Authors' objectives: In medicine, x-rays are used to generate images of tissues and structures inside the body. X-rays are emitted by a source device and, after passing through the body, strike a detector, which forms an image of the tissues and structures the x-rays passed through. Dual-energy subtraction (DES) x-ray systems use radiation of different energy spectra (energy levels) and the principle of differential absorption characteristics of bone and soft tissue to produce separate bone and soft tissue x-ray images, in addition to a conventional x-ray image. The aim is to minimize potential issues with anatomical overlap with conventional x-ray that may obscure some findings. Single-exposure, DES flat panel x-ray detectors produce a conventional x-ray image in addition to DES bone and soft tissue x-ray images using a single x-ray exposure. We conducted a health technology assessment of single-exposure, DES digital flat panel x-ray detectors in adults for indications such as pneumonia, pneumothorax, and pulmonary nodules, and for visualizing lines and tubes, compared with conventional x-ray. Our assessment included an evaluation of the diagnostic accuracy, the impact on diagnostic confidence, patient management and clinical outcomes, the budget impact of publicly funding the technology, and the experiences, preferences, and values of health care providers.

Authors' results and conclusions: The use of single-exposure, DES flat panel x-ray detectors may lead to an improvement in the sensitivity and specificity to detect pulmonary nodule calcification compared with conventional x-ray, but the evidence is very uncertain for its effect on the visibility of the tips of lines and tubes, diagnostic confidence, and time to review the x-ray images compared with conventional x-ray. Evidence gaps include lack of evidence for the use of the technology for most populations and outcomes that we sought to evaluate. Due to limited clinical and economic evidence, the cost-effectiveness of single-exposure, DES flat panel x-ray detectors is currently unknown. We estimate that purchasing 3 detectors to retrofit with existing x-ray machines may lead to an additional cost of $12,137 per institution. Users of single-exposure, DES x-ray detectors who viewed and interpreted the images produced spoke positively about their experience with the technology and expressed an increase in confidence when making a diagnosis. Participants who operated the retrofitted single-exposure, DES x-ray detector commented on issues that negatively impacted their workflow. The experiences of providers with a fully integrated system are unknown at this time.

Authors' methods: We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the QUADAS-C tool and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic literature search on the economic evidence of single-exposure, DES flat panel x-ray detectors. We did not conduct a primary economic evaluation because of limited evidence on the implications of this technology. We analyzed the budget impact of publicly funding single-exposure, DES flat panel detectors in Ontario hospitals. To contextualize the potential value of single-exposure, DES flat panel x-ray detectors, we spoke with people with expertise in diagnostic imaging, including radiologists and other health care practitioners.

Authors' identified further research: Ontario Health, based on guidance from the Ontario Health Technology Advisory Committee, concludes there is currently insufficient evidence to make a recommendation for or against publicly funding single-exposure, dual-energy subtraction flat panel x-ray detectors.

Project Status: Completed

URL for protocol: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024519661

Year Published: 2024

URL for published report: https://www.hqontario.ca/evidence-to-improve-care/health-technology-assessment/reviews-and-recommendations/single-exposure-dual-energy-subtraction-flat-panel-x-ray-detectors

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Pubmed ID: 39697784

Organisation Name: Ontario Health

Contact Address: 525 University Ave, Toronto, ON M5G 2L3

Contact Name: Nancy Sikich, Director Health Technology Assessment

Contact Email: oh-hqo_hta@ontariohealth.ca

Copyright: The copyright for all Ontario Health publications is owned by the King’s Printer for Ontario. Materials may be reproduced for commercial purposes only under a licence from the King’s Printer. For further information or to request a licence to reproduce content, please contact: Senior Copyright Advisor Publications Ontario | 416-326-5153 | Copyright@Ontario.ca