As cutting edge imaging modalities come and go, the primary components that make them function have remained essentially the same: a vacuum tube with a cathode to emit electrons and an anode to collect them, establish a flow of electrical current to generate an X-ray image.

Although the physics remain relatively unchanged, these tubes continue to become more sophisticated to meet the needs of healthcare providers. Today, CT tubes are lasting longer and seeing greater utilization than they did in years gone by. Meanwhile, the market forces that impact tube production and availability have undergone transitions of their own.

The CT tube market has historically been difficult to break into, due to the cost of technology development and access to R&D, and experienced manufacturing engineering expertise. While major imaging OEMs like GE, Philips, Siemens and Canon (Toshiba) manufacturer their own tubes, there are also independent tube manufacturers like Varex, the Dunlee brand of Philips, Chronos, and Richardson Healthcare.

“Anyone can build the mechanical structure of an X-ray device,” said Jerald Olsen, vice president of sales and business development at Richardson Healthcare. “But the out-gassing, processing, and pumping down the vacuum on the inside of the device is difficult to do perfectly, and that’s why there are so few manufacturers of X-ray tubes in the world.”

As an electron strikes the anode an X-ray is created in the tube port at a specific size, focal spot, and even distribution for imaging. “In a CT system, an X-ray tube and the detector need to be completely aligned and calibrated to each other,” said Olsen, who has almost a decade of experience working with R&D engineers who design tubes. “That’s why when you do a tube change it’s vital to get an X-ray tube lined up with the detector properly so all the X-ray beam radiation is centered on the detector array.”

If that sounds simple enough, think again. In the encapsulation of the tube, all the compounds of normal atmosphere, especially hydrogen, (which is highly conductive and will interfere with the high voltage stability inside of an X-ray tube, distorting an image from the tube) have to be meticulously removed.

“You have to heat up an X-ray tube insert and pump down the vacuum inside the insert to create a pure vacuum tight environment,” he explained. “When a tube becomes unstable it can be caused by outside atmosphere that has leaked back into the tube and eventually it’ll start arcing and fail.”

Competition benefits everyone
For any healthcare provider who partners with a high quality independent service organization, the value proposition of a third-party tube manufacturer will ring familiar. As providers seek to operate on smaller budgets and the global install base of CT scanners continues to grow, market competition becomes increasingly important.

“Independent service providers are a competitive force that helps drive lower cost, improve quality of service and accelerate innovations,” said Pat Fitzgerald, executive director of Chronos Imaging. “Without this ecosystem, the market would not evolve, pricing would increase, and customers would have limited options to get the service they need.”

Chronos is a newcomer in the replacement tube market, having taken over a manufacturing facility in Aurora, Illinois that was previously operated by Dunlee. Many of the skilled workers at Chronos, including Fitzgerald, are familiar with the facility and have previous experience working there.

In an effort to consolidate its tube manufacturing business, Dunlee left the Aurora facility last year and produces OEM tubes in Hamburg, Germany. As part of that move, the company retains a mutually-beneficial alliance with Chronos that allows its customers continued access to the full product portfolio of CT replacement tubes that Dunlee has offered over the last two decades.

Richardson Healthcare, which entered the replacement tube market in 2014, employs more than 30 engineers and technicians in LaFox, Illinois that design and manufacture CT tubes. The company introduced its first new CT replacement tube last year, the ALTA750. It’s a replacement for the CXB-750D/4A tube, which is also known as the Varex Imaging MCS-078, and is compatible with a range of Canon Medical Systems (previously Toshiba) CT scanners.

“We offer something that no one has ever been able to do — alternative third-party replacement alternative for Canon/Toshiba OEM tubes,” said Olsen. “We’ve made a $35 million investment to get into the healthcare space to enable alternative service and reduce the overall cost of healthcare.”

He noted that Richardson is also considering other replacement needs based on market demand and feedback from imaging users. Their current technician and engineering staff have worked on GE, Siemens and Philips tubes in their careers.

With 2,000 employees turning out over 25,000 X-ray tubes per year and over 65 years in the industry, Utah-based Varex Imaging Corporation is a market leader providing replacement tubes as well as OEM tubes. The company recently introduced the Varex MCS-6074D as a cost-effective replacement designed to meet the specifications of the GE Performix 40 X-ray tube for use with the Optima CT660 CT. They also offer the Varex GS-5172 for certain Philips CT scanners.

Providing customer service and training
While independent tube companies bring value the market, leading imaging OEMs have a footprint that allows them to offer their own comprehensive advantages. Dave Dobson, chief marketing officer, Services, GE Healthcare points to his company’s emphasis on reducing unplanned downtime associated with ordering, delivery and installation of replacement CT tubes.

“Some customers prefer a service agreement which includes tube coverage and others prefer to purchase tubes only as needed,” said Dobson. “The market for on-demand tube replacement is growing as healthcare providers take action to manage operating cost.”

Engineering and field service are key to GE’s approach to improving the customer experience, he added. This includes not only the CT system and tube, but extends to technologist training, image quality, and radiation dose efficiency. GE offers technologies to continuously monitor system and tube parameters so that proactive steps can be taken to replace a tube on a day and time that is planned.

For tubes specifically, Dobson points to GE’s Tube Watch remote monitoring program as a way his customers can take preventative action before a component fails and causes unplanned service disruption. The system integrates artificial intelligence and software analytics to build a unique digital twin model of the tube, enabling high-accuracy predictions.

“We help customers understand which tube is right for their needs and offer CT tube upgrades or replacement,” said Dobson. “We support customers with usage data, flexible service, trained engineers, warranty, tubes shipped from inventory and remote monitoring.”

Varex is also emphasizing customer experience as part of the value it can deliver its service partners, including increasingly comprehensive support capabilities. Its new Service Solutions Group offers new warranty and service contracts, exchange programs, increased inventory at regional stocking locations, and enhanced technical support.

Dunlee, which is owned by Philips and provides OEM tubes as well as replacement tubes, supports its distributors with continuing education that keeps them up-to-date on CT technology and installation. For example, in 2018 Dunlee partnered with AllParts Medical to provide specialized training to representatives from three new Dunlee distributors in China through a week-long session on how to install the DA200Ultra, DA200 P40 and Reevo240G Dunlee tubes.

The session included both in-class and hands-on training. “These installers had a solid foundation in tube installation, so we were able to build on their knowledge and use our class time very efficiently,” instructor Jerome Howard told HCB News at that time.

Richardson has two full-time service trainers to help hospitals become independent in managing their own service, according to Olsen. The company also offers remote diagnostics, provided a hospital or clinics allows them access to their IT system.

“The Chronos Health Group is a collection of companies that offer solutions throughout the end-to-end value chain on a global basis,” said Fitzgerald. “We come from an independent service provider heritage and understand the needsof our customers intimately.”

An evolving market
Fitzgerald with Chronos agrees that OEMS have become more competitive in recent years in response to independent providers and tube makers. But, he pointed out, in markets where there is no independent service competition, OEM pricing may be higher.

This relationship between pricing and competition has been playing out for some time in the medical equipment sector, with some manufacturers arguing that independent companies may compromise patient safety. After opening an investigation into the issue in 2016, the FDA issued a report in 2018 finding there was not sufficient evidence of a safety issue to warrant further regulation of independent organizations.

“Chronos Imaging competes by offering the highest-quality replacement CT tubes at competitive pricing, and through continuous investment in new products and solutions,” said Fitzgerald “We encourage customers to keep in mind that competition is what has created this more favorable environment and support independent suppliers wherever possible.”

Olsen with Richardson said that quality, not quantity, will drive the alternative tube market.

“We invest heavily in our people and consider them our most strategic asset,” said Fitzgerald, adding that innovation is the lifeline of any company wanting to succeed in the alternative medical imaging tube space.