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Signify Premium Insight: What Providers Want – Keeping Demand for CT Systems High

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Research Manager, Bhvita Jani

As with many medical imaging modality markets, the story of CT is closely entwined with the all-encompassing story of the Covid-19 pandemic and its spread around the world. This story is detailed in Signify Research’s CT Equipment – World – 2022. But, as the report’s author, Research Manager Bhvita Jani explains, the effects of the pandemic are nuanced and will affect the market for years to come, while other clinical trends and technological innovations are also set to have a significant impact.

The Signify View

In China, the first country to be affected by Covid-19, CT quickly became the preferred modality for the diagnosis and assessment of the infection. As a result, demand for the modality quickly increased.

“However,” explains Jani, “given this significant increase in demand in China, there was some expectation that there would be a similar increase in demand across the rest of the World. What actually happened was that while some countries, particularly in Western Europe adopted CT as the main diagnostic modality, most other countries used mobile DR as the first diagnostic imaging tool, and only used CT to monitor critical cases.

“Even with some increased demand in the US, and Asia Pacific, for example, and emergency funding made available to pay for equipment purchases, in many cases in developed countries, hospitals had spare capacity with the systems which were already installed. So, unlike in China where CT systems were already operating at full capacity, these countries didn’t need large numbers of extra systems to meet the increase in demand.”

Even without some of the anticipated demand for CT systems coming to fruition in 2020, it still represented a significant jump from 2019, reaching $5.1bn globally in 2020, up from $4.1bn in 2019. Despite this rapid increase in 2020, however, further growth is still anticipated over the report’s forecast period until 2026.

High vs Low

“There are still moderate growth prospects from 2021 to 2026,” Jani continues, “With a 3.7% CAGR for the period.”

“What we’ve found is that, as a result of CT’s use in Covid care, there were more sales of the lower end of vendors’ portfolios, the 17-63 slice systems, in 2020. That product segment had one of the largest increases in 2020. In 2021, this dynamic shifted, and most growth came from hospitals modernising their fleet of CT systems, in order to better deal with the backlog of procedures delayed amidst the disruption caused by Covid in 2020.

“There is still demand for the lower tier products, but this is mainly in developing markets which are aiming to expand access to advanced imaging. However, in developed markets, demand is highest for mid-to-high end offerings, as hospitals face huge waiting lists and want access to the latest available clinical capabilities.”

The impetus to upgrade to more modern systems is therefore currently high. Many providers are looking to take advantage of CT imaging and the technological developments in the CT space over recent years. Reductions in dose, reduction of scan times, improved image quality and better efficiency all have made CT more attractive across a range of clinical settings including neurology, musculoskeletal imaging, cardiology and orthopaedics.

“This is particularly true on the software side,” notes Jani. “CT is an advanced imaging technique, which means that scan times and the time it takes for post processing images can be high. That means there is a lot of opportunity for innovation to make significant improvements. So, in developed markets in particular, providers are willing to upgrade to access the better operational features which allow higher patient throughput, more accurate patient positioning, bespoke software applications for dedicated clinical use cases and other features that can help improve a hospital’s operational workflow.”

The Next Technologies

Vendors are also making technological leaps on the hardware side, with two of the most significant innovations being dual energy or spectral CT and photon counting CT. The commercial impacts of these technologies varies throughout the forecast period, with the impact of photon counting CT in particular likely to be slight.

Though dual energy devices do not provide as greater image quality and definitive tissue characterisation as PCCT devices, they are more affordable and accessible, and so will have a continuing impact in the CT market over the short- and mid-term in developed economies, and a growing role in developing and emerging economies over the longer-term. Commercialisation of photon counting CT is not expected to accelerate for around five years with widespread use expected to take even longer, at around five to seven years. However, there is expected to be continued investment and uptake at leading university hospitals, which will continue to demonstrate the clinical benefits of the technology. The price, however, at around 50 percent more than other top-end scanners, will remain a barrier for the immediate future.

This is less of a hurdle for dual energy CT which is already deployed in China, and tends to be more affordable than photon counting CT, but longer term, photon counting CT, at least according to its acolytes, is expected to become ubiquitous.

“It’s a technology that offers better image quality [compared to conventional CT], decreased noise, better spatial resolution, lower radiation dosing and better tissue determination, so when it comes to diagnosis and treatment planning, its impact could be dramatic,” Jani explains.

“But, until there are more entrants to the market which will help to bring down the price, these impacts are still some way away. Other entrants are beginning to emerge though, Siemens Healthineers received FDA approval for a photon counting CT system in late 2021, while Samsung Neurologica was the second vendor to receive approval in March 2022 for its mobile photon counting CT system. Other vendors such as GE HealthCare, Philips and Canon are also developing products. These are in the testing and evaluation phase are still not commercially available, but should lead to a decline in prices when they enter the space commercially.”

There are other factors that will also improve the affordability of such systems over time.

“Photon counting CT requires considerably more computing power to process the vast amounts of data generated. The cost of this processing power will inevitably fall in the coming years.”

The Way to Work

One of the other technologies driving CT sales growth is artificial intelligence. Much of the excitement surrounding AI focuses on image analysis, but for CT, the technology can also offer significant advantages across an imaging workflow.

“In CT, AI is typically being used in edge applications,” comments Jani, “there is a focus on the operational aspects of CT imaging such as dose reduction, patient positioning, image acquisition and image reconstruction.

“What this means is that in developed healthcare settings, high-end hospitals are increasingly starting to purchase premium CT systems with embedded AI as they are able to benefit from the increased patient throughput that these systems offer.

“This continued focus on reducing scan time, increasing operational facilities, increasing the return on investment, and all these tasks that AI is being used for, is giving providers a reason to upgrade before systems were originally meant to be ready for replacement.

“The CT image analysis market, on the other hand, is primarily being driven by start-ups and scale-ups, alongside modality vendors. This is being driven by several high-value clinical applications, such as coronary artery disease, cardiac assessment, stroke assessments, chronic lung assessment and vertebral compression fractures, while in the mid-term lung cancer, traumatic brain injury, bone density and liver disease are also set to be key clinical use cases driving the market forward.”

Providing for Providers

Although supply to the market is very consolidated, with almost 93 percent of the market accounted for by just six vendors, the current pace of innovation means that CT sales are forecast to grow over the coming years. Short-term challenges such as the logistical headaches and component shortages affecting most areas of medical imaging will cause costs to rise for users, but these aren’t expected to dampen demand.

Instead, new features, new capabilities, and new opportunities afforded to providers will keep demand high.

“There is currently a lot of focus on usability, with consideration given to noise reduction, reliability, enhanced image quality, ease of operation, faster throughput, and more efficient image acquisition all taking a central role.

“Futuristic technologies such as photon counting CT will maintain this momentum in the years ahead, while a diverse portfolio, serving both the performance as well as the high-end market will help current sales.

“In the end, what this comes down to,” concludes Jani, “is putting providers’ needs first.”

About Signify Premium Insights

This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify Research. To view other recent Premium Insights that are part of the service please click here

Signify Premium Insight: Blurring Boundaries: CT, X-Ray and KA Imaging

This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify Research. To view other recent Premium Insights that are part of the service please click here.

Canadian X-ray detector manufacturer KA Imaging recently announced that it is investing almost $1.5m in the development of what it claims is the world’s first dual-energy mobile X-ray system.

The move marks a shift for the vendor, which has hitherto only produced flat panel detectors for medical applications. As such, the new system will utilise its own Reveal 35C dual-energy X-ray detector. This will enable the system to create three images in a single exposure. As well as a standard X-ray, a soft tissue image without bone, and a bone image without soft tissue are also captured simultaneously.

KA Imaging says the device expands on the diagnostic capability of X-ray, and will be most useful in cases where critical patients cannot be moved to traditional imaging rooms, or in rural or remote communities where access to fixed X-ray systems, CT scanners and MR systems is limited.

The Signify View

The volume of diagnostic medical imaging procedures is, and is set to continue, rising. Signify’s Diagnostic Imaging Procedure Volume Database showed growth in both CT and X-ray imaging, with the growth in CT outstripping that of X-ray, this is true in North America, where X-ray procedure volumes are forecast to grow at just 0.6% CAGR between 2019 and 2025 compared to 2.7% for CT.

This difference in growth masks a burgeoning trend which sees an increasing convergence between high end X-ray imaging and lower end CT. This is evident in both directions, with value-oriented CT systems being chosen over high-end X-ray systems in some cases, while high end X-ray systems are, in some cases, also beginning to bridge the gap in capability to low end CT. KA Imaging’s dual energy mobile system is indicative of this convergence, promising to offer improved image quality compared to traditional digital radiography (DR), at a lower radiation dose than CT, and requiring less technical expertise.

The lower infrastructure requirements of X-ray systems compared to CT systems means that they are, in some respects, more versatile, easier to install and can be deployed across a greater range of clinical settings. This versatility has also been one of the focuses of KA, which for its first foray into device manufacture, decided on a mobile system. This is a sensible decision. One of the developing trends in medical imaging is an increasing shift toward outpatient sites. These sites could benefit from higher image quality than a traditional DR system affords. Such fidelity could allow these centres to improve their diagnostic precision and promote the use of the more sophisticated modality as a differentiator from their local competition. However, the cost, infrastructure, and expertise required to purchase and operate CT could be prohibitive, leaving these centres to instead utilise devices effectively occupying a middle ground such as that promoted by KA.

System Builder

The fact that KA Imaging has sought to make a device at all is also significant. The vendor’s mobile X-ray system is reliant on its previously released Reveal 35C X-ray detector, a category that, for medical applications at least, the vendor is better known. Its decision to release a system, instead of merely relying on the detector itself, raises questions as to the traction the detector has so far received in the market. The vendor’s decision to launch a system could therefore represent a bid by KA Imaging to promote its dual energy technology directly to the providers and physicians that will utilise it, rather than being beholden to large medical imaging vendors who must first select KA’s dual-energy detector for use in their systems, before themselves selling it on to the end users. KA Imaging’s strategy has also been to sell directly to end users, and the decision to create an end-to-end dual energy mobile DR solution was primarily driven by feedback from end users.

This is unlikely to be a long-term strategy for KA Imaging, which will instead use the device to increase awareness of its detector technology and demonstrate its benefits in a clinical setting. This, KA will hope, will be enough to convince the likes of GE Healthcare, Philips and Siemens Healthineers to use KA’s detectors to adopt the technology in their own systems. However, this will mean the dual energy mobile DR system will also be in competition with KA Imaging’s OEM customers. Longer-term, KA Imaging could struggle to compete with larger medical imaging vendors, given their advantages in scale, medical device manufacturing, and established supply networks and sales channels. However, producing a system in the near term, selling to several, well-heeled and influential customers, could help promote the vendor’s dual-energy detector.

The Cost of KA

These first customers, who must be willing to pay the significant premium the dual energy technology demands compared to traditional X-ray systems, could find benefit in some of the advantages in image quality and usability that the system offers compared to X-ray and CT respectively. However, at present the cost is likely to be prohibitive for any broader adoption, given that for providers, it represents a significant investment in what is still a limited niche. KA Imaging has suggested some use cases and are conducting studies to support them, with one paper referenced by the company claiming that the technology helped detect 25% more pneumonia cases than traditional X-ray.

The vendor will be targeting providers who are looking to bring the detector to the point of care, making imaging more comfortable and convenient for patients, as well as more challenging settings like critical care units and paediatric wards. Another possibility is for several departments to share a dual energy mobile detector, reducing each department’s reliance on busy shared CT resource. This could be helpful for time sensitive acute conditions which benefit from earlier particularly given the quicker turnaround times offered by X-ray compared to CT.

However, in some countries, such as China, providers are increasingly skewing towards the purchase of CT instead of high-end X-ray systems. These sites are increasing the proportion of CT scanners they have compared to high-end X-ray systems. This trend is particularly driven by the increased affordability and maturity of CT systems from local manufacturers. There are penalties for such a shift, with lower throughput than X-ray systems, as well as a higher level of expertise required by radiologists and technicians in terms of patient positioning and image interpretation. However, the improved image quality, CT’s versatility and, importantly for providers, the additional reimbursement that CT affords, could render KA Imaging’s target of the premium X-ray an insurmountable challenge.

The Hard Sell

Price is a constant consideration for providers when it comes to purchasing medical imaging equipment. At present, this is major challenge that KA Imaging will face with its dual energy X-ray system. The device does offer advantages compared to other mobile X-ray systems that will be valued by some, and the ability to upgrade existing systems with the dual energy detector will help mitigate the cost of upgrading, but at present, progress for KA Imaging will be hard won. If KA can gain traction with its dual energy detector, and garner interest from large international imaging vendors, the price of acquiring the technology will fall and a successful niche could be established.

However, this boundary between X-ray and CT will increasingly become a bitterly fought space. Digital tomosynthesis solutions, currently being promoted by the likes of Adaptix and Nanox for example, could be used outside of breast imaging, combining some of the advantages of X-ray and CT. Another potentially transformative technology is AI. Workflow tools could be used to improve the efficiency of CT imaging and to aid less experienced technicians, while diagnostic algorithms could be used in reading rooms to supplement the expertise of radiologists.

Whether KA Imaging can make headway in such a changeable space remains to be seen. The device and the detector technology it relies on could help doctors, particularly if its cost can be reduced enough to be a viable alternative for more providers. Unfortunately, given the price differential, without a key application or remarkable use case, its appeal could be lost on providers who have the luxury of choosing between several viable options. KA Imaging’s dual energy system and particularly its dual energy detector has an opportunity, but the vendor must now work to make sure that providers get a chance to experience its potential.

About Signify Premium Insights

This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify Research. To view other recent Premium Insights that are part of the service please click here