Economic factors remain the greatest threat to innovation in the coming years, as healthcare providers call on manufacturers for low-cost technology. The tussle is now between enhancing clinical diagnostics and improving cost and efficiency.

Diagnostics imaging is in high demand as procedures form the basis of diagnosis and also the treatment of various medical conditions. The healthcare sector has made significant technological advancements within the country, which has in turn led to growth in the medical imaging market. The increasing awareness about preventive healthcare and the rising ability of the country's population to spend on diagnostics services has further boosted the prospects of this industry.

As per a trend analysis, large multinational companies are looking to modify their products to match the requirements of Indian healthcare facilities. GE Healthcare has launched Discovery IQ, a PET/CT molecular imaging system designed in India. Philips has introduced Allura Centron and PrimaryDiagnost radiography solutions, both developed in India. Toshiba Medical Systems has introduced Vantage Elan MRI system with optional power-saving mode and compact design. Entry of Dabur into imaging segment in Delhi/NCR region is an interesting development in this niche marketplace.

Domestic companies, with a presence in the X-ray and ECG equipment segment have much to catch up with when it comes to high-end equipment. Indian Radiological and Imaging Association (IRIA) is also promoting research on imaging modalities using various platforms. Going ahead, the diagnostics imaging market is expected to record solid growth.

mriIndian Market

The Indian MRI equipment market is estimated at Rs.1150 crore, at 230 units in 2015. The 1.5T continues to be popular with a 75 percent market share, with 3T systems constituting the balance. The 0.2T-0.5T is gradually exiting this segment. The Indian market has not yet procured any 7T systems.

The market which saw a 45 percent increase in 2014 over 2013 saw a mere 12.5 percent increase in 2015, over 2014.

GE, Philips & Siemens have a combined share of 95 percent in the Indian market; the balance is shared by Hitachi and Toshiba.

MRI equipment offering silent scan that makes the sound of an MR scan as silent as a whisper have gained popularity over the last couple of years. While providing excellent image quality, these systems ensure clinicians make a confident diagnosis.

At Radiological Society of North America (RSNA) annual meeting in November 2015, the leading brands showcased systems delivering multiple, adjustable contrast images, and quantitative data from a single scan. These systems have started to make their way into the Indian market too. Designed to lower total cost of ownership and using considerably less power than previous-generation MRI systems, they require a smaller footprint for installation. These products are built on a platform designed to help clinicians increase imaging productivity and diagnostic confidence, while addressing patient comfort and the MR experience.

The department of IT's R&D laboratory SAMEER is scheduled to launch India's first MRI machine by 2018. The R&D laboratory is in advanced stage of product development.

Global Market

The global MRI equipment market is poised to reach USD 5813.6 million by 2020, with a CAGR of 4.9 percent over the period 2015 to 2020, estimates Meticulous Research. The MRI equipment market reflects a balance of cost-constrained, saturated mature market, and emerging market with a low MRI-installed base. In mature markets, the purchase of systems continues to be dictated by cost; this is not only due to austerity measures, but also because of more focus on spending in healthcare IT and the replacement of CT equipment.

Emerging regions continue to show increasing interest in advanced imaging. However, political and economic pressures are influencing a number of markets, especially Middle-East, Argentina and Brazil, leading to limited growth in healthcare spending.

In 2015, closed MRI equipment emerged as one of the most lucrative segments accounting for majority of the market. High usage of these systems amongst majority of hospital chains and advantages associated with it such as rapid and accurate diagnostic results are a few factors attributing for its large share. Budget limitations have halted a move to the widespread use of more expensive advanced functionality 3-T systems. However, encroachment on closed 1.5-T systems has been seen from the mid-field open segment, with improved technology in the latter offering a competitive alternative to value-segment closed 1.5-T systems.

Very-high-field MRI equipment are expected to grow at a lucrative rate over the forecast period of 7 years. Key application areas of MRI equipment include brain and neurological MRI, spine and musculoskeletal MRI, pelvic and abdominal MRI, vascular MRI, cardiac MRI, and breast MRI. The brain and neurological MRI system segment accounted for the largest share of MRI market. Lack of substitute imaging tool for brain and neurological diagnostics is one of the key factors for its large share.

Technology Update

Historically, from the discovery of X-rays by Roentgen in 1895 to the introduction of MRI by Damadian in 1969, radiological advances have revolutionized the practice of modern medicine. The last few decades have witnessed dramatic innovations and improvizations in MR imaging technology.

A new way of using MRI scanners to look for evidence of multiple sclerosis (MS) in the brain has been successfully tested by researchers at The University of Nottingham and Nottingham University Hospitals NHS Trust.

Research team at Nottingham has found a way to use clinical MRI to distinguish between MS lesions and other brain white spots, which are found in MS. The study is published in the Multiple Sclerosis Journal. They have used a clinical MRI scanner of the type all neuroscience centers have to carry out a special type of scan called a T2-weighted imaging process, which is able to reveal lesions in the brain's white matter that are centered on a vein ' a known indicator of MS. A total of 40 patients were recruited from the neurology outpatients' department of Nottingham University Hospitals NHS Trust. Within the test cohort, all patients with MS had central veins in more than 45 percent of brain lesions, while the rest had central veins visible in less than 45 percent of lesions. Then, by applying the same diagnostic rules to the second cohort, all the remaining patients were correctly categorized into MS or non-MS, by the blinded observer, taking less than two minutes per scan.

The new study is significant because currently among patients referred to MS treatment centers with suspected MS, fewer than 50 percent are found to have it. This shows that diagnosing MS in a significant minority of cases can be challenging.

The next decade will witness further sophistication of these techniques and with data available from larger studies, it is expected that imaging will continue to provide new and unique insights in neurology and neurosurgery, which should hopefully contribute to better management of patients with diseases of the central nervous system.

Key Growth Drivers

Since the beginning of this decade, a lot of importance has been given to an early diagnosis of clinical disorders, which have paved the way for many technological advancements and innovations. MRI technology is a milestone in the diagnosis of many chronic health conditions due to its ability to capture more complex soft tissue structure. This enables the physicians to diagnose the disorders in time so that the chances of cure are increased.

Early detection of chronic disorders like cancer and neurological diseases greatly increases the chance for successful treatment; with the result that the healthcare sector is now emphasizing on early detection of such diseases, rather than spending on expensive treatment later. For instance, the World Health Organization (WHO) has launched various cancer prevention programs in different countries including India, Ireland, and Korea. These programs aim to reduce the number of cancer cases and deaths by improving quality of life of the patients, through systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment, and palliation.

American Cancer Society has made recommendation for a guideline for screening all cancer suspects. The guidelines are issued for almost all types of cancer including breast cancer, lung cancer, colorectal cancer, skin cancer, and brain cancer. The screening includes physical examination and scanning through imaging technologies like MRI.

Similarly, government bodies have also started to realize the need for early detection of chronic disorders and save the economy from added healthcare expenditure. For instance, the Affordable Care Act passed in 2010 makes prevention and early detection services free of charge for the aged people through Medicare coverage. While in Europe, 10 nonprofit organizations have formed an unprecedented alliance that aims to raise the awareness for early diagnosis of the chronic and non-communicable disorders. Such initiatives are expected to propel the diagnosis rate of chronic diseases across the globe.

Growing geriatric population and technological advancements such as the introduction of software application in the system that in turn increases the accuracy are some other key factors attributing to the growth of MRI market. Introduction of technologically advanced products and the way the entire RF subsystem has been operated in MRI are the major drivers of this market. Moreover, increase in incidences of road accidents caused by rash driving or driving after being intoxicated and increasing prevalence of cardiovascular diseases, tumors, and other neurological disorders are also few factors propelling market growth.

Battle between Cost and Development

Despite numerous advances in MRI capabilities, economic factors remain the greatest threat to innovation in the coming years, especially as healthcare providers call on manufacturers for low-cost technology. The battle is now between enhancing clinical diagnostics and improving cost and efficiency.

Some other factors impeding market growth include high capital investment, lack of long-term data on use of MRI in patients, limited availability of venture capital, shortage of helium gas deposition, and declining reimbursement rates for MRI procedure. However, manufacturers are now more concerned about analyzing more applications and developing effective equipment with improved patient comfort, which is expected to reduce the impact of these restraining factors.

Future Horizons

Approximately 80 million MRI scans are conducted on 24,000 MRI scanners worldwide each year. In the United States alone, more than 40 million MRI scans are conducted each year. The second largest market, Japan, enjoys the best access with the highest number of systems per million people. In the world's most populous Asia-Pacific region, the compound annual growth rate for MRI is projected at 16 percent. Although the MRI market is well established in Europe and Asia, where a number of major manufacturers are also based, it is still in its infancy in developing countries. China, for example, is spending tremendously on MRI equipment for its hospitals and developing MRI manufacturing capability. To date, improvements in MRI images have been possible primarily with more powerful, better-designed magnets, and to a lesser degree with advanced electronics and software. The industry continues to pursue even more powerful magnets and refinements based on multiple sensors and processors. However, the resulting gains are forecasted to be marginal overall with little improvement in basic operation or patient experience.

Digital superconductor electronics, proven in metrology and wireless communications, provide significant benefits for medical imaging. Digital-RF transitions MRI to fully digital MRI with reduced scan times, improved image resolution, lower cost, enhanced safety, and improved accessibility to people worldwide. Digital-RF technology can be used to both modify existing MRI systems and develop new small, portable machines that can be operated safely in any environment. These portable MRIs could be taken to the patient - in the doctor's office, emergency room, or even on the battlefield in a military field hospital.

The quality and resolution of MRI have improved in the past two decades, primarily due to more powerful magnets. Electronics and imaging software have also improved as in other imaging technologies. At present, there is little that can be done to further improve the operation of the basic MRI system while significant limitations and challenges remain. Operating costs, installation complexity, and safety concerns need to be addressed. Scan time - arguably the most important factor in operating costs and patient concerns - has not improved in any meaningful way. Healthcare professionals are in agreement that shortening scan times while preserving image quality is the biggest game-changer.

Dr Dinesh Kapoor, Director & HOD Radiology, Fortis Hospital NOIDA, UP
Second Opinion
MRI - Boon to Healthcare

Gone are the days when MRI scans were associated with studies only for brain and spine. Today MRI scans can be used to examine almost any part of the body, including the brain and spinal cord, bones and joints, breasts, heart and blood vessels, and internal organs such as the liver, womb, or prostate gland. The results of an MRI scan can be used to help diagnose conditions, plan treatments and prognosticate, and assess the effects of the treatment. Advent of newer sequences and dynamic imaging is a boon to investigative healthcare.

The market is catching on to novel application areas such as multiple sclerosis and breast cancer, and advent of hybrid MRI system, viz., MRI-PET provides new growth opportunities. However, high costs of MRI system, high rates for MRI procedures, shortage of helium gas deposits, dearth of trained personnel, and uncertain outcomes of changing healthcare reforms are some short-term obstacles to the growth of this market.

Stress is now more on patient-friendly and silent MRI scanners. To improve patient experience, vendors are trying to give wider bore machines. The decibel factor is being improved to provide almost silent function of the magnet. Shorter scan times are being introduced with the help of improved technology both in the hardware and the software.

In developing countries, there is yet the factor cost of the machines. Keeping the drive initiated by our honorable Prime Minister Make in India as the goal will help the companies lower their cost so that the acceptance advantage accrues to each and every one, especially in a country like ours. If penetration in Tier-II and Tier-III cities is improved then the numbers will offset the rates, and the availability to the common man will improve. The modality being radiation-free has a lot of advantage in terms of wider application. Even fetal MRIs are being done to exclude or confirm the presence of congenital defects.

MRI is already a boon to healthcare and is poised to make further rapid advances. Aim should be to provide the advantage to remote rural settings 100.

Dr Dinesh Kapoor
Director & HOD Radiology,
Fortis Hospital NOIDA, UP

Dr Seema Sud, Senior Consultant Radiologist, Sir Ganga Ram Hospital
Second Opinion
Planning Better Treatment

There has been a rapid development and proliferation of MRI in the field of medical imaging. There has been an exponential growth in the MRI modalities besides technological advancements. For imaging central nervous system, particularly detecting brain tumors, spine lesions, stroke-affected areas of brain and imaging blood vessels, MRI has become the sought-after diagnostic imaging method. This technology has got importance from technology manufacturers and developers who wish to make it more patient-friendly.

A number of factors like aging population and increasing awareness are responsible for the growth of MRI equipment market. Apart from this, increasing use of MRI in detecting diseases in their early stages, its non-invasive nature, technological advances, and increasing inclination are providing requisite impetus to the market. In addition, MRI systems produce better images with more contrast as compared to conventional imaging techniques. Companies are focusing on studying more applications for MRI systems and developing cost-effective equipment, with improved patient benefits.

Silent scans, though expensive, provide improved image quality with reduced acoustic noise. Silent MRI systems use high-fidelity gradient and ultra-fast RF system electronics to eliminate the sound at source. Efficiency is increased by making technology faster. 3T machines can produce images in as less as 15 minutes, around half the time of the 1.5T. The 3T MRI machines have a field strength twice the strength of the standard 1.5T MRI, providing quick scans and higher resolution images. With body imaging, shorter breath-holds produce sharper images because the patient moves less. Manufacturers are moving toward many advanced applications to make MRI more comprehensive.

New ways are being developed to use the equipment in fields such as abdominal imaging, cancer diagnosis, and cardiac imaging. 3T is better for vascular, neurology, and orthopedics because it provides a better-quality image. Newer imaging applications for different anatomies are becoming popular. A suite of innovative applications has made imaging vasculature anywhere in the body possible without injecting intravenous contrast. Suites with new coil technology for pediatric imaging have special designs, specifically for imaging head, neck, spine, and bodies of children. Technicians can now see small vessels in the brain and make out brain tissue better following a stroke. MRI systems that provide good visualization of micro-trauma, a clearer picture of nervous system diseases, and exceptional details of small joints, such as the ankle or wrist are gaining importance. This has helped in planning better treatment methods.

Dr Seema Sud
Senior Consultant Radiologist,
Sir Ganga Ram Hospital

Dr PK Dave, Ex Director AIIMS, Chairman Advisory Board, Rockland Hospital, New Delhi
Second Opinion
An Obligatory Tool

For a very long period 1.5T MRI scanners were the preferred choice even though MRI scanners at lower field strengths at 0.3, 0.5, and 1T were available. In the last 5 years, high field strength 3T MRI scanners are being used in routine clinical practices, though 1.5T MRI will satisfy approximately 90 percent of the need.

Technology Development

MR scanner hardware. Recently, with the development of 7T MRI, research and clinical diagnosis has stared and plans are there for manufacturing 11.7T human MRI scanner. Already one such system is in place at NIH, USA. On the receiver channel configuration, 16-channel receiver coils are increasingly common and systems have been designed for modular upgrade to 32, 64, and 128 channels and beyond. Research has shown the benefits of 32-channel RF coils in brain imaging with greater sensitivity and resolution and up to 128-channel devices have also been designed.

Advances in diagnosis. In today's MRI investigations, diffusion and perfusion measurements have become central to many neurological protocols, particularly in acute stroke, based on the kinetic tracking of a bolus contrast agent injection. Also arterial spin labeling shows real promise of providing clinically useful images of cerebral blood flow (CBF). Improvements in respiratory compensation techniques lessen the current need for patient cooperation and breath holding. The use of MRI contrast agents has become an indispensable part of modern MRI investigations. The most commonly used compounds for contrast enhancement are gadolinium-based. Magnetic particle imaging using iron oxide nanoparticles that are super paramagnetic is being explored. These are used to monitor blood supply to the heart, the speed and velocity of blood flow in the heart, and other data critical to coronary surgery.

Integration with other modalities. The integration of information from other diagnostic modalities is increasingly being used for improved sensitivity and specificity of diagnoses in many diseases. In this connection, advances in the MRI field have demonstrated that combination with other imaging modalities is possible; taking into account the inherent flexibility and advantage of MRI that gives unparalleled soft tissue contrast and spatial resolution. The integration of PET with MRI as a single modality would allow more accurate rendering of metabolic and structural data with improved patient throughput as PET and MRI data are collected simultaneously in the same scan session. Also, fusion imaging with other modalities like ultrasound and hybrid MRI systems in operating room suites has already demonstrated the effectiveness of combining MRI with other modalities.

Cost-Effective MRI

As of today, only major hospitals in metropolitan cities and big towns have MRI scanners. However, since it came to clinical medicine in late 1980s, the cost of an MRI scanner shows a downward trend because of improvements in technology and manufacturing processes, as well as increasing supplier competition. This has led to relatively low-cost MRI systems (mostly 1.5T field strength or less) with very good performance and excellent image quality with many advanced features like diffusion and perfusion MRI, functional MRI, MR spectroscopy, and many more.

Challenges

Today's MRI scanners use cryogen liquid helium for cooling the superconducting magnets. The cost of helium gas is high and there exists a severe shortage in the availability of helium across the globe, which eventually would affect significantly the MRI systems and their growth. Every year the price of helium rises which would eventually lead to higher healthcare costs but research is required for an alternative technique for cooling MRI magnets. Another area of active research is reducing the noise of MRI scanners. The noise generated by today's MRI scanners is in excess of 110 decibels. Many leading manufacturers have introduced noiseless MRI silent scan which will address one of the most significant impediments to patient comfort as well as be useful for young children and un-cooperative patients.

 

Dr PK Dave
Ex Director AIIMS,
Chairman Advisory Board,
Rockland Hospital, New Delhi


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