The proportion of fixed general X-ray systems in the U.S. equipped with digital radiography (DR) technology has risen to over 80 percent of the installed base, according to the IMV 2019 X-ray/DR/CR Outlook Report.

The statistic indicates a rise by 30 percentage points from its 2015 status when half of the installed base had switched to DR, and is further evidence that the adoption of this change is expected to continue on an upward trajectory among healthcare providers.

“The timing may be a convergence of improvements,” Lorna Young, senior director of market research at IMV Medical Information Division, told HCB News. “DR technology has evolved to make the X-ray image quality acceptable to radiologists. The radiology community and healthcare systems have fully adopted the use of PACS technology to store and communicate digital images for all modalities. Healthcare providers can transition to DR, not only by replacing their general radiography systems, but as an alternative, by using DR retrofit kits, which is a lower-cost alternative, as they can retain their existing patient table and tube assembly while retrofitting the detector.”

The motivation for converting X-ray to a digital-based system stems from the emergence of CT and MR systems in the 1980s, which enabled providers to produce digital images. Initially making a switch to cassette-based CR technology, manufacturers eventually began developing general radiography units with DR technology, speeding up the acquisition and processing time for images.

These transitions are made clear in an overview of the last nine years, with DR technology in 2010 only present in a little over a quarter of fixed general X-ray systems installed in U.S. hospitals. Seventy percent of machines were computer-radiography-based, and four percent used film.

The passage of the Consolidated Appropriations Act of 2016, however, helped changed this scenario by providing funding to speed up the transition to DR, and subjecting providers who did not adopt the technology to penalties for noncompliance in 2017-2018. Young says inclinations to hold on to CR technology may be due to a variety of reasons.

“CR technology may still be preferred by certain providers to do scoliosis or long leg exams as it can cover a very large field of view. Some DR providers do provide long-length DR detectors, but this is more costly than CR technology, due to its size,” she said. “Providers, particularly small hospitals, also evaluate the financial trade-off of cost to replace or upgrade to DR versus the reduced Medicare payments. In addition, priorities for using capital funds for other imaging equipment may take precedence.”

While CT, MR, PET and nuclear medicine technologies hold greater clout as “high tech” imaging modalities, their combined number of procedures pales in comparison to the number performed on fixed general X-ray and mobile/portable X-ray units by U.S. hospitals. This is mainly due to cost, with multiple departments outside of the radiology department more readily able to afford and utilize radiography scanners, compared to other imaging modalities.

For instance, a total of 152.8 million procedures were performed using fixed general X-ray scanners in 2018, compared to 114.9 million with CT, MR, PET and NM. Out of 267.7 million imaging procedures performed by U.S. hospitals, this comprises 57 percent of the top five modality procedures for chest, abdomen/pelvis, extremities, and spine studies, which make up almost 90 percent of procedure volume, according to IMV estimates. The inclusion of 61.4 million exams performed with mobile/portable general X-ray units raises the amount of general X-ray procedures to an estimated 214.2 million, which is 65 percent of the five-modality total.

The addition of this technology to general radiography is expected to open doors for further clinical and workflow improvements through the influence of emerging AI and machine learning applications. While still in their infancy, these tools are predicted to enhance a variety of aspects in imaging, including image quality output, workflow and clinical decision support for radiologists.

Locations that may be slow to follow suit include critical access hospitals, which are exempt from the payment reduction penalties, and children’s hospitals, which have low Medicare populations among patients.

Young, however, says a number of these hospitals are planning to replace CR with DR for increased productivity, and predicts that plans are or will be put in place over the next three years to either replace about three quarters of the remaining CR-only systems with new DR systems, or retrofit them with DR detector kits.

“We have been tracking this trend over the past decade. Certainly the legislative push sped up the process, and the rate of conversion is what industry watchers are interested in,” said Young. “One can say DR is ‘dominating’ the install base, with 80 percent of the total units installed in U.S. hospitals having DR capability, and going forward, very few future orders will be for CR technology.”