Improved resolution and new clinical applications that can help physicians to diagnose and stage diseases even earlier than is done now will continue to be the big trends in the future.
Since the advent of the first computed tomography (CT) scanner half a century ago, the CT technology is on the precipice and witnessing an era of unprecedented growth and technological innovations. The present day innovations are much more multidimensional, with improvements in speed, slice count, radiation dose, and image quality, boasting greater clinical applications and new digital cloud-based technologies. The new platforms deliver the highest spatial resolution, the highest temporal resolution for freezing the motion of the heart in cardiac scanning, and the widest coverage in terms of the number of slices or the amount of anatomy one can image in each rotation. Introduction of spectral CT and dual-energy CT technologies, along with the breakthrough improvements in the detector resolution have driven precision in diagnostic imaging across a wide range of clinical disciplines and offered the potential to reduce examination time, preparation, and follow-up care. New product developments in the portable CT scanners market are being facilitated by technological advancements like wireless devices and capital deployment in healthcare. Growing preference for diagnostic techniques that are minimally invasive and can be brought to the patients’ doorstep will further propel the growth of portable CT scanners.
Cardiac CT imaging took off a decade ago with the introduction of 64-slice scanners, which today is the standard for most CT imaging. Many hospitals are now looking to replace their older 64-slice systems with newer technology, which may offer an even bigger boom in cardiac CT usage. The newest generation of scanners marketed for cardiac exams use more sensitive detectors, faster gantry speed rotation, and the latest generation of iterative and model-based image reconstruction software. These technologies combine to enable low dose scans to be made at diagnostic quality at dose levels that would not have been possible just a few years ago.
Advancements in technologies such as fractional flow reserve (FFR)-CT and CT perfusion imaging take CT beyond anatomic assessment to now allow physiologic assessment without the need for nuclear perfusion scans or invasive diagnostic angiography. Cone-beam CT (CBCT) technology has shown tremendous progress since its introduction in dentistry and reformed the efficiency and effectiveness of orthodontic care. There has been a great revolution from its use as a predominantly diagnostic tool to an imaging method now used for predicting treatment outcomes and planning treatment.
Indian Market Dynamics
In the year 2016, Indian CT Scanners market is estimated at 900 crore with the sales of 828 units. The market is dominated by the smaller machines, which have a 40 percent share in value terms. The less than 16-slice category account for 40 percent of the market and the 16-slice machines contribute 38.9 percent. The market is dominated by three brands GE, Philips, and Siemens.
CT scanners market is driven in part by increasing popularity of independent diagnostic centers, which are increasing in number with patient demand and the relatively low set-up cost compared to a full, multi-disciplinary hospital. Other growth drivers include the increasing demands from the government for high quality healthcare delivery that is supported with CT imaging.
The Ministry of Health and Family Welfare, under the National Health Mission (NHM), approved 649.29 crore for 24 states/union territories for the year 2016–2017 for implementing NHM free diagnostic service initiative. Provision of these services is expected to significantly strengthen the public health facilities in states and enhance the availability of modern medical care at affordable cost.
Government of Assam, under NHM free diagnostic service initiative, has launched free CT scan services for the people of Assam. In May 2017, GE Healthcare closed a Public Private Partnership project with Spandan Diagnostic Center, to install ACTs 16-slice CT machine across each of the districts of Assam. The 16 centers are ready and the remaining will be operational in the next couple of months. Revolution ACTs, a Made in India CT is an advanced yet affordable CT scanner that is transforming the way trauma, stroke and other conditions are managed in India.
In the wake of the rising number of these public–private partnerships, different states have come up with the proposals for the installation of CT scan facilities in their respective medical colleges and district hospitals. With these initiatives, the country will soon become one of the leading destinations for high-end diagnostic services with tremendous capital investments for advanced diagnostic facilities.
Global Market Dynamics
The global CT scanners market is expected to reach USD 6.2 billion by 2022 from USD 4.76 billion in 2017, growing at a CAGR of 5.4 percent, states MarketsandMarkets. The market of portable CT scanners is expected to surge with the increasing number of device installations across major markets, growing application horizons, and the lower switching costs provided by portable CT scanners. The growing number of clinical applications for CT, coupled with an aging population with significant diagnostic needs, along with a growing incidence of chronic diseases, is propelling the market for the modality.
In the recent years, major players have focused on collaborating with other players for the development and distribution of advanced CT scanners and to increase their market presence. In December 2016, Canon Inc announced the completion of acquisition of Toshiba Medical Systems Corporation. Following the acquisition, Toshiba Medical Systems announced that the company has decided on a new name, Canon Medical Systems Corporation that will be officially introduced around the beginning of 2018 after the completion of all regulatory procedures.
Siemens Healthcare collaborated with National Institute of Healths (NIH) Clinical Center, in February 2016, to develop photon-counting detector CT scanners and enhance the quality of imaging and reduce exposure to radiation.
In June 2017, Samsung has received U.S. Food and Drug Administration’s (FDA’s) approval for its BodyTom Elite, an upgraded version of its portable, full-body, 32-slice CT scanner. The upgraded system features a new visual design, and upgraded software, hardware, and workstation.
In April 2017, Toshiba Medical launched Aquilion Lightning CT, the 80-detector row (160-slice) system designed for full-body imaging and routine volumetric scanning. It delivers fast reconstruction speeds of up to 50 images per second at full resolution, and it optimizes workflow and patient comfort with thin slices at 0.5 mm and a 78 cm bore. Last year in November, the company launched Aquilion One/Genesis. The system provides improved spatial resolution and faster slice reconstruction, as well as reduced radiation dose to the patient.
In February 2017, GE Healthcare announced US FDA’s 510(k) clearance of GSI Xtream on Revolution CT. It is one of the first volume spectral CT technologies designed to improve small lesion detection, tissue characterization, and metal artifact reduction, with a simplified workflow.
In August 2016, Siemens Healthineers announced US FDA clearance of the Somatom Drive CT equipment. This new dual source scanner is designed to drive precision in diagnostic imaging across a wide range of clinical disciplines, from pediatrics and emergency medicine to cardiology and oncology, and also deliver a new level of quality in patient care, with the potential to reduce examination time, preparation, and follow-up care.
Strides in Technology
The CT scanners industry has witnessed a dramatic growth in technical aspects of CT with newer generation scanners focusing on the key technical capabilities. Wider detector systems tend to have a higher sensitivity, offer better iterative reconstruction software to improve both contrast and spatial resolutions, and tend to have more powerful workstations. Major vendors have made significant improvements in the technology and put forth the best of their innovations in order to sustain their hold in the market.
Rotation speed. Significant improvements have been made in the rotation speed of the gantry, which translates into faster temporal resolution to reduce motion blur, important for the heart and areas near the lungs. Rotational speed in some of the newer scanners is under 300 milliseconds, compared to 400–500 milliseconds with older-generation systems.
Image resolution. Detailed images of smaller anatomical structures are dependent on the spatial resolution of the CT system being used. Leading vendors in the market are coming up with the detector/software combinations to reduce the spatial resolution. Detector resolution is another area of research to increase the image sharpness, especially to better define smaller structures like plaque composition and stents inside coronary vessels. With the ongoing advancements in the technology, CT detectors have undergone a series of improvements, expanding the potential of the modality for new applications. The next generation of photon counting detectors is gaining traction for offering improved spatial resolution by employing mechanisms different from current CT detectors.
Integration of portable CT scanners and PACS. The advances in technologies in the healthcare sector will augment the demand for the integration of medical imaging equipment with PACS. The integration of these systems will help hospitals with storage, management, and retrieval of a huge volume of medical images. These machines are designed for enhanced productivity in the digital imaging sector and will revolutionize the workflow in radiology, cardiology, and other medical facilities. Moreover, the advent of 3D in medical imaging, data management, and retrieval will give a boost to the demand of CT in the market.
CT perfusion imaging. CT perfusion imaging has enabled radiologists to see and quantify brain stroke and gain a deeper understanding of changes in blood flow to the patient’s brain. In combination with CT angiography, this new approach is a potentially disruptive technology for the rapid evaluation of acute stroke. CT perfusion of tumor is also being used to evaluate the impact of modern cancer therapy regimens, much sooner than with older techniques.
Cone-beam CT. A traditional CT takes a narrow slice of the area of interest with a fan beam of X-rays. To produce an extended volume of the anatomy, many slices are captured as its detectors rotate multiple times around the patient. In contrast, the cone-beam CT (CBCT) has a larger area detector that can image the patient in a single rotation. The CBCT units for extremities are catching on because they provide high-quality, low-dose, 3D imaging of musculoskeletal conditions quickly. They also offer weight-bearing images that can be important when diagnosing and treating orthopedic conditions, especially with knees, ankles, and feet.
Cardiac CT. The biggest advances in CT scanners over the past few years have been the introduction of new dose-lowering technologies, easily upgradeable scanners to allow conversion to high-slice systems, and faster gantry speeds to freeze cardiac motion. The newest generation of scanners marketed for cardiac exams can perform routine, very-low-dose cardiac scans of 3 mSv or less. They use more sensitive detectors, faster gantry speed rotation, and the latest generation of iterative and model-based image reconstruction software. These technologies combine to enable low dose scans to be made at diagnostic quality at dose levels that would not have been possible just a few years ago.
The advancements in CT technology has traveled largely predictable paths over the last two decades; from single-slice, to dual, to 4, 8, and 16-slice, doubling slice counts every few years into the current stratosphere of 320 or 640 slices per rotation. The latest generation of CT scanners offer better patient care, including lung cancer screening, dose guidance and regulation, spectral and multienergy imaging, and expansion of cardiac and brain imaging, allowing clinicians to make a more confident diagnosis at low dose, without increasing complexity in their routines. The technology in the future will transition from a good interpretation tool to a machine with more quantification and a speedy and direct diagnosis. There will be growing interest and demand for analytics solutions that can help medical imaging professionals deliver more value by reducing length of stay, improving compliance, increasing revenue, decreasing medical errors and medical legal risk, and evaluating outcomes and quality.
CT will be able to routinely deliver anatomical information and feature the ability to characterize structures based on their material makeup within a single scan. Dose reduction is one of the several key focuses for CT innovation in the years to come. Advances in image reconstruction and dual-source technologies, and a market emphasis on applications for the cardiac, pediatric, and emergency department spaces are on the horizon.
The CT market is more than a billion-dollar market, and is expected to continue to flourish in the years to come following the pace at which the technologies are evolving. Improved resolution and new clinical applications that can help physicians to diagnose and stage disease even earlier will continue to be the big trends in the future.
The 16 Slice CT is Not Dead
If one looks at the different types of CT scans done at a radiology department in a general hospital, or even a diagnostic center in a large city, one realizes that around 70-80 percent of the CT scans performed are either plain or contrast studies of the head, chest and abdomen. In certain trauma centers, plain studies of the extremities might also be a sizable chunk of the scans done. The balance 20-30 percent of scans comprise of high-end angiographies, perfusion, coronary angiograms etc. This means, that if one looks at it objectively, there is not much difference between a 16 slice, 64 slice or 128 slice scanners for performing around 80 percent of CT work – hence the case for the 16 slice CT. Notably today, 16 slice CTs have become so good that they can do peripheral CT angiograms, triple-phase liver studies (including volumetric assessment) and whole body screening for trauma patients.
This leads me to state that there is also a case to be made for imaging centers equipped with only a 16 slice CT scanner. Such centers can be in close proximity to several small nursing homes which do not have CT scanning facility and hence will supplement the services provided there. This works out well from perspective of all three key stakeholders. First and most importantly, patients get scanned at a specialized imaging facility catering to several nursing homes, run by experts. Second, the nursing homes and small hospitals can avail of high-quality CT scanning services without any capital cost and without the operational troubles associated with running a full department. Lastly, the diagnostic center itself benefits since having an only-CT scan facility is relatively low on investment, floor-space and manpower requirements. My personal view is that the role to be played by the 16 slice CT scanner will only increase in the days to come and it will be compounded by the facts that CT scans are now possible at higher-resolution and lower radiation than ever before.
Dr Harsh Mahajan
Mahajan Imaging Pvt. Ltd., New Delhi
Evolution of CT scanners
On market trends
With growing concerns and awareness about radiation dose and reducing imaging scans, advancements in CT scanners have brought about technologies such as iterative reconstruction software, intraoperative capabilities, and dose-tracking software. CT scanners are now evolved as portable or mobile CT scanners, which can be wheeled into the ICU, OR, and emergency or trauma care unit. Besides having utility in clinical decision-making, the portable CT scanner is a cost-effective investment. Independent cost-benefit analysis shows a 169 percent return on investment with portable CT. Portable CT scanner is also apt for smaller hospitals, clinics, and private imaging centers creating an extra revenue stream; the advantages of portable CT scanner outweigh those of a fixed machine.
On technology trends
There has been a paradigm shift in the utilization of portable CT scanners in ambulances for acute stroke management. Mobile stroke unit (MSU), equipped with a portable CT system, a registered nurse, paramedic, emergency medicine technician, a CT technologist, and laboratory capabilities, brings the CT to the patient experiencing stroke. All the diagnostic tools and therapeutic treatment required at the crucial time of stroke are provided by the MSU. MSU with telemedicine can eliminate the need for an on-site neurologist making it more resource efficient.
On buyer’s perspective
Buyer is looking for a cost-effective, one-stop solution for a multidepartmental CT scanner to cater to hybrid OR along with ICU, ER, and trauma care units.
On opportunities and challenges
The portable CT scanners market is projected to reach USD 6.20 billion worldwide by 2022 from USD 4.76 billion in 2017, at a CAGR of 5.4 percent. The market in India will be largely driven by the minimal invasive surgical approach. A hybrid operating room will combine the surgery and intraoperative imaging systems. These modalities will increasingly replace the conventional open surgery approach with minimal invasive surgery (MIS).
CT scanner market growth reflects uncertain reimbursement scenario across developing nations. Ongoing market shift toward image-guided medical interventions demands implementation of portable CT scanners. Growing adoption of refurbished CT scanners and a dearth of well-trained and skilled healthcare professionals however remains a concern even today.
The market for the neurosurgery segment is expected to register the highest CAGR in coming years. Surgeons will increasingly look for safer and efficient methods to perform their surgeries. Therefore, there will be a definite increase in the demand for newer applications for minimally invasive procedures assisted by a portable CT scanner. Going forward, with the increase in demand of portable CT scanners, we can also expect the MSU to become a norm and not just a concept.
Technical Head – Radiology,
Schiller Healthcare India Pvt. Ltd.