Towards the establishment of national diagnostic reference levels for chest x-ray examinations in Sri Lanka: a multi-centric study

The establishment of diagnostic reference levels (DRLs) is an effective tool for optimising radiation doses delivered to patients during medical imaging procedures. This study aimed to compare the institutional DRLs (IDRLs) and propose a multi-centric diagnostic reference level (MCDRL) for chest x-ray examinations in adult patients in Sri Lanka. A prospective cross-sectional study was conducted with 1091 adult patients across six major tertiary care hospitals. Data on patient characteristics, such as age, sex, weight, and body mass index, and exposure parameters, such as tube voltage (kVp) and the product of tube current and exposure time (mAs), were collected. Patient doses were measured in terms of kerma-area product (P KA ) using a P KA meter mounted on the collimator of the x-ray tube. IDRLs were computed for each hospital according to the International Commission on Radiological Protection guidelines, and the 75th percentile P KA was used to propose the MCDRL. The relationship between patient weight and exposure parameters was examined using Spearman’s rank correlation to investigate the radiographic practice among hospitals. Results showed that IDRLs varied from 0.10 to 0.26 Gy cm 2 . The proposed MCDRL was 0.23 Gy cm 2 , substantially higher than the recently published DRLs from other countries. The median kVp ranged from 95 to 104, while mAs ranged from 2.5 to 5.6. Large variations in the P KA and exposure parameters were observed within and among hospitals. The elevated P KA values observed in this study were mostly due to the use of high mAs in clinical practice. The weak correlation observed between patient weight and exposure parameters suggests the need to standardise examination protocols concerning patient size. The observed dose variations demonstrate the need for the establishment of national DRLs. Until then, the proposed MCDRL can be considered as the benchmark dose level for chest x-ray examinations in Sri Lanka.