4 Sept 2022
While MRI and CT have long been seen as the preserve of referral centres, a growing number of first opinion businesses have begun investing in these advanced imaging modalities. Big benefits exist for practices going down this route, but also significant risks for those making such as big investment without taking a close look at all the finer details…
James Westgate
Job Title
Image © andrey_orlov / Adobe Stock
CT and MRI don’t come cheap, with new machines costing hundreds of thousands of pounds or more, and annual maintenance costs often running into five figures.
Installation can also carry a hefty price tag and finding room for such sizeable pieces of equipment may require substantial building work – or even an extension to the existing premises.
But despite the financial outlay, with the right caseload, the right people and the right training, advanced imaging can deliver huge opportunities for practice development and bring a big boost to the bottom line.
That has certainly been the case for Anrich Vets, a first opinion business in Wigan that, for nearly two decades, has been making the most of these modalities.
After acquiring its first MRI machine, the practice initially offered advanced imaging solely as an outpatient option, but it now delivers a referral service through its subsidiary company, Northwest Referrals.
The business performs around 80 CT and MRI scans per month, and has built up a clinical team capable of handling most things that come its way.
But it’s been a long learning curve, as managing director James Weston explained.
“We bought our first MRI machine in 2007, but back then we only scanned a few animals because the caseload wasn’t very big as at the time, as we were only a two or three-vet practice,” he said.
“Things started to pick up when we began offering it to local vet practices and then we discovered VetCT, which gave us a lot more credibility because we had a diplomate reporting on the images and it started to build a little bit of momentum.”
Offering a specialist-backed service meant an increasing number of practices began to refer cases as outpatients, giving James the confidence a market existed for expanding the service.
James added: “It probably took us three years to go from four scans a month to maybe 30 MRI scans a month, and it was at that point I got the opportunity to buy a CT scanner.
“The reason we opted for that too is because we were getting a lot of people referred for MRI when CT would have been better for it and we had a consistent amount of work to make that viable.
“I bought the CT scanner in 2017 and we got a great deal on that from MIUS [now Probo Medical], who helped make sure it was a really seamless transaction, and I know a lot of the equine practices have been making the most of Hallmarq’s very good standing MRI system for many years.”
Hallmarq and Probo Medical both offer a “bolt-on” pod solution that allows practices to add MRI or CT without the need for extra building or infrastructure work, but James opted to just buy the machine, and manage the installation and integration of the machine in-house.
He said: “We did save money doing it that way as I built the room for the CT scanner myself and I sourced all the material, and I would say that the project management side of it saved us tens of thousands of pounds.”
Of course, not all practices will have the time available to manage such a large-scale project, and even with James doing the installation and building work himself, installing the CT machine still cost £35,000.
James added: “You hear some horror stories about installations, but that is often because nothing is ready; there is no network point, there is no power where you want it to be – it is a three-phase machine, so that needs bearing in mind.
“We were lucky because we already have a three-phase power supply, but there are practices that have had to buy different machines, such as the Siemens machine from PLH Medical, which can be run off a normal supply as it runs off 100 amps, whereas ours needs 140 amps.
“So, it is important to consider that; you may want to buy a more powerful second-hand machine, but you may not have the power supply you will need and it will cost a lot of money to rectify that, and that is when things start to get really expensive and make this a less viable proposition.”
One of the other big considerations for practices is space, and James’ advice is to ensure there is room to get the machine in and out and for the clinical team to use it.
He added: “I have spoken a lot on this subject as I believe it is the future. There should be nobody setting up a vet practice that does not at least have a space for a CT scanner.
“Whether they are planning to have it now or in the future, CT needs to be part of the plan.
“I would always advise that – just have the room, keep somewhere ready and then when you have the caseload and maybe have the money, add in the scanner.
“You have to have a decent-sized room, otherwise your team will hate it and if the team hates it, then it is not going to work.
“It is also important to consider housing the machine in an area where you have the necessary throughput, so you need to have a way to get it in and out for upgrades when needed, as they need upgrading.”
In the early days, Anrich modelled its entire scanning business around outpatient scans because, at the time, the practice did not have the numbers or the right clinical skills in place to deal with those cases in-house.
But since the formation of NorthWest MRI – now Northwest Referrals – the practice has grown its team and developed the skills needed to deal with most cases in-house.
James said: “You need good people in place. We have a certificate holder in surgery and we have lots of other vets here who are just about to complete their own certificates, so we have some very, very good people and we make sure that everyone gets the training they need to make the most of the technology.
“There are external places – I think Improve International is probably one of the best training centres for hands-on stuff, but there are lots of other places where you can get the external training you need to develop your skills with these machines and to perform the work. They show what needs to be done.
“It is great for business and it is great for the people in those businesses as they get to develop their clinical skill set.”
But according to James, a certain fear factor means many practices remain reluctant to take the plunge into the world of advanced diagnostic imaging.
He believes many vets are “scared” of making an incorrect diagnosis due to the amount of pressure from clients to get it perfect every time.
“In those cases where it is a bit more complicated, just do the CT or the MRI and send it off to a specialist who can tell you exactly what the problem is – probably within a few hours,” he said.
“They will also tell you if you need to do anything else and they will tell you exactly what you need to do.
“So, with the help of people who know what they are doing, it is very easy for a first opinion practice to build a case and work a case up.”
Another important piece of advice is for practices not to become too obsessed with buying the most expensive MRI or CT their budget will allow.
While the bells and whistles of a top-spec machine may appear attractive on paper, in practice, such high-end equipment will drive up costs that will ultimately have to be passed on to clients.
James added: “Two years ago, we bought the Esaote Grande model and that has been brilliant; it is much quicker than our old one, the field of view is much bigger. That cost us £500,000 and that included a brand-new RF room, which is very, very good.
“Sometimes, we get frowned upon because we are not using high-field MRI, but of course, high-field MRI is more expensive – just to maintain that will cost between £80,000 and £100,000 a year just for the maintenance, and just to feed the helium.
“Ours plugs into the wall and it doesn’t cost us anything apart from getting it serviced every six months because it gets so much use, but that costs us around £3,000 a year – there is a massive difference.
“There are practices out there with 3 tesla MRIs and, for most cases, that isn’t needed, and just means those practices have to charge between £6,000 and £8,000 for one scan because it is such a huge investment – whereas we charge £1,300 for an MRI scan.
“And we don’t charge the earth for CT either because we have the caseload to ensure that the machine is well used, which keeps the cost down.
“I could charge more, because everyone else does and I wouldn’t really lose much business, but I want it to be accessible. We have some really big guns on our doorstep here like Northwest Veterinary Specialists, ChesterGates, Kentdale and Paragon – these are massive players and yet we punch well above our weight against them.
“We do really well with this and there is no reason why other practices can’t do the same,” James concluded.
CT has been in clinical practice for 50 years and MRI, the relative newcomer, was introduced 40 years ago. During the past decade, CT and MRI have been increasingly available and purchased by the veterinary profession.
These advanced imaging modalities have a huge potential for increasing the sensitivity and specificity of diagnosing pathology, and have significantly changed patient management.
CT and MRI are continually developing, rapidly advancing specialities, and mastering
their operation – and keeping abreast of latest developments and legislations – requires a full investment in training.
To get the most out of the kit, and understand the software, protocols and parameter options to produce optimal image quality with the highest patient care, staff require continuing educational development to provide the underpinning theoretical knowledge with additional clinical training.
To adapt and amend the scans for individual patients, staff operating the scanners must learn 3D anatomy; for correct positioning, setting up scans and for identifying both normal and abnormal anatomy.
It is essential to fully understand the individual hazards of CT and MRI to ensure safe environments for patients and staff. The dose in CT is massively higher than plain radiography; therefore, the scans must be carefully selected and accurately set up, keeping the radiation dose to a minimum to answer the clinical question.
MRI has the hazard of the very strong magnetic field that needs to be fully understood and managed properly to keep the patients, staff, equipment and environment safe.
To optimise image quality, many protocols and scan parameter options exist in CT and endless options in MRI.
To get the best out of the complex systems, to select the correct protocols to optimise image quality, staff need to have a solid understanding of the underpinning principles and clinical applications of CT and MRI.
All scans produced by staff should be of the same optimal diagnostic quality, irrespective of who is scanning.
Positioning, scan length, protocol and parameter selection should be consistent and reproduceable. Staff training needs to be standardised with a continuity of training to provide a robust, consistent and accurate service.
With proper training on the equipment, protocol selection, scan preparation and patient positioning, patients can be sedated or anaesthetised for a minimal length of time to produce best-quality, accurate scans.
This is essential for best clinical practice and patient care while speeding up the workflow. CT and MRI equipment is highly complex and using it efficiently – minimising waste and procedure duration – requires thorough understanding of the controls and parameters, which in turn requires sound and effective training.
As a diagnostic radiographer with more than 30 years of CT and MRI experience (both medical and veterinary), my advice to achieve best practice, staff confidence and increase your referrals is to invest in a combination of dedicated classroom training, clinical supervision and continual practical support/training.
Eden Learning can provide comprehensive classroom and practical training to encourage independent thinkers and decision makers in the clinical setting of CT and MRI. For advice and more information, contact [email protected]
