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If You're Thinking of Buying...Flexible Endoscopes
The trick is to have just the right number of scopes so you don't have idle docs or idle scopes.
Pat Rowan
Publish Date: October 10, 2007   |  Tags:   Gastroenterology

Most of us would rather have a colonoscopy than purchase the equipment to perform one. But knowing a few tips and trends up front can help smooth the process. I looked back over my 15 years of GI experience as a staff GI nurse, the manager of a hospital GI lab and the administrator of a freestanding endo center and came up with a list of eight things you need to know about purchasing flexible endoscopes.

1. It's better to have too many than not enough scopes.
Colonoscopy equipment is so expensive that the tendency is to get by with the fewest scopes possible. Avoid this common trap. Nobody will be happy if your docs are waiting for a scope to finish processing before they can start the next case. An equipment shortage should never be the reason for a long turnaround time. You'll make up the cost of additional scopes with productivity. If you wish to tread carefully and buy some now and some later, make sure you know how it would change the contract to add a few scopes down the road.

The trick is to have just the right number of scopes so you don't have idle docs or idle scopes. Here at Northern Utah Endoscopy Center, which I helped launch four years ago, our magic number of scopes for our three GI docs and two procedure rooms is 11: two therapeutic uppers, three diagnostic uppers, five colonoscopes and one pediatric colonoscope. There's no formula for knowing your magic number - it's something that will become apparent over time. For our facility, we have the perfect mix. All 11 of our scopes are in use all the time, and docs aren't ever forced to wait for a scope to be processed. And if we had to go a day or two with one scope down, we could make it through.

2. Know what your docs are using.
Sales reps are great to give you information about the use of each type of scope, but only your docs can really tell you what they're using. For instance, some physicians use the larger therapeutic size upper for every EGD they perform. Even if you don't do pediatric cases, a lot of gastros use a pediatric colonoscope for cases that have a lot of diverticuli, on elderly patients, those with excessively angulated curves or just simply all flex sigs. Try not to gag, but they also use the peds colonoscope for uppers when they need to go further into the small bowel.

3. Forecast your needs.
A few years ago, we were doing many more diagnostic uppers (EGDs) than colonoscopies, and our scope-purchasing habits reflected that. Recently, however, that trend has shifted and so, too, have the numbers and types of scopes we have on hand. Why the shift? In large part, NBC-TV's Katie Couric and other people in the public eye raised colon cancer awareness and spurred more people to schedule colon checkups. The lesson here: In addition to knowing your docs' case mixes, keep an eye on outside trends that might influence your scope inventory.

4. Buy a service contract.
In our experience, we prefer having an initial lease that includes repairs (also know as cost-per-case leasing). We've had it both ways over the years, and we found we really spent about the same with a service contract as without. The lease inclusion in the contract just spreads it out better for cash flow. Make sure the manufacturer will pay shipping both ways for the repairs, and find out where the repair centers are and approximate turnaround time. Loaners should be guaranteed to be available and shipped overnight. An on-site loaner is a good thing to negotiate for, but make sure it isn't going to be a dinosaur with a quirky adapter.

One important note if you opt for a cost-per-case lease: Don't over-project the number of cases you'll do. If you fail to use the scope the number of times you thought you would, expect to get hit with an even-up charge at the end of each year so you meet your yearly projections.

Also be on the lookout for ballooning repair costs. After the original three-year lease expires, it's not uncommon for a new contract to have decreased equipment costs per case but ridiculously increased costs for repairs per case. If you know your equipment is in good general condition, you might want to consider walking away from the lease as promised, or perhaps using another reputable repair vendor. Negotiating is part of this process. That may also be a good time to evaluate other companies. If your doctors are also owners, they might be pretty willing to explore new brands.

5. Look beyond equipment to services.
The companies like to tout how great their resolution is. But when we did head-to-head comparison, we really felt they were all acceptable. You really can't go wrong with your choice of equipment. The three major manufacturers, Fujinon, Olympus and Pentax, each make exceptional products. Given that, it might make sense to look beyond the equipment's features to the services each company offers. How many repair centers does each have? What about turnaround time for repairs and on-site loaners? Spend a good part of your negotiations on these post-purchase points.

6. Focus on the ergonomics.
The physical characteristics of the colonoscope insertion tube are important. For an efficient yet comfortable procedure, it's best to have good flexibility, yet ability to stiffen for more difficult sections of the colon. Again, ask the physicians. Some feel the stiffening feature can be accomplished with the introduction of the biopsy forceps. Ergonomically, our docs have complained about the upper scopes having the flushing port too close to the hand controls.

7. What scopes can you forgo?
There's usually no reason to buy the short flexible sigmoidoscopy scopes if you do a variety of cases. A regular colonoscope or peds scope can accomplish the same purpose and they're not as limited as the flex scope is. Some docs are known to do a flex sig that goes to cecum if they're having findings and the colon is clean.

Even though your docs do ERCPs (endoscopic retrograde cholangiopancreatography), if your center doesn't have fluoro or overnight stays, you don't need that type of scope because they'll be doing those cases at the local hospital. If the only reason you'd be getting fluoro is for this purpose, make sure your docs will be doing enough cases to make it pay.

8. What about product cycle?
Something not asked nearly often enough is where the model you're looking at is in its product cycle. If it is "state-of-the-art," but has been out for a couple of years, you might sign a three-year cost-per-case lease or purchase it only to have it be outdated in one year when the new models hit the market. Also, if you already have some older scopes that are keepers, make sure the new light source will accept them. If the company assures you there are adapters, check out how cumbersome they really are.

What really matters
At the end of the day, you want to make sure your endoscopists are happy doing their GI cases at your facility. If your physicians have an adequate number and the right scopes, and have been actively involved in the process, they'll prefer to do cases at the center that took their considerations into account.

The Five Ps of Purchasing Flexible Scopes

Collecting and analyzing some simple baseline data about how you anticipate your endoscopists will use scopes in your facility is the best way to take the guesswork out of the scope-buying process, says Bunny Twiford, RN. Ms. Twiford is the director of clinical support for Physicians Endoscopy, a development and management company specializing in GI endoscopic centers. She figures she has purchased more than 100 scopes in her career, most for the seven - and soon-to-be eight - GI centers Physicians Endoscopy has outfitted across the country. Here's the baseline data Ms. Twiford suggests you gather:

' Procedures. Sit down with your physicians and understand the proportion of uppers and lowers they'll be doing, and buy your scopes in a corresponding ratio. Keep in mind that 70 percent of diagnostic procedures done in ambulatory settings today are colonoscopies, based on national data and Ms. Twiford's year-long benchmarking study.

' Procedure rooms. Procedure rooms are one thing, using those procedure rooms is something else altogether. Don't overbuy based on the fact that your facility has three rooms when you're only using one or two. When Ms. Twiford outfitted a recently opened facility, she bought 21 scopes for 16 docs using three rooms. That was fine then. But one year and two rooms later, that center's monthly volume doubled to 1,200 procedures, and the facility needs to buy five more scopes. Staggering a purchase is not a bad thing, says Ms. Twiford. "Scopes only last so long," she says. "If you buy all your scopes at one time, they'll start to break down at the same time."

' Physicians. Consider not only how many GI docs will be using your facility, but their tendencies as well. One doc might take longer dictating and talking with the previous patient, while another can move quicker through the patient flow. Create a spreadsheet listing your doctors' "average, honest" turnaround times, says Ms. Twiford, for both upper and lower procedures.

' Processing. How quickly your facility can process scopes will have a direct bearing on how many scopes you should purchase.

' Preferences. When you ask your doctors if they prefer one scope over another, they'll tell you one of three things: They have a strong preference, they're willing to compare their preferred vendor with another or they're willing to try something completely new. If your docs haven't used the scope you're planning to purchase, arrange with the vendor to demo the scope. Keep in mind that even if your doc is familiar with a line, he might not know a particular scope.

- Dan O'Connor