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X-ray Equipment

A closer look at the X-ray equipment market

While Covid-19 may continue to receive a lot of attention as mutations lead to fresh outbreaks of illnesses, 2022 also looks to be a watershed year for medical image management.

Over the last few years, medical imaging has undergone a dramatic evolution owing to digital radiology solutions. Diagnostic accuracy is at the core of the healthcare industry, and X-ray imaging plays a significant role in improving diagnostic accuracy. In addition, the integration of artificial intelligence (AI) in digital X-ray systems has contributed to market growth. Furthermore, major market players are engaged in the development of advanced modalities, such as multimodal/hybrid imaging systems.

The Covid-19 pandemic turned the spotlight on diagnostic imaging by demanding a need for high-speed workflow and efficient patient management. This helped to highlight the importance of the role of digital radiography (DR), which offers fast turnaround with less than one minute needed between exposure and image acquisition. As we start to enter the post-pandemic period, the continuing need for DR technology is still as strong as ever.

Furthermore, the demand for mobile X-ray systems has increased as a result of the pandemic. With the consumers being more aware of the benefits of mobile X-ray systems, and the possibility of another pandemic in the future, healthcare facilities may consider switching to mobile diagnostic equipment owing to its faster image processing, workflow optimization, integrated AI, and other features.

The Indian X-ray machines market in 2021 is estimated at 18,532 units, valued at ₹940 crore. The analog machines, with a 46-percent share by quantity, contribute a 24-percent share by value. The CR machines, at a 38-percent share by quantity, dominate the segment by value with a 41-percent share. The DR machines constitute 29 percent of the market by value and 16 percent by quantity. The full-field digital mammography (FFDM) machines, for which we have estimated the market size for the first time, are largely imported, at an average unit price of ₹1 crore. Two indigenous brands, Allengers and Panacea have recently made an entry into this segment.

While, with the price difference narrowing between DR and CR systems, there has been a shift in favor of the DR segment, and during Covid a preference for mobile models, within the DR segment, the retrofit detectors constitute about 57 percent share by volume and value. And once considered along with OEM panels, they hold a combined share of 96 percent by volume and 88 percent share by value.

Indian X-ray equipment market – 2021*
Analog brands CR brands
Tier 1 Allengers Fujifilm
Tier 2 Vision, Kiran, Medion, and Epsilon Carestream
Others Skanray, BPL, Alerio (Iatome Electric), and regional fragmented brands Agfa and Konica
DR fixed brands
Imported    Agfa, Carestream, Fujifilm, and Konica
Indian    Allengers, Prognosis, Kiran, Skanray, and BPL
DR mobile brands
Imported Indian
Tier 1 Samsung Allengers
Tier 2 Carestream BPL
Others Agfa Skanray, Alerio (Iatome Electric),
and Kiran
DR retrofit brands
Tier 1 Konica, Carestream, and Fujifilm
Tier 2 Agfa and CareRay
Others PZ Medical, Rayence USA, and Canon
*Vendors are placed in different tiers on the basis of their sales contribution to the overall revenues of the Indian X-ray imaging market.
ADI Media Research

Some distinct trends are observed. While the funds are not a constraint at the hospitals, and they are keen to equip their facilities with high-end equipment, the government’s Make in India push is restricting procurement. Orders are being placed on Indian integrated and assembled equipment, especially on tendered procurements, a case in point being 21 machines purchased by HLL recently. With the tightening in the regulatory environment, new product launches are now taking longer, sometimes as much as six months.

The buyers are inclined to de-risk their institutions from technological innovations, and are shifting to OpEx models and opting for pay-per-case. Others are preferring to buy value models. Having said that, new players are keen on the Indian market and Chinese and Korean brands find their way here.

Indian X-ray equipment market – 2021*
FFDM brands
Imported Tier 1 Fujifilm and Siemens
Imported Tier 2 Hologic, GE, Planmed, and United Imaging
Indian Allengers and Panacea
OEM brands
Tier 1 iRay
Tier 2 Varian and DR Tech
Others PerkinElmer, Varex, Toshiba, and Thales
DR without panels brands
Tier 1 Fujifilm
Tier 2 Carestream & DRGEM
*Vendors are placed in different tiers on the basis of their sales contribution to the overall revenues of the Indian X-ray imaging market.
ADI Media Research

The global X-ray systems market size was valued at USD 6.7 billion in 2021 and is anticipated to expand at a compound annual growth rate (CAGR) of 2.3 percent from 2022 to 2030. The major factor driving the market is increase in the demand for early-stage diagnosis of chronic diseases. In addition, continuous technological advancements, rise in product development, improved funding, and investments by the government, especially in developing countries, such as India and China, are also expected to contribute to the market growth.

Increasing awareness and adoption of preventive healthcare and disease screening programs are expected to propel market growth. Improvement in the quality of image output is expected to enhance diagnostic accuracy in the early stages of various diseases. This can help with the faster diagnosis and treatment of a variety of life-threatening disorders, including cancer and a number of cardiovascular conditions. Thus, the growing usage of X-ray systems for diagnosing various diseases is expected to contribute to market growth.

The computed radiography (CR) segment dominated the market for X-ray systems and accounted for the largest revenue share of 54.6 percent in 2021, owing to its lower initial costs. CR is the first digital replacement for traditional X-ray film radiography with cassette-based phosphor storage plates (PSP), which provides significant benefits, such as the elimination of consumables and a significant reduction in image development time. In developing countries, where the adoption of new technology is slower, computed radiography has been found to be in high demand.

The digital radiography (DR) segment is anticipated to witness the fastest growth rate over the next eight years. There is a growing demand for DR since this system produces, high-contrast resolution images at lower ionizing radiation, using flat panel detectors (FPD). Moreover, this system is more efficient, compact, and has the capability of rapid image viewing. The growing adoption of DR technology by end-users to enhance the workflow is expected to boost the segment growth in coming years.

The stationary X-ray systems segment dominated the market and held the largest revenue share of 65 percent in 2021. In developing countries, where the adoption of new technology is slower, stationary X-ray systems have been found to be in high demand. The mobile X-ray systems segment is expected to exhibit the fastest CAGR of 3.3 percent over the next eight years. Mobile systems are superior to fixed systems because of their portability, image quality, speed, safety, and cost, which makes them more convenient and versatile to operate.

An increase in demand for mobile X-ray systems is noted, ever since the Covid-19 pandemic, as this system has the flexibility to be carried around the hospital or to a patient’s home, thus decreasing the risk of virus transmission. The focus of market players in developing innovative and improved mobile X-ray units is also leading to the increasing adoption of this system.

The radiography segment dominated the market and accounted for the largest revenue share of more than 49 percent in 2021. The segment is further expected to continue its dominance over the next eight years. For the majority of the patients, radiography is the initial diagnostic imaging step recommended by doctors on their way to a definitive diagnosis as this system has a wide range of applications and is less expensive and time-consuming than other systems. Furthermore, the increasing technological advancements are expected to boost market growth for this segment.

The mammography segment is also expected to grow at a significant rate during 2022 to 2030, with the increasing incidence of breast cancer and rising awareness about the same amongst the population. As per the global cancer observatory, in 2021, there were about 2,261,419 new breast cancer cases and the disease accounted for 684,996 deaths globally. Furthermore, the adoption of mammography systems by end-users is expected to expand as technology continues to progress.

The hospital segment dominated the market and accounted for the largest revenue share of 68.7 percent in 2021. In the outpatient settings, X-ray system is a substantial source of revenue; also, there is an increase in the number of patients visiting hospitals with various chronic disorders. As a result, these systems are frequently installed and upgraded in hospitals. Furthermore, the increasing partnerships between hospitals and market players are likely to boost demand for new installations in the coming years.

The diagnostic imaging center segment is expected to witness significant growth during the forecast period. Imaging centers provide a comprehensive range of diagnostic and preventative health services. Most hospitals lack the necessary space for specialized imaging equipment rooms; also, they require high investments and frequent maintenance. According to United Healthcare, medical imaging in a hospital outpatient department is up to 165 percent more expensive than in a diagnostic imaging center. The growing patient population with chronic disorders is an opportunity for radiologists to provide stand-alone outpatient imaging centers. For instance, in September 2021, Intermountain Healthcare, the largest healthcare provider in the US, announced the launch of Tellica Imaging, a stand-alone outpatient imaging center.

North America dominated the market and accounted for the largest revenue share of 30 percent in 2021. The market is being influenced by factors, such as increasing adoption of modern technology and improved healthcare infrastructure, strong purchasing power, and a fair reimbursement framework.

In the Asia Pacific, the market for X-ray systems is estimated to witness the fastest CAGR during 2022 to 2030 owing to the increased demand for better imaging devices and supportive government initiatives for improving healthcare infrastructure in the region. Rapidly developing economies and improving healthcare services in Southeast Asian countries, China, Japan, and India are expected to propel growth. For instance, according to Enhance International’s Sam Radwan, China’s estimated healthcare spending in 2050 might be greater than Germany’s overall GDP in 2020. Furthermore, the increasing prevalence of chronic disorders and the rise in the geriatric population is expected to boost the market growth in Asia-Pacific.

The key players are developing high-end mobile X-ray systems, which gained popularity since the Covid-19 pandemic, as well as integrating Al into these imaging systems, which have demonstrated impressive accuracy and sensitivity in the detection of imaging abnormalities. As a result, it is being more widely adopted and used in the field of medical imaging.

Some of the prominent players in the X-ray systems market include Koninklijke Philips NV, GE Healthcare, Siemens Healthineers AG, Canon Medical Systems, Shimadzu Corporation, Fujifilm, Carestream, Mindray Medical International Limited, Hologic, Inc., New Medical Imaging, and Agfa.

A hybrid OR essential – Motorized digital C-Arm
Navjot Singh
President – Medical Imaging,
Trivitron Healthcare

Medical practitioners perform critical surgical procedures with precision and minimal invasiveness by using C-arms and cath labs, which are based on X-ray platforms and offer high-resolution X-ray pictures in real time throughout the surgery.

The necessity for a smarter, easier-to-use medical imaging system has evolved as the prevalence of minimally invasive procedures continues to rise. Cath labs are typically utilised for complex neurosurgeries as well as cardio-vascular operations like angiography and angioplasty. Mobile C-arms are mostly used in orthopaedic, urology, spine, and general surgical procedures.

Analog C-arms have a multi-fold image processing that begins with conversion of X-ray to visible light. This visible light is then captured by a CCD camera. Flat panel-based digital C-arms, as opposed to analog C-arms, directly convert the X-ray, using digital technology, into an electrical charge, which is then digitized in the detector’s readout matrix. With the help of image-enhancing processing tools, an image-processing software transforms the digital input from the detector into a digital picture, producing high-contrast and high-resolution images that aid in the visualisation of incredibly minute anatomical details.

Digital C-arms deliver precise, distortion-free pictures that span the whole viewing area. In case of CCD-based analog C-arms, the CCD camera provides limited field of view and images with a slight distortion. Flat panel-based digital C-arms provide an extended field of view and deliver images that are completely free of distortion.

A variety of clinical applications are available with digital C-arms, such as digital subtraction angiography for vascular applications and road mapping to help surgeons locate target regions during surgery.

Using a sophisticated touch-screen interface, the surgeon may access the intuitive selection tab menu and the generated images without disturbing the sterile area. Through the accessible tab, the operating technicians may directly control image-processing functions, including image rotation, zoom, and inversion while also receiving a smaller visual
preview.

As a result, the patient experiences less discomfort during the surgery, and they recover considerably faster.

The global digital X-ray market is expected to reach USD 16.4 billion by 2026 from an estimated USD 11.1 billion in 2021, at a CAGR of 8.1 percent from 2021 to 2026. The retrofit digital X-ray systems segment is expected to dominate the market over the next four years. The large share of this segment can be attributed to the greater adoption of retrofit systems among end-users due to their lower cost compared to new digital X-ray systems. However, the new digital X-ray systems segment is expected to grow at a higher CAGR due to the implementation of government initiatives that have reduced reimbursements for analog and computed X-ray systems.

The major factors driving the growth of this market include the increasing geriatric population and growth in disease incidence as well as favorable government regulations, investments, and initiatives. The advantages of digital X-ray systems have played a key part in their adoption; their speed and accuracy, as well as quick processing times allow for significantly higher patient-screening volumes than earlier. This has pushed companies to focus on product development and innovation. However, these systems are priced at a premium, which slows their greater adoption. Other factors, such as declining reimbursements, lack of infrastructure, particularly in developing and underdeveloped countries, and potential risks associated with radiation exposure, are also expected to hinder the growth of this market.

The Covid-19 pandemic adversely affected the economy in 2020 and presented various challenges to clinical healthcare providers and patients across the globe. Covid-19 has also impacted various stages of the value chain, primarily due to strict lockdowns imposed by the governments of most countries. The turnaround time for the delivery of products and services has also been affected due to newer packaging protocols and lockdown measures imposed by countries. All these factors are negatively impacting the manufacturing and supply chain of digital X-ray systems.

However, Covid-19 has unleashed new opportunities for digital X-ray manufacturers and healthcare providers. In settings where laboratory testing (RT-PCR) is not available, or results are delayed, or are initially negative, chest imaging has been considered as an alternative approach for patients with suspected or probable Covid-19. Imaging, including chest radiography, CT scans, and lung ultrasounds, has been considered to complement clinical evaluation and laboratory parameters in managing patients already diagnosed with Covid-19. According to the WHO, chest radiography can be helpful in the dynamic evaluation of Covid-19 pneumonia and its complications. Resolution or the progress of lung consolidation seen on a bedside chest radiograph can help caregivers make better therapeutic management decisions. Chest imaging can also inform the management of pneumothorax or pneumomediastinum.

Technological advancements are a crucial factor for the growth of the digital X-ray market. Factors, such as image quality, image-acquisition time, portability, detector form, and software create and increase the demand for digital X-ray systems. The demand for advanced digital X-ray systems increases due to benefits, such as their ability to process large volumes of data and examine patients rapidly. Various companies are developing digital systems with improved performance and efficiency. These systems enable radiologists to address a broad range of clinical applications with diagnostic-quality images and stitching functionality. Innovation and the development of advanced systems help boost the market for digital X-ray systems. Some recent developments in this market include introduction of AMX Navigate, a portable digital X-ray system by GE healthcare in September 2021.

Digital X-ray systems are priced at a premium and require high investments for installations, which increases the procedural cost for patients as well. This affects the adoption rate of new systems, especially in emerging countries. Most small and medium-sized hospitals cannot afford these systems, as their budgets are low or restricted. Healthcare facilities that purchase such costly systems often depend on third-party payers (such as Medicare, Medicaid, or private health insurance plans) for reimbursements for costs incurred in diagnostic, screening, and therapeutic procedures performed using these systems. The high cost of digital X-ray systems also pushes end-users toward refurbished systems, directly affecting the sales of new and advanced systems. This, along with continuous cuts in reimbursements for diagnostic imaging scans, prevents imaging centers from investing in technologically advanced diagnostic imaging modalities, which restrains the growth of the overall market.

Many hospitals in developing countries cannot invest in digital X-ray systems due to budget constraints, high equipment costs, and poor reimbursement rates. However, hospitals that cannot afford to invest in new imaging systems opt for refurbished ones due to the strong demand for digital imaging procedures globally. Refurbished systems are often priced lower than new systems. However, the increasing demand for refurbished devices poses a major challenge for market players, especially small manufacturers. To strengthen their position in the market and create a strong user base for their imaging systems, market players either have to position their products at lower prices or develop better or more advanced technologies that can address the unmet needs in the market.

The dominant players in the global digital X-ray market are Koninklijke Philips, GE Healthcare, Canon, Inc., Carestream Health, Fujifilm Holdings Corporation, Siemens Healthineers, Shimadzu Corporation, Hologic Inc., Agfa-Gevaert Group, Samsung Medison, Konica Minolta, Shenzhen Mindray Bio-Medical Electronics Co., Varex Imaging Corporation, MinXray, Inc., and Acteon, among others.

Some recent developments have taken in this segment. In November 2021, Carestream sharing its solutions for expanding DR at RSNA 2021. With Carestream’s DR retrofit systems, imaging facilities that have not yet fully upgraded to DR can move forward to full wireless DR imaging at a fraction of the cost of purchasing a new system. The retrofit solutions use a single wireless detector to convert existing equipment to full digital operation, delivering all benefits of a DR system.

In November 2021, Konica Minolta introduced the mKDR Xpress Mobile X-ray system, which offers exceptional imaging performance in a small footprint. Its slim design and collapsible column facilitate easy mobility, including tight spaces in the ICU, CCU, and OR. Ease-of-use is assured with a customizable mobile-specific user interface, remote control, and front and back collimator controls with laser alignment.

In August 2021, Shimadzu Medical Systems USA announced the first North American installation of its RADspeed Pro style edition with GLIDE Technology, DR system at Benefis Orthopedic.
In March 2021, Fujifilm Ltd. announced the launch of its FDR micro, a mobile digital radiology system, which provides high-resolution imaging with low X-ray doses.

In March 2021, Koninklijke Philips NV received 510(k) clearance from the US Food and Drug Administration for a CombiDiagnost R90, a remote-controlled fluoroscopy system in combination with high-end digital radiography.

Development of AI-based digital X-ray system. The opportunities for AI implementation in radiology are vast and exciting. Current research highlights the ways in which AI has the potential to enhance diagnostic imaging care. Advancements in pathology detection, characterization, and monitoring are just a few avenues by which AI is predicted to revolutionize the specialty in the coming years. Improved imaging analysis will lead to more timely and targeted diagnosis and therapies, which ultimately will improve patient outcomes. In the near future, the partnership between radiologists and AI technology will begin to redefine imaging care for years to come.

Many ongoing research and development programs have contributed to the industry in this regard. Currently, R&D activities are being conducted by various companies to provide AI in different imaging modalities, including digital X-ray systems.

In January 2022, Mireye Imaging Inc. launched an AI-based software for X-ray patient positioning. This intelligent imaging technology automates the patient positioning process for X-ray examinations and will eliminate the need for manual measurements and body part alignment.

In November 2021, Agfa launched its new Valory DR room. Valory delivers a simple design with functionality that goes far beyond the basics, bringing reliability, productivity, and first-time-right imaging into reach for any hospital. Valory is the newest addition to Agfa’s comprehensive DR portfolio. It comes with a wide choice of a generator power, ceiling-suspended X-ray tube, and Dura-line cesium iodide detectors that deliver robust reliability, cost-effectiveness, the potential for significant patient dose reduction, outstanding 15-hour battery autonomy, and the ability to share detectors among DR systems.

In November 2021, GE Healthcare received FDA approval for new AI, Critical Care Suite 2.0 that helps bedside staff and radiologists assess patients before intubation with endotracheal tube placements. The suite consists of five AI solutions and is an industry-first collection of AI algorithms, embedded on a mobile X-ray device for automated measurements, case prioritization, and quality control.

In June 2021, the Government of India launched X-ray Setu, a free AI-based platform, to aid doctors for early Covid-19 interventions.

In May 2021, Fujifilm partnered with Qure.ai to make intelligent X-ray solutions. The company introduced X-ray solutions, augmented with qXR, Qure.ai’s computer-aided radiology software application, designed with deep-learning AI technology.

In March 2021, Philips Healthcare entered into a collaboration with Lunit that will make Lunit’s AI software accessible to users of Philips’ diagnostic X-ray solutions. The agreement is the latest extension of Philips’ AI portfolio in precision diagnosis, which leverages this collaboration to achieve better patient outcomes, improve the experience of patients and staff, and lower the cost of care.

In November 2020, Hologic, Inc. received a CE mark for its Genius Digital Diagnostics System, which consists of a digital imager for image acquisition, an AI algorithm for analyzing images, and an image-management server for storing images for cervical cancer screening.

In August 2020, Canon Medical Systems partnered with Zebra Medical Vision (Zebra-Med) to offer its AI1 automated imaging analysis solutions to help clinicians in the US provide faster, more accurate diagnoses for optimized patient care. These advancements have further led to a positive adoption trend for AI in diagnostic imaging.

Mobile radiology represents a transforming concept that is evolving rapidly in line with notable advancements in the point-of-care (POC) testing arena. By wrapping digital X-ray capability into a mobile cart or portable system, the concept allows medical professionals to perform imaging examinations almost anywhere, including at patient bedside. The functionality incorporated into a mobile and compact footprint facilitates seamless examinations and accelerates the imaging turnaround to ensure faster diagnosis and treatment-related decisions. The increasing acceptance of these mobile radiology units in clinical and other settings is anticipated to empower people and help healthcare providers in monitoring and managing patient health in an efficient manner. The mobile radiology trend is anticipated to receive a considerable push from the increasing focus on POC testing and ongoing advances in this direction. The concept is expected to play an important role in complementing traditional imaging practices and enabling users to perform a large number of radiology examinations in an effective way.

Post-Covid teleradiology growth will be fueled by the rise of radiology super groups. As we enter year three of the pandemic and radiologist burnout continues to grow, there is also an increasing competition for talent that puts pressure on hospitals and practices to improve the employee experience while delivering the best possible care. At the same time, increasing consolidation can be seen in the market as radiology practices merge into super groups with regional or national scale and scope.

As these groups continue to merge and grow, many are further embracing teleradiology. This change enables staff to work from anywhere at any time, while also providing the ability to support greater flexibility. In all, this not only gives these practices a competitive advantage in recruiting in a tight market, but it can also improve radiologists’ quality of life and help address rampant burnout.

Teleradiology also provides great benefits to patients, especially those in underserved or unserved areas, as it gives them access to specialists outside their local market. With the ability to review images and scans remotely, radiologists can, in turn, deliver reports much faster, speeding up the diagnosis and treatment of many conditions.

Another trend that was once viewed with suspicion but is now rapidly gaining in popularity is cloud computing and storage. There was a noticeable uptick in cloud services at the conference.
As imaging volumes have ballooned, organizations have begun to question the need for, and/or wisdom of, maintaining all of those data on their own. Many smaller organizations no longer have the capacity to keep all of their data on site. Cloud storage allows them to store and access their data efficiently without the headaches associated with on-site storage.

Data security is always top of mind for radiology administrators, and cloud companies typically employ multiple security protocols. They also tend to have a significant amount of security expertise, which individual organizations may or may not possess depending on the resources that are available to them.

“There is a need for reducing the dose of radiation in conventional radiography, without impacting the quality of the data. Many advancements have been made in the field of digital radiography in recent years, including artificial intelligence (AI)-aided X-ray interpretation, dual-energy imaging, tomosynthesis, computer-aided diagnosis, automatic image stitching, and digital mobile radiography. These advancements have improved image quality, helping to enhance patient care and support better patient outcomes. Additionally, the use of digital radiography reduces the need for retakes, which provides the benefit of lower radiation exposure.

Growing significance of AI and low dose in digital radiography. AI is presently advancing at a fast pace in medical care. AI algorithms, particularly deep learning, have made significant strides in image-recognition tasks and helping in low dose with quick diagnosis. Covid-19 pandemic increased the use of X-rays and CT scans to screen out Covid-19 patients, which created the need for AI-enabled X-ray imaging solutions to help healthcare workers screen patients in less time, and improve the workflow. AI-based X-ray solutions are used for image analysis, detection, diagnosis, and decision support. AI CAD tools assist in detecting the most common thoracic finding more effectively, such as lung nodule, consolidation, interstitial opacity, pleural effusion, and pneumothorax and BSI. AI tool enhances the visualization of lung lesion by supressing rib signal, without the need for additional exposure, thereby lowering the dose. I conclude that recent advances in technology are providing increased efficiency as well as improved patient care. Dr Rakesh Kumar Gupta, Principal Director, Radiology, Fortis Memorial Research Institute, Gurugram

While much of the focus may remain on Covid-19 as variants cause new spikes in infections, 2022 also promises to be a landmark year for medical image management. The move to the cloud, greater reliance on teleradiology, and the increasing emergence of AI and machine learning will help ease the stress and burnout experienced by radiologists, making them more efficient and effective in their jobs, and improving work-life balance. Similarly, these technologies will further enhance the patient experience, supporting greater access to care for the underserved, and hastening diagnosis and treatment.

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