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
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
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opyright © 2012 SciRes. ACT

U. A. RAHOMA, P. K. CHUNDI
24
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
26
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
28
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
F
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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