PET/CT BUYER’S GUIDE

for purchasing used & refurbished PET/CT systems PET/CT Buyer's Guide

Copyright © 2015

Table of Contents

For Starters ...... Page 1

Which PET/CT Do I Need? ...... Page 2

How Do I Know I’m Getting a Good System? ...... Page 6

How Much Will the System Cost? ...... Page 7

Next Steps ...... Page 14 For Starters... For Starters...

Like shopping for a lot of other medical imaging products, the PET/CT market confronts nearly everyone who enters it with a reality that is both a blessing and a curse: options.

With different makes, different models, and myriad software capabilities to consider, it’s easier than ever to get what you need, and at a good value. On the other hand, narrowing the field down to find the system that will be the best fit for your needs (and your budget) can be a daunting task. That’s where this guide comes in. To help you make that perfect pick, this guide will answer the three biggest questions customers ask as they begin shopping for a PET/CT scanner:

• Which PET/CT do I need? • How do I know I’m getting a good system? • How much will the system cost?

If you’re ready to get started, we are too. Read on to prepare yourself to make a great PET/CT selection for your facility!

For a complete listing of Block’s available systems and services please visit 1 www.blockimaging.com Which PET/CT Do I Need? Which PET/CT Do I Need?

The first step to answering this question is to ask another question: “How do I intend to use this system?” PET/CTs are used for a variety of studies, from cardiac, to neurology, to oncology. There are some PET/CTs that do all of these things exceptionally well, but paying for capabilities that are outside the scope of your individual practice can needlessly inflate your equipment budget. Once you know what you are going to do, you can begin to assess your options accurately.

The most significant considerations are slice count, cooling system, software options, whether you intend the system to be mobile or fixed, and, of course, budget.

Slice count:

How many slices you need is based on a couple of considerations: What kind of studies you plan to do and market conditions in your area.

What Kind of Studies Do You Plan to Do? Oncology studies can be performed on any PET/CT system. Cardiac studies are best performed at higher slice counts and, in some areas, are only reimbursed if using a 64-slice system. If you are primarily interested in doing gated cardiac studies (MPI), a 4-slice GE system is sufficient and, perhaps, ideal.

What Are the Market Conditions in Your Area? If competition among practices is high in your area, it may be important to learn which slice counts are available to patients in other local facilities. You might need to be more competitive to draw referrals from local physicians.

In terms of calculating reimbursement revenue by patient volume (access radiology reimbursement calculator here), it’s important to understand this tip: Unlike a CT scanner, a higher slice count on a PET/CT generally has no effect on scanning times and throughput. This is because, regardless of the slice count of the CT portion of a PET/CT, the PET portion is always slower. The overall scan time is a result of that speed, not the CT’s. It’s also worth noting that PET scanner speed is comparable across all manufacturers.

PET/CTs are available from the “Big 3” manufacturers in the following slice counts:

• 2 (Siemens) • 4 (GE) • 6 (Philips/Siemens) • 8 (GE) • 16 (GE/Philips/ Siemens) • 64 (GE/Philips/Siemens)

For a complete listing of Block’s available systems and services please visit 2 www.blockimaging.com Which PET/CT Do I Need? (continued)

Cooling System

Another factor to consider when searching for the right PET/CT scanner is the method of cooling. With the sheer quantity of electrical components operating inside a PET/CT’s gantry, heat builds up quickly. To compensate for this build-up and prevent equipment faults from overheating, there are two main methods of heat dissipation: air cooling and water cooling.

Air Cooling Air-cooled systems rely on open ventilation through the external covers of the gantry via fans. Some advantages of this cooling type include:

• No concerns over water quality • A lower amount of preventative maintenance • No need to purchase/maintain an external chiller unit • Smaller footprint, fewer cabinets

Water Cooling Water-cooled systems rely on external chillers plumbed to a nearby water source. Some advantages of this cooling type include:

• Fewer concerns involving inconsistent humidity or ambient temperature • Do not require additional HVAC accommodations for the room itself • Quieter, more comfortable scanning room • Cleaner gantry (fans tend to pull in dust, hair, etc.)

Software Options

The PET/CT software options that are currently available are too numerous to detail in one place. In addition, many options that perform the same function are called by different names depending on which OEM produced them. For brevity’s sake, we’ll talk about the most commonly sought-after options.

Time of Flight This option takes advantage of very fast detectors and electronics that can measure the tiny (nanoseconds) time difference between the detection of each annihilation photon along the line-of-response between opposite detectors. It allows radiation dose reduction and faster scan times. Philips pioneered this product commercially in 2006.

For a complete listing of Block’s available systems and services please visit 3 www.blockimaging.com Which PET/CT Do I Need? (continued)

Calcium Scoring This option scans heart arteries to find calcium deposits and diagnose heart attack risk. Calcium scoring is available on nearly all PET/CT systems under a variety of proprietary names.

Cardiac Gating Cardiac gating correlates images of the heart with certain phases in the heartbeat. It’s ideal for myocardial perfusion studies. This feature is available on most systems from the factory. If the system you are considering does not currently have cardiac gating, it still may be able to be added.

Another aspect to consider is the software that you will use to acquire or process your cardiac gated studies. Popular cardiac gating software suites are Emory, Cedars, CVIT and 4DM. If you are already locked into a specific software program, be sure to check that it supports the scanner you are buying.

Respiratory Gating Using reflective foam blocks and a calibrated camera, the PET/CT system can compensate for normal breathing movement during a scan. This feature is an add-on. All systems support it. The most popular systems are made by Varian.

Mobile PET/CT Installations

Some of you may be considering the purchase of a PET/CT scanner for installation in a mobile trailer. This fact will make a significant difference in narrowing down the field of machines you have to choose from.

“Mobile-Friendly” Features Here are some features that make a PET/CT better suited to mobile installation:

• Air-cooled gantries (since they don’t require a chiller) • Smaller footprint designs • 16 slices or below (as faster scanning means more vibration)

“Mobile-Friendly” Models The following are models commonly installed in mobile settings:

• GE Discovery ST • GE Discovery STE • Siemens Biograph Duo • Siemens Biograph 6

For a complete listing of Block’s available systems and services please visit 4 www.blockimaging.com Which PET/CT Do I Need? (continued)

“Big 3” Offerings in PET/CT

Check out the chart below for the most common/popular PET/CT model offerings from the “big 3” manufacturers- GE, Siemens, and Philips. As you shop for the perfect system for your facility, these are the models you are most likely to encounter on the secondary market: PET/CT MAJOR MODEL OPTIONS GE siemens philips Discovery LS4 Biograph Duo Gemini Dual

Discovery LS8 Biograph 6 Gemini Power 16

Discovery LS16 Biograph 16 Gemini GXL 6

Discovery ST4 Biograph 40 Gemini GXL 16

Discovery ST8 Biograph 64 Gemini TF 16

Discovery ST16 Gemini TF 64

Discovery STE4 Discovery STE8 Discovery STE16

For a complete listing of Block’s available systems and services please visit 5 www.blockimaging.com How Do I Know I’m Getting a Good System? How Do I Know I’m Getting a Good System?

This is a frequent question from people who have never before considered purchasing a used PET/CT. There are a lot of ways to confirm a system's quality. We recommend the following. Start thinking about these early on to allow time for any changes to be made!

Process Homework When Considering a Pre-Owned PET/CT

Inspection Be sure to have the PET/CT inspected before you pay. Either inspect it yourself (with your tech?) or hire an engineer to inspect on your behalf. This will likely cost you $2,500 - $4,000, but is well worth it. This will let you get to know your prospective system’s current and recent performance, its overall condition, and the environment it's been operated in.

Records Any records you can get will be useful. Error logs, service reports, quality control checks, accreditation certificates- each of these documents will help paint a picture of how well a PET/CT has performed and how well it’s been maintained.

Refurbishment We’ll be frank with you: refurbishment simply isn’t done as much for a PET/CT as it is for other modalities. Given the typical workload and usage environment of these systems, it’s unusual for them to see the harsher wear and tear of trauma or OR imaging equipment. If regular maintenance has been performed on the system, refurbishment on the scale seen among other equipment types is frequently unnecessary.

Accreditation It’s important to consider whether or not the system you’re looking at will be eligible for accreditation but, ultimately, this is not something your vendor can answer for you. Accreditation occurs once a system is installed and operational and is done by a 3rd- party accreditation company. Receiving accreditation involves checking the quality of the scan, the equipment, the room it’s installed in, and even a facility as a whole. Because dealers do not offer accreditation services, the buyer is responsible for making sure their facility is compliant to receive accreditation and, thereby, the applicable reimbursements. Learn more about medical imaging accreditation FAQs here.

For a complete listing of Block’s available systems and services please visit 6 www.blockimaging.com How Much Will the System Cost? How Much Will the System Cost?

This is the question that many customers think of first. We’ve saved it for last because we believe the overall value of an equipment purchase is every bit as important, if not more important, than the up-front price. If you go for the cheapest option up front, you can end up paying even more on the back end of your PET/CT scanner project to get your system where you really needed it in the first place.

That being said, we’re going to share the relative price ranges in the current market for systems as well as options and accessories that will be a part of your overall project cost. AND, to make sure this project is considered from all angles, we’ll talk about a few costs that probably won’t come from your PET/CT vendor but will still be essential to a quality finish.

The PET/CT System

The pricing of an individual PET/CT will vary from system to system as well as from vendor to vendor, but the chart below lists some current industry averages for a used system, delivered and installed, without a 1-year service agreement:

For a complete listing of Block’s available systems and services please visit 7 www.blockimaging.com How Much Will the System Cost? (continued)

PET/CT Accessories

Injectors An injector will generally cost between $5,000 and $20,000 dollars depending on its age and whether it is a single or a dual-head unit.

PET Infusion Systems After the radioisotope dose has been mixed for the patient it can be administered with a syringe or, to reduce exposure for techs, with an infusion system. A good example is the Medrad Intego for 18F-FDG. These systems are about the size of an end table and automate the patient infusion process. At present, the cost of an infusion system averages between $90,000 and $100,000.

Hot Lab Building your hot lab will require a number of components: dosimeters, lead bricks, a calibrator, an L block- maybe even some structural shielding, depending on the design of the room your lab will occupy and the requirements of the state you’re operating in. Your hot lab requirements will need to be assessed on an individual basis, but the median range for building a new hot lab area is $25,000 - $35,000.

NOTE: If you are doing primarily cardiac studies, you can skip the hot lab requirement and go with a solution like a rubidium (Rb82) generator. Pricing on these can be difficult to nail down without an individual consultation.

ECG Trigger Monitors These will be necessary if your site intends do cardiac gated studies. Some systems will come with them, and others will not. Be sure to ask your vendor about them. Their average price ranges between $5,000 and $10,000, depending on make and model.

Workstations There are a variety of workstations that can be added to PET/CT scanners for reading and manipulating images. Workstations can also be added to enable a system with software options that aren’t standard features. Some common workstations include GE’s AWW, Siemens’ Leonardo, Wizard, and Navigator, and Philips’ Extended Brilliance Workstation.

Workstation pricing varies based on the age of the workstation, the software options that are loaded on it, and whether or not the workstation is available on the used market. A 10 year-old, used workstation for a single or dual-slice machine can cost as little as $2,000. On the other hand, a 3 or 4 year-old workstation set up for a 64-slice PET/CT can cost $15,000 to $30,000 on the used market or $80,000 to $120,000 purchased new.

For a complete listing of Block’s available systems and services please visit 8 www.blockimaging.com How Much Will the System Cost? (continued)

Radiation Therapy Lasers These oncology accessories average around $8,000 to $45,000 depending on the number needed and whether or not the lasers are fixed or movable.

Treatment Planning Workstations This workstation is specifically related to planning cancer treatments. Treatment planning workstation prices vary greatly depending on the level of the software packages that are purchased along with them. They start around $10,000 and can cost upwards of $100,000 with the latest applications.

Mobile Trailers If you intend to use your PET/CT scanner in a mobile setting, you’ll need to budget for the price of the trailer itself as well. The price range on these is very broad. A trailer and installation can range from $75,000 for a used trailer to $400,000 for a new trailer.

In addition, you will need to purchase a “hardening kit”. The hardening kit is a rigid plate that is used to anchor the system to the floor of the trailer and increase its resistance to the shaking and bumping that comes with travel. As simple as they may seem, these kits usually run $10,000 - $20,000 and are next to impossible to find on the secondary market.

Contractor Fees Unfortunately, this part of your project will involve far too many variables for a single guide to tackle. Preparing your facility for the installation of a PET/CT may require you to work with a variety of specialists including (but not limited to): building contractors, electricians, plumbers, HVAC technicians, architects, and physicists. Many of these people will each represent a different company with a different pricing structure, some of which will vary yet again by region. With this many possibilities, we can’t rule anything out, but we can offer a few items to help set your expectations and point out some valuable caveats:

• Once you’ve settled on which PET/CT system you intend to purchase, forward a drawing of your space from an architect to your installer as soon as possible. Their site planner will propose a room layout from this drawing.

• Check your state requirements for warning lights and door switches or interlocks. The specification and installation of these items will require interaction among your architect, installer, electrician, and builder. These requirements and their connection to your PET/CT are a common source of delays if not investigated in advance of the project. Find out more about your state’s unique radiology health laws here.

For a complete listing of Block’s available systems and services please visit 10 www.blockimaging.com How Much Will the System Cost? (continued)

• Involve HVAC contractors early in the project to help avoid delays. A drafty scan room can be just as much of an HVAC problem as an overheated room. A proper scan room temperature makes things comfortable for both the PET/CT and your patients (hospital gowns aren’t particularly well-insulated).

• Several drafts of the room layout will probably pass back and forth. When a final layout is agreed upon, be sure to schedule a preliminary visit from the installing engineer. One visit is often enough, but this could be the first of two or three, depending on the extent of the room modifications.

• If you have purchased a water-cooled PET/CT, you will need access to water lines for your chiller. Your plumbing and HVAC contractors will collaborate on this installation.

• Most PET/CT scanners will need 480V, 3-phase power. Pricing will depend upon your electrician, but this can be one of the more costly components of a scan room remodeling.

• Consider dimmable lighting for the scan room. The softer settings help reduce glare that impairs the PET/CT tech’s view of the room and are a comfort factor for patients. The brighter settings are ideal for cleaning and system maintenance.

• Your scanning room will need to be lined with leaded drywall to shield the surrounding areas from radiation. This can be installed by your building contractor like regular drywall, but the material costs will be significantly higher. The cost per sheet is determined by the thickness of the lead lining, and because thickness requirements are dictated by local authorities, lining prices will vary from region to region.

• The control room will need a leaded window for viewing patients and a leaded access door. Once again, your building contractor can install these materials. Pricing on both will vary by the thickness of the glass/ lead and whether or not your state requires door switches or interlocks.

• You’ll need to communicate with your IT specialists to ensure that the proper networking connections are available in the scan room for the engineer to connect the system to the facility PACS network.

• After installation, you’ll need a state-certified radiation physicist to come out and approve your system. Don’t schedule your physicist’s visit too far in advance. A project with this many moving parts can easily be subject to a delay or two.

For a complete listing of Block’s available systems and services please visit 11 www.blockimaging.com How Much Will the System Cost? (continued)

Applications Training

Applications training, or apps training as it is commonly shortened, is a comprehensive program that walks PET/CT techs through all aspects of a system, from basics like turning the unit on and off to quality assurance tests and patient positioning for all study types. In most cases, an applications trainer will customize the protocols for the particular studies your facility will perform most often.

Apps training is a must for users that are new to the PET/CT modality and it is not cheap. A day or two is recommended for the machine to have its protocols set up and for any workflow issues to be settled. Prices can vary anywhere from $1,500 - $5,000 dollars per day, not including travel expenses for the trainer. On the other hand, apps trainers are often accredited and can provide techs with the value-added benefit of continuing education credits for the days that they are in training.

If your techs have a high level of familiarity with systems similar to your incoming purchase, it may not be necessary to provide all of them with full apps training. However, if a PET/CT is being moved from one type of facility to a drastically different one (say, from a pediatric site to a hospital’s oncology wing), an apps trainer will be needed to build the new protocols. Talk to your installer about providing an “in-service” or system demonstration of use in either case. This is sometimes referred to as “buttonology” or “knobology” and is essentially a basic tech tutorial.

Whether you need “buttonology” or a full three days with an apps trainer, it is imperative to communicate with your PET/CT tech staff and get a clear understanding of what they do and do not know.

Service

Even at the prices you can find on the used market, a PET/CT scanner represents a sizeable investment both monetarily and in terms of providing excellent patient care. We recommend accompanying that investment with some type of warranty or service plan. Even if your site wants to take all the risk for parts and labor to maintain the system through your own in-house clinical engineers, it may still be worth asking about parts warranties or parts availability commitments from your vendor, even for only a limited number of months. Equipment downtime affects patient throughput, staff scheduling, and reimbursements, not to mention the anxiety level of your entire imaging department!

The features of a PET/CT scanner service contract will vary from vendor to vendor and so will pricing. Hopefully though, the homework you did on your vendor included a look into some of their service options.

For a complete listing of Block’s available systems and services please visit 12 www.blockimaging.com How Much Will the System Cost? (continued)

The third-party service market offers a variety of creative packages, whether you have an in- house biomed team or are looking for full risk management. Tube coverage, 24/7 coverage, parts AND labor, and chiller inclusions are just a few of the variables to consider in selecting a service agreement and provider.

By way of example, the following are average annual prices for PET/CT coverage on popular models under Block Imaging’s Full Service agreement. Please note that many service providers will offer discounts for multi-year contracts:

PET/CT service Coverage Average annual prices under Block Imaging’s Full Service agreement AVERAGE aNNUAL SERVICE COST SIEMENS BIOGRAPH 16 $136,000 ge DVCT 64 $136,000 phILIPS 64 $148,000 gE LS4 $117,000 PHILIPS GXL 16 $143,000 GE DISCOVERY 16 $126,000

A Final Word on Cost

Once the details of a PET/CT project are broken out, a simple response to the cost question emerges: Prices vary too much for a one-size-fits-all answer. The best way to begin is by selecting a vendor who takes the time to understand all of your specific goals for the PET/CT project. Your patient volume, ideal timeline, technologist’s experience, room size, budget, physician’s demands, and competitor’s equipment are all factors that a vendor must understand in presenting the best equipment and service.

For a complete listing of Block’s available systems and services please visit 13 www.blockimaging.com Next Steps... Next Steps...

Keep reading about PET/CT in these additional articles:

How Much Does a PET/CT Scanner Cost? 2015 Update GE Discovery PET/CT Scanners Compared Four Things to Know BEFORE You Choose a Mobile PET/CT Siemens Biograph Duo PET/CT Review

See which pet/ct is best for you

For a complete listing of Block’s available systems and services please visit 14 www.blockimaging.com