Abstract Background and Aim Issues in patient positioning during chest X-ray (CXR) acquisition impair diagnostic quality and potentially increase radiation dose. Automated quality assessment was ...proposed to address this. Our objective is to determine thresholds on some quality control metrics following international guidelines, that represent expert knowledge and can be applied in a comprehensible and explainable AI approach for such an automatic quality assessment. Materials and Methods An AI-method estimating collimation distance to the ribcage, balancing between both clavicle heads, and number of ribs above the diaphragm as metrics for collimation, rotation, and inhalation quality was applied on 64,315 posteroanterior CXR images from a public dataset (ChestX-ray8). From this set 920 CXR images were sampled and manually annotated to gain additional trusted reference metrics. Seven readers from different institutions then classified the acquisition quality of these images independently into okay, inadequate, or unacceptable following the criteria of international guidelines. Optimal thresholds on the metrics were determined to reproduce these classes using the metrics only. Results A fair to moderate agreement between the experts was found. When disregarding all inadequate rates a classification on the metrics was able to separate okay rated cases from unacceptable cases for collimation (AUC 0.97), rotation (AUC = 0.93) and inhalation (AUC = 0.97). Conclusion Suitable thresholds were determined to reproduce expert opinions in the assessment of the most important quality criteria in CXR acquisition. These thresholds were finally applied on the AI-method's estimates to automatically classify image acquisition quality comprehensibly and according to the guidelines.
