This report originally appeared in the January 2010 issue of DOTmed Business News.

Radiology departments are doing their best to keep down costs and an influx of X-ray tube choices and image intensifier (II) upgrades has made that a little easier over the last year or two.

"The Diagnostic Imaging industry is in the middle of a revolutionary change, as digital imaging becomes the standard on radiology and fluoroscopy systems," says David Hurlock, International Marketing Manager for Varian Medical Systems. "Diagnostic Imaging is where photography was 10 years ago, with the transition from analog imaging to digital imaging gaining speed. Image intensifiers, film, and CR are being replaced by flat panel digital detectors."

Today, hospitals have more tube choices than they did just a few years ago, and many healthcare professionals are not giving in to the belief that they must switch from image intensifiers to flat panel technology right away.

Looking at both segments of the imaging industry, the companies that are successful are those that are helping to maximize equipment life and provide lower cost solutions in replacing or installing X-ray tubes.


"Driving down diagnostic imaging costs per procedure is the most important challenge facing the industry today," Hurlock says. "Equipment costs have to be justified by lowering the cost of individual examinations. A large capital cost can be justified, as long as it lowers the per patient procedure cost."

X-ray tubes are often the most expensive consumable in a hospital. Varian's line of compatible replacement X-ray tubes lowers that consumable cost, and ultimately the cost per procedure.

"Digital imaging will lower the per-patient cost of diagnostic imaging," Hurlock says. "However the differences between digital and film X-ray imaging require new ways of working: for the facility and patient flows, for the design of the equipment, and also for the X-ray tube."

While 2009 was a down year for general X-ray tubes, CT tubes stayed steady and were on the rise when you look at the numbers globally. GE has been the leader in manufacturing X-ray tubes, but Dunlee and Varian Medical Systems continue to grow and are taking over a larger percentage of the industry. Third-party sellers are seeing mixed results in these segments.

"We've seen a big decrease in II sales and if a hospital has multiple rooms with II capabilities, they will shut down a room if it needs a new II, rather than spend the $40,000-$60,000 to replace the II," says Ralph Babcock, general manager of Rural Hill, NC-based Imaging Affiliates. "The daily census reports that all the hospitals are down from 90% occupancy to between 60-70% usage. This has a corresponding reduction in diagnostic imaging procedures and less usage of X-ray tubes and IIs."

It's not that no one is buying tubes or image intensifiers, but the challenge is delivering the latest technology at a reduced price. What hospitals were willing to pay five years ago has decreased substantially.

"The state of business in 2009 is that capital equipment sales are down and most of the tubes we sell are in the CT environment and since CT sales are off, that would lead you to believe that our sales would be off, but that's not the case," says David Kuehn, VP of Global Sales and Marketing for Dunlee, a division of Philips Healthcare. "For us, we have a pretty diversified tube business."

Dunlee provides midlevel tubes in China and other global markets in what they call their value segment, and that has driven its tube business over the last year.

"If we were only selling tubes that were high-tier, our sales would be down, but because we do a lot of sales in the 16-slice and below, those sales are holding really well," says Kuehn.

A big part of Dunlee's tube market is in providing a service business that creates alternative tubes for what the OEMs are offering.

"We don't just make tubes for Philips CTs, we make tubes for GE, Siemens, Toshiba...so we diversified our portfolio so we can serve the entire install base," Kuehn says. "We have a little more dynamic tube business than GE or Siemens, where if the market is off, they don't have an opportunity to grow. We have an opportunity to grow even in a down market because we provide tubes for all brands."

The genesis for this occurred 12 years ago in an effort to fuel its manufacturing facility.

"We knew if we could build a good Philips tube, we could build the others," Kuehn says. "Hospitals were looking to save money and this was one of the areas they could do that."

Tube Options

In the tube market industry, what people are most excited about is having options. One of the biggest things to come along in 2009 is that pre-owned GE MX240 and Siemen Stratton CT tubes are now becoming available in the replacement marketplace.

"In a replacement tube business, which I am in, there will be a need for replacement tubes and from my standpoint, these becoming available on the marketplace is a good thing," says Martin Nash, President of Kans.-based A2X-RAY. "The X-ray tube sector needs new equipment sales levels to return to normal. This will allow companies to fund new system development, and in turn, fund new tube development."

Ralph Babcock, says that since tubes have gotten so expensive, it's important to encourage competition.

"CT Tubes have gotten more expensive and are required to do so much more, the 64 and greater slice-technology that has become the standard for CT," he says. "Since tubes have become so expensive, it has become necessary to provide delivery and pricing mechanisms that provide easier points of sale to the end-users."

This year, the company worked with Dunlee in getting their version of the GE VCT Tube to a successful Beta Test and release.

"Imaging Affiliates was the first to install and operate two beta sites with Dunlee's newest CT Tube, the Reevo 240," Babcock says. "Up until now, there had been only one source for this tube and GE could charge a high price or coerce them into a service contract, but now the monopoly is broken."

Kuehn adds that Dunlee now has every tube that GE makes in its product portfolio, which gives hospitals the opportunity to go outside the OEM service agreement and purchase a tube at a discounted price.


Having expanded CT tube replacements enables companies such as Imaging Affiliates to offer hospitals and imaging centers more choices in providing replacement tubes that can be provided under low-cost transactional sales or monthly contracts that spread the cost and risk out over a three-year period.

Intensifiers on the Way Out

It's been widely assumed around the industry that flat panel DR image detectors will soon replace image intensifiers, especially in demanding cardiac applications. Despite what's going on with the economy, flat panel technology is experiencing double digit growth year-to-year and the OEMs seem to be moving in this direction.

"The images are perhaps the same quality but the OEMs have all moved in the direction of the flat panels and the customers won't have a choice but to move in that direction," Nash says. "The image intensifier sector is in decline, and I don't see that changing."

Digital flat panels make diagnostic equipment more efficient as digital imaging allows a lower dose, which is a direct clinical benefit to the patient.

"Digital imaging enables faster throughput, which allows the facility to schedule more patients or handle its existing throughput in less time," Hurlock says. "It eliminates the costs of film processing, and storage, which are large per procedure expenses. While the capital cost of digital equipment is higher, the cost per procedure will be much lower."

Not that you should start worrying about the intensifiers becoming obsolete. Image intensifiers still have some traction in very cost sensitive X-ray applications, so their survival really depends on how quickly the flat detector manufacturers can hit a price point to displace all image intensifiers and minimize the additional cost for going digital.

"Workflow is improved and there are several other advantages to going digital so flat detectors don't have to hit the exact price point of an image intensifier for most to switch," Kuehn says. "Dunlee will continue to help customers who would like to keep their existing equipment in use, with high quality and cost effective solutions for replacing their image tubes. We cover all major brands of equipment and most sizes and replacing an image tube that has been in service for several years will dramatically improve image quality, without making any other modifications to the equipment."

There will also be a replacement market for image intensifiers that continues for the next 5 to 10 years for existing systems in the field.

Managed Medical Images has seen a rise in the number of remanufactured image intensifiers they sell, and are upgrading them with better cameras.

"Existing image intensifiers are all going to soon be equipped with CCD cameras and this transition is causing upgrade cost challenges, which the clients hope will be offset by the increased efficiency of almost-instant image retrieval," says Ed Ruth, President of the Pembroke Pines, Fla.-based company. "Image intensifiers are mounted on a Spot Film Device and the SFDs are being digitized using digital imaging plates. So the challenges are both with the cost and with deciding which digital technology best fits the clients' needs."


The CCD cameras offer a much better image and since they are digital, they allow you to upgrade further in the future.

"Hospitals are really moving into flat panel technology, but depending on how busy they are, the smaller diagnostic centers are buying these remanufactured image intensifiers, since they don't do enough procedures to require the flat panel," says Bill Calderon, an engineer with Managed Medical Images. "The equipment is getting smaller and lighter which uses less facility space."

Babcock believes that as long as intensifiers still give the bang for the buck, they won't be going anywhere for awhile.

"Some hospitals are still buying image intensifiers because of the high cost of a flat panel room," he says. "If they are just going to use if for conventional R&F, you don't need a half million dollar flat panel. One of our largest hospital groups just bought five new R&F rooms and every single one of them had a conventional image intensifier."

Lean and Green

One of the ways that Dunlee has helped reduce costs for the end users is by internally working on some cost-saving measures.

"We have done things in our factory such as automating processes that used to be manual," Kuehn says. "We've gone to lean manufacturing, which also reduces costs and we have become very good at recycling. Over time that really reduces the cost of the product."

There are some very expensive subcomponents in an X-ray tube since they are made out of precious metals and until a few years ago, many of these tubes were simply thrown away without any consideration of reuse or recycling.

"The tubes may fail for a different reason, so we are able to use these subcomponents and build them into new tubes, thus reducing our overall cost over time," Kuehn explains. "Also the housing that the tube is loaded into, by making them differently, we can reuse them more times because they are more robust."

As for the future, companies are working towards X-ray tubes designed to optimize the efficiency inherent in digital imaging, tubes that manage heat better, and can stand up to a shortened duty cycle.

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DOTmed Registered X-ray Tube and Image Intensifiers Equipment Sales & Service Companies
Names in boldface are Premium Listings.

Domestic

Doug Anderson, DGA Medical, LLC, AZ
Duc Dang, 2D Imaging, CA
DM100
George Fower, Altair Imaging LLC, CA
DOTmed Certified
Carl Frank, DBRS Medical Systems, Inc., CA
DOTmed Certified
Kenn Matayor, Jaken Medical, Inc., CA
DOTmed Certified
Tanner LoRusso, Sound Imaging, Inc., CA
Kurt Bringolf, Eclipse Medical Imaging, CA
DOTmed Certified
Stephanie Espinola, JCF Engineering, Inc., CO
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified / 100
John Macrina, Amax Resources, Inc., FL
German Filgueira, Poder, Inc., FL
DOTmed Certified
Woody Peters, Amber Diagnostics, FL
Bills Adkins, National X-Ray Corporation, FL
DOTmed Certified
Frank Pontillo, Engineering Network Systems, FL
DOTmed Certified
Ed Ruth, Managed Medical Imaging, FL
Rami Marom, ElsMed Ltd & Relaxation, Inc., FL
DOTmed Certified / 100
Steven Anderson, Dunlee, IL
Mike Ghazal, Zetta Medical Technologies, Inc., IL
Greg Kramer, C&G Technologies, IN
DOTmed Certified / 100
Martin Nash, A2X-RAY, KS
Ralph Babcock, Imaging Affiliates, NC
Scott Sobolik, Superior Radiographic Systems, ND
John Race, Lakeshore Technologies, NY
Joshua Glas, ADAM Medical Sales, Inc., NY
DOTmed Certified / 100
Robert Muzzio, GXC Imaging, NY
Mike Baxter, One Call Medical Imaging, PA
Trey McIntyre, MedicalPartsProvider.com, SC
DOTmed Certified / 100
David Hurlock, Varian Medical Systems, MI
Glen B. Harris, J&M Trading, Inc., TN
DOTmed Certified
Jay Oyakawa, ReMedPar, TN
Dwayne Tucker, MES Inc,, TX
Joseph A. Nelson, JOJ-XRS, TX
DOTmed Certified
Jeremy Probst, Technical Prospects LLC, WI
DOTmed Certified / 100

International

Leungbun Liu, SKB (Hong Kong), Ltd., China

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