DR upgrades gain ground, but film-based systems persist

High prices continue to stymie sales

The market for digital radiography appears huge. More than 200,000 x-ray systems with an average age of 10 to 14 years are operating in hospitals, clinics, and private practices worldwide. Industry pundits believe this installed base could support a DR replacement market ranging from 4000 to 13,000 new units a year. The high cost of new digital systems makes this fertile ground for digital upgrades, which offer all the benefits of going digital at a much lower cost.

InfiMed has planted the seeds of this argument. The Liverpool, NY, company reported in January that sales of its retrofit StingRay DR flat-panel systems quadrupled worldwide and doubled in the U.S. in 2002. The company was strong offshore in Asia, particularly Korea, as hospitals made the move to DR and built on large-scale, government-funded PACS installations. U.S. institutions, slower to adopt PACS, are beginning to come around to DR.

Upgrades are attractive because hospitals don't have to alter structural beams, lead shielding, or electrical supplies. The DR upgrade niche nevertheless is a tough bird to land. Digital upgrades take a certain panache. The detector has to be exactly integrated with the generator, console, and x-ray tube as well as PACS and HIS to capture patient and billing information and store and move images. And at least one of these components is under the control of the hospital or a dealer, according to Jim Culley, director of marketing for Hologic DirectRay Systems of Bedford, MA.

Every existing x-ray installation has its own peculiarities. An upgrade, therefore, must accommodate different tables and generators, adjust to cross-table and other types of imaging, and fix anything that doesn't work.

On top of that, upgrades have to meet federal standards. Because of regulations passed by the FDA in the late 1980s, companies that refurbish existing systems must be licensed as retrofitters and make sure their upgrades meet original equipment specifications, said John Allen, national sales manager for Canon Medical Systems of Irvine, CA.

For this reason, many major DR vendors have shied away from upgrades, opting instead to sell whole new systems over which they have more control. Hologic, however, has perched on both sides of the DR fence. The company has developed a successful upgrade business in Europe and Asia. Dealers there are experienced in modifying equipment to fit varying working conditions and skilled in integrating the company's detector, which, unlike most others, is based on amorphous selenium. In North America, where its dealer base has not been as strong and Hologic is now building a dedicated sales and service force (see related article, page 2), the primary focus has been on selling new turnkey systems.

Although most of its 500 installed DR systems are new, Canon also sells retrofit units. The company manufacturers an array of flat-panel products that it markets to companies such as Quantum Medical and end users. The CXDI-11, its first flat panel designed for chest imaging, was introduced in 1998. Last year, the company added the CXDI-31, a 9 x 11-inch, 100-micron portable panel, and this year it will unveil the 14 x 17-inch CXDI-50 portable unit.

For the upgrade market, Canon produces the CXDI-22 retrofit digital sensor and the CXDI-40G, which accelerates image processing by providing a stationary grid and removing grid lines. The CXDI-50G can be deployed in existing rooms for cross-lateral or extremity work. Canon also has relationships with licensed equipment refurbishers in Florida, Louisiana, California, and Texas to handle upgrades, Allen said.

The most successful companies in the upgrade market have made this segment their primary focus. InfiMed, for example, is a retrofit company that does not sell full DR rooms, tables, or chest stands, concentrating instead on replacing imaging chains on installed systems. Its digital bucky slides into the bucky tray that normally houses the film cassette in the table or chest stand and connects with StingRay, which works with an amorphous silicon flat-panel detector built by components supplier Trixell (see accompanying story, page 1).

"Because we don't make the sensor, we can focus on the user interface and workflow, the presentation of images to the clinician, and the movement of the data to printers," said Brian Fleming, InfiMed president.

Among StingRay's features are Automatic Image Optimization, which optimizes image density and contrast and customizes images to meet site-specific preferences, and customizable magnification factors that can be sized to match table and bucky analog films. Because of its ability to deliver full, 9-megapixel images in eight seconds or less, StingRay allows immediate quality control and review, enhancing productivity. StingRay's multiple printing formats allow users to choose between one- or two-on-one horizontal or vertical printing formats, define individual printing needs, and reduce the number of films printed as well as the costs associated with printing, according to the company.

Varian Medical Systems of Palo Alto, CA, competes with Trixell in the supply of flat-panel detectors, marketing amorphous silicon flat-panel detectors to OEMs or system integrators, which add a computer image processing workstation, an x-ray generator, and other parts of a DR system retrofit. It is part of a consortium that owns dpiX, a Palo Alto subsidiary of Xerox that manufactures amorphous silicon thin-film transistor arrays for the flat panel.

Still, no matter how a company approaches DR retrofits, upgrades won't begin to soar until DR itself takes off. Although the first radiographic flat panels were introduced some eight to 10 years ago, market penetration is only 1% to 2%, said Chuck Blouir, marketing manager of flat panels for Varian.

While most DR companies are doubling the number of units they ship every year, the numbers remain quite small, Culley said. Worldwide, only about 1000 DR systems are sold annually. That will not likely change until the price of DR products comes down, according to Fleming.

"Growth will be steady, but we won't hit the meat of the market until we see the cost of the systems cut in half, and that's mainly related to sensors," he said.

New conversion materials may eventually lower the cost of DR panels enough to make the technology popular, but developers are struggling with technical challenges. One involves efficiently and effectively coating the glass panel with the component material needed to translate x-rays into electrical signals. Increasing the number of plates manufactured would also drive down costs, but doing so depends on a rise in sales, which-again-are being hamstrung by high prices.

"It's been tough to convince people that DR is the future," Allen said. "More and more, hospitals are realizing this is the road they want to take. But while DR is gaining acceptance, it comes with a high price tag, which won't go away overnight."