You may want a new C-arm, but do you need one? The OR managers and industry insiders we talked to say you can find the answer to that question in these three factors:

• What and who? First, determine exactly what you'll use the device for and who will use it.
• How many? Second, realistically estimate the number of procedures that will require the new C-arm.
• How much? Third, be sure to assess your reimbursement for the procedures, so you can be sure the investment will be worthwhile.

Deciding to invest in a major piece of equipment such as a C-arm is no easy task when you consider the price - $80,000 for a basic model to $300,000 for an instrument with all the bells and whistles - and such alternatives to buying new as leasing or buying a refurbished unit. In this article, we'll break all the factors down so you can make the best purchasing decision for your facility.

1. What are your surgical needs?
Knowing your surgical needs is paramount to selecting the right C-arm, new or refurbished. Orthopedic and podiatric centers, for example, may be well served by a mini-C. If you plan to offer full-service pain management, a full-body C is mandatory. Only full-body Cs have enough power, or anode current, to penetrate deep, dense tissues and allow visualization of target areas such as the lateral lumbar spine.

2. What cases are increasing in volume?
There isn't a magic number that applies to every facility, but if the cases that require a C-arm are increasing by a steady amount - say 15 percent or more - for six consecutive months, it's likely you can justify the investment in a new or additional C-arm. Further, experts say the growing popularity of C-arms in minimally invasive surgeries means that mobile imaging equipment has gone beyond simply being a diagnostic tool.

At the Ohio State University Medical Center, an increase in orthopedic trauma surgeries that required fluoroscopic imaging was making access to the C-arm more difficult to guarantee for elective cases, says Lynda Petty, RN, director of perioperative services.

Another way to look at it is whether your C-arm is in use all the time. When she opened the Surgery Center of Kalamazoo in Portage, Mich., last year, Christine A. Therrien, RN, purchased two C-arms - one for the seven orthopods that use the regular C-arm all the time (as many as three orthopods and a pain management specialist may be doing cases at the center at the same time) and a mini C-arm (the so-called little giants of fluoroscopy) to serve the plastic surgeons.

3. What cases could increase in volume?
This number is a bit trickier to figure, because it doesn't just involve the cases that require a C-arm. You also need to evaluate what other cases you could do if you had an additional - or a more updated - C-arm.

"C-arms do not pay their way, as they do not generate an ROI based on what can be charged for fluoroscopy. However, they are an enabling technology that provides a facility the ability to perform more and new procedures that have a favorable ROI," says Roby Trierweiler, the senior director of surgery and urology for Siemens Medical Solutions.

Another aspect to this question is the age of your current C-arm. Assess whether the technology you have is truly meeting your surgeons' needs in terms of efficiency. Experts say you should replace your C-arm every five years or so. Why five years? That's the expected life of the X-ray tube, which is a primary and expensive component of any unit. Additionally, capital equipment is usually depreciated over a five-year period.

"If your equipment is outdated, the image is poor, and the physicians cannot see what they need to see, they cannot get cases done quickly. This slows down billing and revenue," says Ken Derentz, president of Kenquest Medical Equipment of Las Vegas.

To perform a more focused analysis, Ms. Therrien suggests that you look at the CPT codes for procedures that require a C-arm. "Are there procedures you aren't handling because you don't have the equipment? Pain management is one specialty that uses a C-arm continuously. If it makes sense for you to add pain management procedures, then it makes sense to invest in a C-arm. Without it, you could lose a lot of cases," she says.

On the flip side, she says that a CPT code analysis may show you don't need the extra equipment. In one center, physicians requested a mini C-arm, but the center couldn't see the potential for the procedures that would require a mini C-arm and in the end didn't add the instrument.

4. How many cases are you turning away?
This question may be the most important, experts say. The magic numbers here are 40 (orthopedic) or 150 (pain management) - as in the number of cases per month surgeons are taking elsewhere either because you don't have a C-arm or the one you have is too often in use, says Ms. Therrien.

Let's say that reimbursement for each case you're losing is $363 and that profit margin on each case is $200. Multiply $200 by 150 cases and you get $3,000, which is a standard monthly payment for a new C-arm. If you were losing orthopedics cases, the multiplier would be about 40 cases, says Ms. Therrien.

St. Joseph Hospital in Tucson invested in an additional C-arm about four months ago because it was turning away about three cases a day.

"We do vascular procedures, and they use the C-arm all day. We have three days of neuro, and they need it all day. We need another C-arm for our GI lab," says Carol Martin, director. "We couldn't afford to not invest in another C-arm."

Ms. Petty says her facility increased its capacity from four ORs to six, thanks to two additional C-arms. "We were restricted to running four ORs of cases that may require a C-arm. Now we can schedule at least six ORs concurrently. The additional two C-arms allow for much more flexibility in OR scheduling as well as decreases in OR delays. As you know, OR efficiency equals more revenue," she says.

5. What do surgeons want (and what surgeons do you want)?
Limited access to your C-arm or the age of your technology may impair your ability to compete for the most desirable surgeons.

"The best way for a surgery center to succeed is diversity in its physician base. There may be a surgeon who could bring in more procedures, not all of which require a C-arm, but he needs access to your C-arm for some of his cases. If he can't get access, he won't bring any of his cases to your center," says Mr. Derentz.

He points out that an additional C-arm will solve your access problem, but new technology has an additional draw: "The newest equipment will bring surgeons in."

When you think of a C-arm as both a portable imaging center and an information center, you need to consider network ability and full DICOM connectivity and functionalities, says Mr. Trierweiler.

6. What is your strategy for growth?
Although day-to-day costs are always on managers' minds, looking at the big picture may help you make this kind of investment decision. "Our administration always looks at the cost-benefit of capital purchases and return on investment for high dollar equipment such as C-arms," notes Ms. Petty.

If you value quality and positive outcomes, investing in new equipment is a necessity, says Luz Robles, RN, patient care coordinator for surgical services at Greenville Hospital in Jersey City, N.J. "Less anesthesia time for the patient is the most important priority," she says. "Less surgical time, since the surgeon sees the image right in front during surgery and has no need to develop the films, also avoids delays. And we achieve easier working conditions with all personnel in the room."

"Sometimes a facility can't afford not to have the latest technology. Competition is strong, and that's how you attract the physicians that will bring cases," says Mr. Derentz. "If you don't have it, your facility won't do well."

Consider purchasing options carefully
If you're sold on buying new, call other centers to determine which companies are reputable and look into buy-back or trade-in programs so you'll be able to upgrade to a new machine in the future.

Leasing might be the way to go if you're not convinced the unit would pay off or if you want to stay on top of technological advances. You might also want to consider a refurbished unit. Experts advise taking a hard look at both the unit (will it provide the image quality you need?) and the company (is it dependable?) if you go this route. Purchase a device that is currently in production so you don't get caught short on parts.

Wait until you've selected the model before negotiating the price and service contract, says Catherine Sayers, RN, MSHA, senior vice president of clinical operations with Pinnacle III, an ASC development and management company. Prices are mostly comparable among the high-end units, especially when the digital add-on packages are included. Prices are almost always negotiable. It's more important to first get the features you want. Then you can turn your attention to negotiating an acceptable price, she says.