On-site and in-OR imaging has become increasingly necessary to ambulatory surgery, particularly in such specialties as orthopedics, pain management and urology. Digital C-arm systems are the state of the art in the imaging field. As with any capital equipment purchase, their costs and considerations can make any buyer pause. Here are a few tips to keep in mind if you're in the market for one.

Early calculations
It should go without saying that the first thing you'll need to address is for what types of procedures your facility and surgical staff intend to use the equipment. That assessment will clearly determine the configuration of the C-arm you'll want to purchase in terms of size and computing power.

Those are important distinctions. Basic C-arm models provide standard fluoroscopy for image-guided device placement. They store, print and transfer images. If you're just documenting pre- and post-procedure, you won't need a lot of computing power on board the system.

Also, you won't need a high-end model that's more suited for interoperative use during minimally invasive or interventional procedures. These larger imaging systems have larger image detectors to cover a broader operative area, such as the spine, and more computing power to capture motion pictures of a surgical maneuver or perform digital subtraction to highlight aspects of the anatomy.

If you've identified who's going to use the C-arm, don't neglect an accompanying preliminary fiscal analysis. Realistically estimate the volume of procedures the equipment will be used for and factor in your reimbursement for those procedures - along with staffing, service and storage costs - versus your lease or loan payments. Running these numbers will give you a good sense of whether your investment will pay off.

Sweat what's important to you
For any purchase, you've got to separate the facts from the marketing hype. This is especially important when you're talking about a capital equipment purchase like a digital C-arm.

One way to do this is to build comparative data around what aspects - cost, power, mobility and so on - are important to your organization's users and materials managers; that is to say, judging the products that vendors are offering strictly on how well they meet your specific needs, not on the aspects that vendors are promoting as important.

It's incumbent on you to have a side-by-side, objective analysis of each equipment candidate's features and benefits. The effort spent doing that up front pays dividends on the back end, but it's an effort that many buyers don't seem to take the time to do.

It can also be a way to engage your surgeons and collect their input early in the selection process. Once you've made your list of important aspects, take it to each of the physicians who'll be using the equipment and ask them to rank the criteria in order of importance to them. This, along with their preferences based on which manufacturer's equipment they're comfortable using, can provide weighting in the discussion. Plus, it will be very difficult for anyone to say that the decision wasn't made objectively.

Hands-on factors
Before you make that decision, though, you'll undoubtedly want your surgical staff to trial the equipment in your own ORs. Your surgeons will know what they're looking for in terms of operation and output; but as a manager, you should keep a few physical aspects in mind.

The equipment's ergonomics don't just apply to how easy it is for your staff to control, but also how much access it allows to the patient while the equipment is in place, as well as whether it operates through wires - which stand to add to the floor clutter, trip OR staff and accidentally unplug - or through wireless infrared technology.

If it's a mobile C-arm, remember to find out how well it moves from room to room and where it will be stored. Also, know that while mobile systems tend to occupy a smaller footprint in equipment-laden rooms than fixed systems do, fixed equipment is at lesser risk of damage than mobile devices are.

The issue of radiation is another important consideration. Make sure you get a good idea of the minimum amount of radiation necessary to obtain a high-quality diagnostic image and the radiation dose that patients and operators receive in the surgical setting in order to provide adequate protection. Some states have legislation establishing requirements for the training and credentialing of C-arm operators and monitors. These laws vary from state to state.

Future features
The price you'll pay for equipment is always a weighty consideration, especially in an era where capital is constrained. It's difficult to suggest an estimate or range that a facility should pay for a digital C-arm, since so many variables - including its level of functionality, your purchasing contracts and your buying history with the vendor - affect price.

While getting the lowest price is important, if you've done your up-front analysis of needs and comparison of products and a piece of equipment meets those needs, you can be reasonably sure that you're making the right choice.

Price isn't everything, though. You won't want to close the sale without negotiating what's in the initial purchasing agreement, which can eliminate potentially unpleasant surprises down the road.

One critical issue is whether and how well the company will be able to service that equipment after you've bought it and upgrade new software capabilities as they become available. Make sure to find out what's standard on the service contract, and what'll represent an additional cost.

Another concern is how much training the vendor is willing to provide and how often. A digital C-arm is complex equipment, and if your facility sees frequent turnover, you might want to arrange for ongoing training programs, every year or two years, for instance, and not just once-and-done at the time of purchase.

GE Healthcare
OEC 9900 Elite'
(801) 328-9300
www.gehealthcare.com
Price: $150,000 to $250,000, depending on system configuration
FYI: GE Healthcare's OEC 9900 Elite raises image quality to a new level with precision imaging technology using Dynamic Range Management, a patented technology that processes each imaging profile uniquely to highlight the anatomy of interest, says the company. The 9900 Elite's flat-panel monitors are mounted on an articulating arm for viewing flexibility and the DICOM 3.0 interface connects easily to networks for advanced information management, says the company.

Hologic, Inc.
Fluoroscan InSight
(781) 999-7300
www.hologic.com
Price: $60,000
FYI: The InSight mini C-arm answers the need of orthopedic surgeons for precision and versatility in extremity surgery, says the company. Hologic says InSight combines maneuverability, ultra-fine fluoroscopy images and automated adjustments to deliver the optimum image every time, for every patient.

Philips Medical Systems
BV Pulsera
(800) 229-6417
www.medical.philips.com
Price: not disclosed
FYI: Philips' flagship BV Pulsera C-arm raises the bar in mobile digital fluoroscopy, says the company. A new, all-digital 1K2 imaging chain, the motion-stopping pulsing of its rotating anode and a powerful new 15kW generator produce outstanding image quality. The 3D-RX feature allows rapid acquisition and reconstruction of three-dimensional image volumes and a compact viewing station incorporates the full functionality of a PACS workstation.

Siemens Medical Solutions
Arcadis Orbic 3D
(888) 826-9702
www.usa.siemens.com/surgery
Price: not disclosed
FYI: The Arcadis Orbic 3D is a mobile C-arm with intraoperative three-dimensional imaging capabilities that can generate 3-D images directly in the OR, says the company, revolutionizing intraoperative imaging and navigation and making surgical interventions more precise.

Simad SRL X-ray
Medical Technology
Moonray Compact C-arm
011 39-051-974324
www.simad.net
Price: not disclosed
FYI: Simad's Moonray mobile C-arms are designed for a wide range of surgical applications, from orthopedics and pain management to gastroenterology and urology, says the company. Technological features such as an upgradeable fully digital system, query and retrieve, CCD camera, 13-inch image intensifier, automatic dose report, low dose control and dynamic density compensation ensure performance, reliability, high quality images and a solid investment, says Simad.

Ziehm Imaging, Inc.
Ziehm Vision FD
(800) 503-4952
www.ziehm.com
Price: $330,000 to $350,000
FYI: Ziehm Vision FD incorporates cutting-edge technology and state-of-the-art design to offer fully digital imaging with distortion-free images, says the company. The flat-panel detector is insensitive to magnetic fields, which makes it possible to work close to MRI devices or other sites where strong magnetic fields are present. Ziehm says Vision FD can produce fine quality soft tissue and skeletal imaging simultaneously.