar to CT and similar conclusions apply. From technology and features of dose display in machine, the authors wanted to assess practice of dose recording. It is unfortunate to see that only 40.3% stated that, if needed, he/she can provide CTDI and DLP values of all patients done in his/her hospital for the past 1 year, or if not working in a hospital, can get from several hospitals in his/her country. Rather 55.8% indicated difficulty in providing data as records are not kept. This requires creating momentum on dose monitoring and recording. Understandably the situation with dose records is somewhat more difficult for angiography machines than CT with 59.7% indicating difficulty in providing data as records are not kept. The solution of creating momentum on dose monitoring and recording is valid here also in addition to requiring new machines to have DAP/KAP and cumulative air kerma display. PACS seems to be penetrating much slowly than one can anticipate as only about a quarter (23.4%) stated that almost all hospital in country have PACS and nearly half (46.8%) stating that most hospitals in the country do not have PACS. Obviously, there is no point of talking about PACS when there is lack of digital imaging but keeping PACS part of upgradation to digital imaging seems wise step to propagate. Despite limitations in technology and availability of features for dose monitoring, there has been substantial momentum in recent years on patient dose management and a recent paper reviews the situation in Africa(7). Eighteen countries provided more than one answer. No serious discrepancies have been observed between the answers of different individuals from the same country. There were few differences in answers, for example, the estimates of the percentage of use of rare earth screens or screen-film systems, but this can be expected, as the answers in most cases are not based on an accurate statistics. Some of the answers of clinical specialists may be based on their local practices. In such cases, email clarification was resorted to arrive at common figure. Another observation stems from use of classification system for countries. The UN system used in this report(1,) classifies countries like Singapore and Saudi Arabia as developing economies. These countries are high income economies by per capita gross national income(1). They have wider use of better imaging technology with features of monitoring patient dose indices included. This skews the results in favor of developing economies having better technology. ACKNOWLEDGEMENT This article is based on survey request sent through email and electronic online system for response. It was conducted through the International Atomic Energy Agency (IAEA), Vienna, Austria. There is no financial disclosure or conflict of interest. REFERENCES 1 United Nations . World Economic Situation and Prospects 2018 . Statistical Annex: Country Classification. https://www.un.org/development/desa/dpad/wp-content/uploads/sites/45/publication/WESP2018_Full_Web-1.pdf. 2 Vassileva , J. et al. . A study to establish international diagnostic reference levels for paediatric computed tomography . Radiat. Prot. Dosim. 165 ( 1–4 ), 70 – 80 ( 2015 ). Google Scholar CrossRef Search ADS 3 Rehani , M. M. Multi-national findings on radiation protection of children . Pediatr. Radiol. 44 ( Suppl 3 ), 475 – 478 ( 2014 ). Google Scholar CrossRef Search ADS PubMed 4 Vassileva , J. et al. . IAEA survey of pediatric CT practice in 40 countries in Asia, Europe, Latin America, and Africa: procedure and protocols . Eur. Radiol. 23 ( 3 ), 623 – 631 ( 2013 ). Google Scholar CrossRef Search ADS PubMed 5 Rehani , M. M. et al. . Radiation protection of patients in diagnostic and interventional radiology in Asian countries: impact of an IAEA project . Eur. J. Radiol. 81 ( 10 ), e982 – e989 ( 2012 ). Google Scholar CrossRef Search ADS PubMed 6 Muhogora , W. E. et al. . Patient doses in radiographic examinations in 12 countries of Asia, Africa and Eastern Europe: initial results from IAEA projects . Am. J. Roentgenol. 190 , 1453 – 1461 ( 2008 ). Google Scholar CrossRef Search ADS 7 Muhogora , W. and Rehani , M. M. Current status of radiation protection in diagnostic radiology in Africa . J. Med. Imaging (Bellingham) 4 ( 3 ), 031202 ( 2017 ). Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com

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Radiation Protection DosimetryOxford University Press

Published: Feb 9, 2018

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