Tag Archives: General Radiography

Strong Revenue Recovery of 15% for Fixed Digital Radiography in 2021, Whilst Fluoroscopy Grew by 18% Year-on-Year

Co-written by Graham Cooke

The fixed digital radiography (DR) rooms market experienced strong growth in 2021, with 15% growth in revenue reported, with revenues estimated at $1.2 billion. Likewise, the fluoroscopy X-ray market returned to growth after a year of retraction in demand in 2020, with 18% year-on-year growth in 2021, with an estimated market size of $509 million. These figures, taken from Signify Research’s General Radiography and Fluoroscopy – World 2022  report, show a strong recovery from the challenges experienced during the heights of the COVID-19 pandemic.

Demand returns to fixed room radiography in 2021.

Demand for fixed room digital radiography systems returned to growth in 2021, as procurement budgets were made available, having been temporarily diverted to fund mobile X-ray purchases in the early phases of the pandemic. This allowed previously planned projects to resume, and upgrades and replacements to be installed. For developed regions and countries, higher end features to help tackle the backlog are now increasingly sought after, including auto-positioning, cameras to ensure minimal patient movement before imaging and AI based image analysis. Such features improve workflow, increase the throughput of an imaging department, and should help healthcare providers gradually clear some of the backlog created from the pandemic.

Conversely, the digital mobile X-ray market retracted by 18% in revenue terms in 2021, closing at $684 million. However, this decline was not as severe as previously forecast, with some sustained demand remaining. During the pandemic, obvious benefits of mobile imaging were reinforced, including portability for bedside imaging. Growth is expected to return for mobile DR in 2024, as replacement of older mobile systems drives demand.

For mobile radiography, the importance of brand loyalty in purchasing decisions also returned, after temporary focus solely on inventory available during the pandemic. This allowed, smaller, local vendors to win significant share in new markets as they could service demand from local inventory more readily than global brands. Once global vendor inventory returned to a more normal level, purchasers often reverted to previous purchasing habits.

The general radiography market has experienced issues across the supply chain. Many components, including steel and semi-conductors, are in short supply. Coupled with rising costs of transportation and limited availability of shipping, average selling prices are expected to rise by approximately 8% in the short term for general radiography systems, before stabilising and declining again. This is also adding to lead times for projects, with systems taking a lot longer to reach customers.

Fluoroscopy also returned to growth, but demand is expected to become more specialised

Demand for fluoroscopy also returned to growth in 2021, with 18% year-on-year revenue growth to $509 million reported, up from $431 million in 2020.  However, fewer fluoroscopic procedures are now being performed, with other modalities like CT and MRI taking precedence for procedures traditionally conducted on fluoroscopy systems. Upper GI and barium swallow procedures remain the most procedures maintaining clinical demand for fluoroscopy and will remain essential for the long-term health of this modality.

With fewer fluoroscopic exams being performed and increased focus on return of investment in purchasing decisions, multi-purpose systems are now even more desirable, especially in North America and Western Europe.

Fluoroscopy revenues will surpass 2019 pre-COVID levels next year, but growth will be limited after this, as other imaging modalities continue to challenge fluoroscopy. The fluoroscopy market is set to reach $614 million by 2026.

Key trends by region

North America

  • The US continues to be one of the few countries still favouring classical fluoroscopy systems, due to historical training practices, concerns of patient movement threatening image quality and potential litigation. Demand is expected to gradually transition to remote systems, as new generations of radiographers are trained on remote systems; classical is however still expected to be dominant in the next five years.
  • In the general radiography market, demand for high end features is increasing, with tools to aid workflow becoming highly desirable for many imaging centres and hospitals.

Latin America

  • The Latin America market continues to be highly cost sensitive, with options like computed radiography, retrofit and analogue systems remaining popular. For many end users, there is a desire to digitalise, but currently, the price point remains prohibitive. For the digital solutions that are sold, low-end systems with a lower price point are by far the preferred option – over 50% of fixed and mobile solutions revenue came from the low-end in 2021.
  • Fluoroscopy remains a very small market in Latin America, with the high price point proving a significant barrier for entry to this market. Brazil is the largest adopter of fluoroscopy in the region, with most other Latin American countries seeing minimal sales.

Western Europe

  • High-end product continues to dominate the general radiography market in Western Europe, with 68% of revenue for fixed room product coming from High-end in 2021. Floor mounted systems sell more in unit terms in Western Europe, but with a lower ASP, revenue from ceiling mounted solutions accounts for a higher proportion of the market.
  • Most Western Europe markets have limited demand for fluoroscopy, with France being the key exception. Almost 30% of all revenue in Western Europe comes from this country. France is also unique in that many healthcare providers prefer to use dedicated fluoroscopy systems, rather than multi-purpose which is generally utilised in the rest of Western Europe.

Eastern Europe, Middle East and Africa (EEMEA)

  • Parts of EEMEA remain very cost sensitive, with Africa and less developed countries in the Middle East seeing high adoption rates of computed radiography, analogue and retrofit. For many, digital solutions are too costly, especially with the added infrastructure costs to enable PACS and other healthcare IT solutions on top of the imaging systems. Servicing imaging equipment can also be a barrier to adoption, with few engineers available locally to quickly fix broken systems.
  • Fluoroscopy remains very small for most of EEMEA. The areas that have stronger installed bases are in French-speaking north Africa, where demand follows France. In parts of the Middle East, such as in Saudi, some trends follow the US, as some radiographers were trained in the States, and therefore follow classical fluoroscopy installation practices.

Asia Pacific

  • Asia Pacific remains cost sensitive in many parts of the region, with 57% of fixed room revenue coming from the low-end segments. In countries like India, high levels of analogue and computed radiography remain significant. In China, CT imaging is increasingly preferred over high-end digital radiography.
  • Japan remains essential to the long-term growth of the fluoroscopy markets, with 45% of all unit sales in the region coming from this country alone. Elsewhere, demand is minimal with costs proving prohibitive to adoption.

Competitive landscape

A return to a more conventional vendor landscape was evident in 2021, with global brands such as Siemens Healthineers, GE HealthCare and Philips regaining market share temporarily lost during the pandemic when demand outstripped the available supply. With these vendors able to fulfil demand, smaller local vendors dropped share.

In the fixed DR market, Siemens Healthineers strengthened its position, with a gain of 2.5 percentage points.  For Mobile DR, GE reclaimed the top position, as Carestream experienced a difficult year after a very strong 2020.

For the fluoroscopy market, Siemens Healthineers led, with a very strong 2021, gaining further share. Shimadzu follows with strong sales in its domestic market.


The Fixed DR market will continue to recover. Budgets will continue to return for fixed room, and projects previously postponed will be able to restart. Additionally, in some countries like the US, replacement cycles will stimulate further growth towards the end of the forecast. Globally, ceiling suspended fixed room product revenue will grow at a faster pace (5% CAGR 2021-26) than floor mounted (4% CAGR), especially in more developed markets, where the desire for high-end features often found in ceiling-mounted solutions, are increasingly required. Low-end system demand will continue to be driven by cost sensitive markets such as Latin America, Africa, the Middle East and parts of Asia. However, the price of digital solutions will need to significantly reduce to be an attainable option for these regions. Until the price falls sufficiently, analogue, CR and retrofit will continue to play an important role.

Fluoroscopy systems will also see limited growth but will also come under increasing pressure from other modalities like CT and endoscopy. At the end of the forecast, low single digit annual revenue growth is predicted.  In many countries and regions, the demand for fluoroscopy will come predominantly from multi-purpose systems; as fewer procedures are performed on the systems, budget holders will want to minimise downtime by enabling other general radiography imaging.

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

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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.

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Revenue growth for fixed General Radiography and Fluoroscopy is set to reach 10% and 8% respectively in 2021

The fixed digital radiography market is expected to grow at 10% year-on-year in 2021, reaching $1.1 billion, whilst the fluoroscopy market will also experience good levels of growth at 8%, closing 2021 at $463.2 million. These figures, taken from Signify Research’s General Radiography & Fluoroscopy – World 2021 report, show an encouraging rebound after a challenging 2020, during the COVID-19 pandemic.

Demand to switch from mobile to fixed radiography in 2021

The general radiography market grew by 12% in 2020, due to the exceptional demand for mobile radiography systems. The world market for mobile radiography systems is estimated to have increased by an impressive 77% year-on-year.

Mobile digital radiography (DR) systems are at the forefront in providing initial screening for pneumonia, a secondary and more progressive stage of COVID-19 in severe cases. Mobile DR systems are also used to track progression of pneumonia due to the capabilities of bedside imaging, enabling their use in emergency rooms, A&E facilities and in the ICU. During the peaks of the pandemic, hospitals and healthcare facilities around the world were desperately attempting to procure mobile radiography systems to supplement existing inventory in the face of supply shortages at most of the leading vendors.

As healthcare facilities rapidly sought out mobile systems, often discarding brand loyalty for whatever systems were available, budgets were diverted away from fixed radiography systems and fluoroscopy systems. The fixed digital radiography (DR) market declined by 14% year-on-year in 2020. In unit terms, 11% fewer fixed DR systems were sold in 2020. As the pandemic begins to subside, and healthcare budgets gradually return, investment in the fixed general radiography market is projected to return to pre-pandemic levels by the end of 2021.

On the contrary, the global market for mobile radiography systems is projected to see a sharp decline of 39% in 2021. With most hospitals and health clinics having recently purchased mobile radiography systems during the pandemic, the inflated installed base will restrict the need for new systems in the coming years. The market is forecast to return to growth in 2023, driven by the replacement of older analogue systems.

Stronger growth forecast in multi-purpose fluoroscopy

The fluoroscopy market experienced a challenging year in 2020. With fluoroscopy budgets diverted to COVID-19 response, alongside fewer fluoroscopy procedures, the market saw a 19% decline in revenue. Clinical demand is shifting away from fluoroscopy to CT and endoscopy, further threatening this market. The main procedures that remain a stronghold for fluoroscopy include barium-swallow scans and upper GI procedures. Stronger growth is forecast for multi-purpose systems which can perform both radiography and fluoroscopy, due to wider clinical usage and associated higher return on investment. After the steep decline in 2020, the fluoroscopy market is expected to gradually recover and surpass 2019 revenue levels by 2024.

Key trends by region

North America

  • Unlike most other world regions, North America and in particular the United States, remains a classical fluoroscopy market, with far lower uptake of remote imaging, due to the associated detachment from the patient and concerns of jeopardising image quality and subsequent litigation.
  • Brand loyalty continues to be strong for general radiography equipment, to prevent retraining and adjustment of workflows.

Latin America

  • Demand for analogue and CR systems remains high in Latin America, with the lower prices being a key deciding factor. In Brazil it is estimated that 85% of general radiography exams are still conducted on analogue systems, a far higher number than many other emerging countries. However, with falling prices of flat panel detectors, digitalisation is expected to gather pace in the coming years.
  • Fluoroscopy remains a small market in Latin America due to the relatively high system prices yet lower utilisation due to the niche clinical applications they address. The shortage of trained radiographers is also holding back the fluoroscopy market.

Western Europe

  • The general radiography market in Western Europe continues to remain focused in the higher end market segment, especially floor-mounted systems.
  • Fluoroscopy continues to be a very small market in most Western European countries, with France being the exception, where the market for remote systems is forecast to increase over the coming years. France is unique in that hospitals use fluoroscopy for patient positioning and to localize where to start imaging, and this modality is therefore used frequently. Additionally, there is a strong replacement market and older systems are typically replaced like-for-like and not with a multi-purpose system. Most other Western European countries have much less uptake of dedicated fluoroscopy equipment.

Eastern Europe, Middle East and Africa

  • Lower-cost analogue solutions continue to sell well in the African general radiography market. In Eastern Europe there remains a focus on floor-mounted digital X-ray solutions, as the lower price point is a key factor in this price-sensitive market.
  • French speaking parts of North Africa still have a strong demand for fluoroscopy systems, following France in this trend. Elsewhere, demand remains lower.

Asia Pacific

  • The fluoroscopy market is largest in China and Japan, with all other Asian countries having very limited uptake, as other modalities are favoured for traditional fluoroscopy procedures.
  • Lower cost floor-mounted systems continue to dominate the general radiography market, especially in China.

Competitive analysis

In 2020, Carestream consolidated its position as mobile DR market leader, followed by GE Healthcare, Siemens Healthineers, Philips and Fujifilm.

Siemens Healthineers and GE Healthcare secured the position of joint market leaders in the fixed DR market, with GE Healthcare gaining significant share in 2020.

Siemens Healthineers was the world market leader for fluoroscopy in 2020, with Shimadzu, Canon Medical and Philips following.

Future outlook

The fixed DR market will rebound in 2021, as budgets and investment will return to fixed radiography rooms. Signify Research forecasts investment will gradually return for high-end DR solutions, such as ceiling suspended and multi detector systems from 2021 onwards. Growth in the low-end fixed DR market is forecast to primarily come from emerging regions, such as Africa, Latin America and Asia, where there is a significant installed base of analogue radiography and computed radiography ready for digitalisation. Growth in the fluoroscopy market will be limited as clinical procedures move from fluoroscopy to CT or endoscopy. As a result of increased focus on cost-efficient solutions and return on investment, most of the demand for fluoroscopy equipment will be captured by multi-purpose systems capable of performing general radiography procedures.

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