- Jan 1, 2006
There are no easy answers to these questions, and there will be broad variances from practice to practice and owner to owner. A large practice that deals with a clientele comprised of expensive racehorses or sport horses often will find that its clients demand the best and latest in equipment and technology and are willing to pay more for it. On the other hand, for a one-person practice in an area where recreational horses comprise the clientele, such an investment might not be justified from an economic viewpoint.
A prime example of developing technology that has distinct advantages, but also costs more to purchase, is digital radiography. Many veterinarians in private practice are making use of digital radiography, and some teaching hospitals--such as the one at The Ohio State University--have converted completely to digital radiography.
The issue involves more than just whether a veterinarian wants to make use of digital radiography. It also involves determining what type of digital radiography should be employed. There are two basic types, and each has a different price tag as well as advantages and disadvantages.
Credited with pioneer work in the field is Robin Winsor of Calgary, Alberta. Today, Winsor is chief technical officer of Imaging Dynamics Company, which produces the digital radiography equipment that he designed. Winsor recently was presented with the $10,000 Manning Innovation Award, sponsored by the Arthur J.E. Child Foundation, for his work with digital radiography.
The Winsor story, as outlined in an Imaging Dynamics Company news release, began about 10 years ago when Winsor was working in the Calgary oilfields as a research and development official. His wife is a veterinarian.
As the story is told, Winsor was helping a geologist download satellite photos one day, showing him how to use the system to find long linear geological features on the earth's surface. He wondered if this technology could be put to use by veterinarians to produce better X rays. He began researching and developing his idea, using a digital camcorder and an X ray beam in his wife's veterinary clinic. After a year of research, he applied for a patent for a system that would create a high-quality X ray and achieve it in a shorter time than film-based technology.
In 2000, Imaging Dynamics Company, a firm established by Winsor and some friends in 1995, installed its first direct radiography imaging system in a chiropractic clinic in Calgary. (The company went public on the Alberta Stock Exchange in November of 1995.)
Today, there are many players in the game with large global corporations developing and marketing their own digital radiography systems.
The two basic approaches in digital radiography are computed radiography (CR) and direct digital radiography (DR). Computed radiography systems replace the film, intensifying screen, and cassette used in traditional radiography systems with an imaging plate. Additionally, the wet film processor used in conventional radiography is replaced with a digital imaging reader. This means the film and chemicals involved in conventional X rays are no longer needed. Instead, once an exposure is made, the imaging plate is placed in an imaging reader. The plate is then exposed to a series of laser lights that read the information on the plate and a radiograph appears on a computer monitor.
While this approach does not do a whole lot to speed up the process from exposure to viewable picture, it does eliminate film and chemicals. It also allows the practitioner to use a conventional X ray unit and avoid the need for purchasing a new X ray machine.
Mathew Wright, DVM, MS, Dipl. ACVR, a board-certified veterinary radiologist in Massachusetts, outlined on his website "Animal Insides" these advantages for the CR approach:
* A digital image is generated;
* Existing radiography equipment can be retrofitted;
* Mobile radiography is easily accomplished;
* Image quality is excellent; and
* It's initially less expensive than DR.
The following were listed as disadvantages by Wright:
* The practitioner still must use an imaging plate;
* There's no real time-saving benefit over traditional radiography; and
* One must purchase an imaging reader.
Digital radiography is the most sophisticated and currently the most expensive approach. It is a method of digital radiography where the conventional radiographic cassette and film are replaced with a digital imaging sensor. The imaging sensor is either permanently affixed to an X ray table or attached to the DR computer by a wire.
As is the case with today's digital cameras, there is instant feedback. The veterinarian knows instantly what the X ray has captured. It's a quick, one-two procedure: 1. The imaging sensor is exposed by X rays. 2. An image appears on the computer screen.
Here are the advantages of DR as listed by Wright:
* No processing time and immediate image acquisition;
* Only requires one imaging plate, not multiple; and
* Excellent image quality.
The disadvantages by Wright are listed as follows:
* More expensive than CR;
* Radiography necessitates a wire between computer and imaging sensor;
* Cannot perform cross table (on the table) radiography if the imaging sensor is attached to the table; and
* The imaging sensor is more expensive to replace than an imaging plate or cassette.
The next question involves whether one approach or the other produces a better image. There does not appear to be a consensus on that issue. Some who have studied the two systems maintain that the DR images are much better, while others claim there is no significant difference.
There does seem to be a consensus, however, that DR is perhaps the wave of the future--that it will be fine-tuned and improved, leaving other systems in its wake. The CR approach, it seems, came into being as a way in which digital radiography could be employed without having to buy a new X ray machine.
Mark R. Crootot, DVM, who owns a small animal practice in Saratoga, N.Y., has been researching digital radiography for the past two years. In the July 2005
issue of Veterinary Practice News, he reported on what he had learned.
He gave these cost comparisons for radiography technologies: Purchase of a traditional X ray machine, $18,000 and up; purchase of a CR system plus X ray machine, $35,000 and up; purchase of a DR system, $80,000 and up plus X ray machine.
Crootot was quick to point out that the price range depends upon the manufacturer, the number of additional workstations, and the quality of the monitors. He also said that many manufacturers offer to lease equipment if the practitioner doesn't want to make an outright purchase.
A prime benefit of digital technology, Crootot said, is the ability to send images electronically.
Cost Vs. Value
Can digital radiography be justified economically in the average practice? Crootot quoted a fellow veterinarian as saying that if one were to install CR, the break-even point would be about 20 studies per month and with the DR approach, it would be approximately 60 studies per month. His estimates were based on the national average charge for a two-view study.
The bottom line is that the decision on whether to buy the latest sophisticated equipment will be a practice-by-practice basis, with the clients having something of a say in the matter. One veterinarian, for example, reported that her clients were insisting on digital radiography and would likely go elsewhere if she didn't provide it.
Western Bloodstock Agency, a firm that conducts a series of sales in conjunction with the annual NCHA Cutting Horse Futurity each December in Fort Worth, Texas, insists that for one of the prestigious two-year-olds in training sales, all four of a sale candidate's limbs must be X rayed with digital radiography.
As mentioned earlier, The Ohio State University has converted its X ray department to digital radiography. Using technology from Eklin's Medical Systems, the hospital has installed three of Eklin's EDR3 (one of which will be used by the OSU Equine Field Service for field exams) and two EDR6 RapidStudy DR systems with an additional EDR5 system to be installed later this month. In addition, 13 workstations with Eklin's state-of-the-art PACS (Picture Archiving and Communications System) were installed, which will allow online integration of a patient's DR images with all other digital images, such as MRI, ultrasound, CT, and nuclear medicine.
Magnetic Resonance Imaging
While magnetic resonance imaging (MRI) purchase and installation is still not practical for the average solo veterinarian, some important strides have been made in MRI usage that bode well for both veterinarians and their equine patients, especially those patients with foot and leg problems.
One of the drawbacks of the technology has been the need for the patient to be anesthetized. Enter an MRI approach that involves imaging the limb of a standing horse. The horse is sedated, but not anesthetized.
At the 2003 American Association of Equine Practitioners meeting in New Orleans, Tim S. Mair, BVSc, PhD, MRCVS, DESTS, Dipl. EIM, ECEIM, a partner at the Bell Equine Veterinary Clinic in Kent, England, reported that the first unit with that unique capability had been installed there. The scanner was installed in 2002, and when Mair gave his report, some 60 horses had been scanned.
Mair told his listeners that the results in general were positive and that the approach might put MRI in the affordable range for many practitioners. "We believe," he reported in the AAEP Proceedings, "that this system will allow the application of MRI technology in general equine practice, which would be unlikely with higher field closed magnets because of their inherently higher cost."
At Washington State University, the cost of a traditional MRI examination was listed in a news story as running between $1,000 and $1,500.
Diagnostic ultrasound equipment is becoming commonplace in veterinary clinics and hospitals. One company that sells and leases units released figures that it feels demonstrates that utilization of the service is good business for a veterinarian, even if he/she does not wish to purchase the equipment. It stated that hospitals and clinics currently charge an ultrasound procedure fee ranging from $35 to $250, depending on the complexity of the examination.
It also pointed out that leasing large
animal ultrasound units might cost from $99 to $191 per month. On a per week basis, the company said, a practitioner would realize $105 per week for three exams if $35 per exam were charged. If 30 exams were performed, the amount would be $1,050. Obviously, the amounts would increase accordingly if the exam charge were higher.
Interventional Radiology and Endoscopy
A non-surgical approach called interventional radiology and endoscopy is being studied at the Matthew J. Ryan Hospital at the University of Pennsylvania's School of Veterinary Medicine. The university maintains that this is the first approach of its kind to be established at any veterinary teaching hospital. Minimally invasive medical and surgical techniques for such ailments as tumors, liver shunts, urinary stones, and bile duct obstructions are being performed.
The college describes the approach thusly: "Interventional radiology utilizes fluoroscopy to visualize the placement of catheters, stents, balloons, and coils into blood vessels, the urinary system, respiratory system, and other tubular structures. Interventional endoscopy utilizes the endoscope under fluoroscopic guidance (for) the diagnostic and therapeutic endeavors. These procedures are still largely experimental in animals and are under investigation at Pennsylvania for many different applications in animals."
The university also had this to say: "An established tool in human medicine, interventional radiology has tremendous potential for the treatment of serious maladies in pets. Interventional radiology involves the use of contemporary imaging modalities to gain access to different structures in order to deliver materials for therapeutic reasons. The veterinary community is acquiring and refining similar procedures as human medicine to provide non-surgical alternatives with decreased morbidity/ mortality rates, minimal anesthesia time, reduced hospital stay, and lower costs."
About the Author
Les Sellnow is a free-lance writer based near Riverton, Wyo. He specializes in articles on equine research, and operates a ranch where he raises horses and livestock. He has authored several fiction and non-fiction books, including Understanding Equine Lameness and Understanding The Young Horse, published by Eclipse Press and available at www.exclusivelyequine.com or by calling 800/582-5604.
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