Europe's hospitals play catch-up

Hospitals throughout Western Europe increasingly rely on aging medical imaging hardware, as squeezed healthcare budgets and a lack of long-term financial planning keep the lid on regular upgrades and replacements. The slide toward outdated equipment may be halted only by massive investment in modern systems.

Following an investigation of the installed base of medical imaging devices, the European Coordination Committee of the Radiological and Electromedical Industry (COCIR) expressed alarm at the continued lack of investment in new systems. The overall situation is now worse than that outlined in COCIR's first report published in 1996.

"This is the third report we have done, and we see a worsening overall trend," said Tom Egelund, COCIR chair and executive vice president of Philips Medical Systems. "We are not exploiting new opportunities. This should concern the medical imaging industry and also all citizens of Europe."

COCIR's report draws on data supplied by GE Medical Systems, Philips Medical Systems, Siemens Medical Solutions, and Toshiba Medical Systems. Representatives from each company provided exact figures on the number and age of CT, MRI, nuclear medicine, and x-ray systems installed in nine European countries as of Dec. 31, 2001. The data provided a comprehensive overview of medical imaging equipment available in Belgium, Finland, France, Germany, Italy, the Netherlands, Spain, Sweden, and the U.K.

"The joint market share of these companies in the countries we cover is so large that this is very close to the total installed base," said Hans-Peter Bursig, COCIR secretary general.

A major share of many types of hardware surveyed was over 10 years old, an age at which COCIR regards equipment to be ripe for replacement. All modalities except MRI failed the committee's "golden rule": that no more than 40% of the installed base should be over five years old. Radiography and fluoroscopy systems proved to be the only modality with a growing share of newer installed equipment, compared with data collected in 1995 for COCIR's first report. Improvements to the age profile of angiography and mammography units, noted during COCIR's second round of data collection in 1998, were undone by delays in equipment replacement and upgrade documented during 2001.

"We fear that the quality of medical services is deteriorating as the age profile of equipment deteriorates," Bursig said. "Even before the systems grind to a halt, damage is done to the quality of services."

Jerome Galbrun, CT marketing manager for Europe at GE, is confident that patient needs, combined with their eagerness for greater transparency in healthcare and more information, will trigger strong investment from hospitals. Prospective patients are better informed than ever about the level of service they could be receiving from state-of-the-art imaging systems.

Rapid advances in CT technology, coupled with the modality's growing value in a wide range of applications, have persuaded many hospitals to upgrade CT facilities over the past 12 months, according to Galbrun. This upsurge in sales, driven mainly by the emergence of four-, eight-, and 16-slice scanners, is not highlighted in the report, because the data were gathered before the widespread release of the most recent generation of multidetector CT systems.

"Between December 2001 and now there has been a kind of catch-up," Galbrun said.

The launch of multidetector CT was already beginning to have a positive impact on scanner sales in Europe when COCIR was collecting data in 2001, according to Egelund. Four of the nine countries surveyed met COCIR's golden rule on the age of their CT systems. Heavy investment in MRI, as the modality comes of age as a routine clinical tool, is also likely to be reflected in the next set of figures.

Enhancements affecting the installed bases of these two modalities may be revealed in COCIR's next analysis, which will likely take place at the end of 2004.

The trend toward digital x-ray imaging may also be strong enough to fuel significant investment in new radiography systems, Egelund said. Outlay on modern ultrasound systems, however, will not influence the report's findings. The modality is excluded from COCIR's assessment for logistical reasons.

"It is almost impossible to count ultrasound systems," Bursig said. "To reach a similar level of reliability of data, we would have needed to include at least three or four more companies active in the ultrasound market in Europe, and that would have complicated the whole exercise tremendously."

Investments made due to the release of new products, regardless of the modality, cause only minor fluctuations in the overall picture, according to Egelund. The main cause of COCIR's headache is an ingrained strategy of cost-containment in the European healthcare system. This contrasts sharply with the situation in the U.S., where imaging equipment is used to earn money (via reimbursement), which can then be put back into system upgrades.

"We would like governments to take action and make sure that sufficient investment money is available to prevent the age profile from deteriorating further," Bursig said. "The findings from our three studies show quite clearly that we need a sustained level of investment over time. It is not enough to wait until you can you can no longer repair it and then replace it."

A more consistent, drip-feed approach to equipment purchase, upgrade, and replacement would be no more expensive, Egelund said. He cites examples from his home country of Denmark, where individual counties run 98% of public hospitals. Some counties invest regularly in equipment and budget for ongoing replacement, whereas others try to keep costs low then suddenly have to make large investments. The former option gives managers more long-term control over spending patterns, whereas the latter makes budgets subject to sudden, unpredictable, large demands.
"If you always delay spending on equipment to reduce costs, the need to replace hardware will keep building up, leading to bigger economic problems later," Egelund said. "You may need an infusion of capital to get to a better level of service, but maintaining this level requires good understanding and planning, not more money."

COCIR would like to see hospitals implement a three-tier system for managing investment in imaging equipment:

? no more than 10% of their installed base over 10 years old
? no more than 30% between six and 10 years old
? at least 60% five years old at the most

The committee is broadcasting this message publicly and engaging in talks with professional associations in the hope that politicians and decision-makers will take note.