Geoffrey Browne, MD, chief of radiology and nuclear medicine, Alamance Regional Medical Center.

Alamance Regional Medical Center, Burlington, NC, may serve a fairly small community, but that does not stop it from working hard to remain competitive with the larger medical facilities in the state. In fact, this 240-bed facility recently put its radiology services on a par with those of the much larger University of North Carolina at Chapel Hill when it added a new 16-slice CT scanner. The two facilities are now the only medical centers in the state to offer the most advanced technology available in diagnostic imaging today.

The decision-making process that led to the addition of the 16-slice CT scanner took place in several stages, though it was made simpler by the fact that Alamance serves as a show site

for Siemens Medical Solutions, Malvern, Pa. The facility's administration and its radiology department had already been impressed by a four-slice CT scanner that was installed in March 2000.

Chris DeAngelo, imaging coordinator for CT, says, "When we added the four-slice scanner, we noted an immediate difference in the way our radiology equipment was being utilized overall. We found that we no longer used the single-slice CT scanner already in our radiology department because the multislice scanner proved to be far superior. Since only one of the two scanners was being used, that pointed out two things to us: we were not utilizing our department to its full capacity, and, by adding another multislice scanner, we could open up new avenues with CT angiography and cardiac CT."

In July 2002, the department made the decision to replace its remaining single-slice CT scanner with Siemens' Somatom Sensation 16 CT scanner. The decision to acquire the more advanced technology, rather than simply adding another four-slice CT scanner, was made for several reasons. Geoffrey Browne, MD, chief of radiology and nuclear medicine, says, "As a show site for Siemens, Alamance's radiology department is pretty well abreast of the latest advances in imaging, especially in CT." Browne, who was heavily involved in acquiring the new technology, adds, "We were supported by the administration in obtaining the 16-slice scanner because they felt that it was cutting edge, and that it would give our patients the best care. That keeps us competitive with larger centers because it makes us more efficient, and this offers us a wider scope of practice within the population in this area."

Alamance's administration also realized that there was a need for diagnostic images with higher resolution, and the Somatom Sensation combined superior image quality with a very low radiation dose. The 16-slice CT scanner has the added advantage of faster acquisition time, as it can perform a routine chest study in 8 seconds or a view of the abdomen or pelvis in 8 to 10 seconds. "Every administration is going to be hesitant about spending a lot of money, and the 16-slice scanner costs around $1.3 million," De Angelo says, "but the four-slice CT scanner was such a success that the administration understood that adding another multislice scanner would increase volume and revenue. It also maintains a continuum of care within the department, so having two multislice scanners is really advantageous to Alamance."

Chris DeAngleo, imaging coordinator for CT, Alamance Regional Medical Center.

IMPLEMENTATION AND PERFORMANCE

The installation process was appealing, as well: it took only 4 days, and since the system uses Siemens' Syngo software (the same software used by Alamance's four-slice CT), only minimal training was required. "All of Siemens' scanners have the same software," DeAngelo says. "It was, consequently, very simple to make the transition from a four-slice scanner to a 16-slice scanner. There was no downtime in switching technology."

Browne adds, "We use all of our Siemens machines extensively and they work and work and work; they do not break down frequently. We probably have more downtime due to our scheduled preventive maintenance than because of interrupted services."

The multislice system is fully loaded with all the currently available options, DeAngelo notes. Among those options are LungCARE CT, which allows diagnosis of pulmonary nodules and lesions in the early stages of disease. HeartView CT provides two modes of data acquisition, one of which allows sequential scanning to be performed at a single, predetermined phase of the cardiac cycle. The other mode combines spiral acquisition in parallel with electrocardiogram recording, allowing image data to be reconstructed at different phases of the cardiac cycle. Alamance also uses Vessel View, which is good for stenosis quantification, aneurysm assessment, and semiautomatic visualization of vessels from CT and MR angiography data sets. The Leonardo multimodality workplace allows the radiology department to complete all aspects of image processing in one location.

"Our remote workstation is in the process of being connected," Browne says. "Since we are not a facility that uses a picture archiving and communications system, this will be particularly helpful in manipulating images." DeAngelo adds, "The workstation is great in terms of saving time. For instance, if we need to reconstruct 1,000 images on a CT angiogram and it takes a second to transfer one to two images, there is significant time being lost. That processing time is virtually nil with this feature, and we also can use it to transmit images to our four-slice CT scanner."

The multislice scanner has a large-capacity hard drive and can store all image files and raw data for a week. "We want to maintain the raw data for as long as possible, and they are also archived to a rewritable 4.1-gigabyte magnetic optical disk," DeAngelo says. "We use the same archive media with the four-slice and have the same storage for those images as well."

Since the addition of the 16-slice CT scanner, Alamance's radiology department has been performing an average of 1,300 CT scans per month. The department performs around 90,000 examinations annually, including MRI, nuclear medicine, mammography, and special procedures such as cardiac catheterization. The majority of the radiology department's patients are 60 or more years old, although DeAngelo says that it is starting to see younger patients through the emergency department and referrals.

"We are still doing routine studies, such as traumas, radiation treatment planning, and some angiography, on the four-slice scanner, but our primary focus is on the 16-slice scanner," DeAngelo says. "If an emergency study needs to be done and the other scanner is tied up, we will use the four-slice scanner."

Most of the procedures completed on the new 16-slice CT scanner are routine examinations, although the department is shifting to emphasize more orthopedic three-dimensional (3D) imaging and CT angiography. "In orthopedics, the technology allows our physicians to visualize the anatomy more accurately; this, in turn, allows better preoperative planning," Browne says. "The vascular surgeons also have enjoyed it because of the faster reconstruction time. Vessel View will allow them, more accurately, to follow lung lesions over time and detect small changes." Browne continues, "We do a lot of carotid artery and other angiography with the 16-slice scanner. In particular, this technology is a great advantage because we can enhance the carotid artery without any venous return (so we get an unobstructed view). We can acquire the information from a carotid artery CT angiography scan in 7 seconds."

ADDING CAPABILITIES

The radiology department is looking forward to more software upgrades for the 16-slice CT scanner. Siemens will be releasing software that makes it possible to perform virtual colonoscopy in January or February 2003, and DeAngelo reports that the department has already included this new capability in its 2003 budget.

Using CT for diagnostic screening is a controversial topic in the radiology community; Browne notes that Alamance's radiology department is still weighing the evidence on this issue. "We are sitting on the sidelines, watching the debate over screening CT studies (which are more attractive with the Siemens system because of its constant monitoring and adjustment of radiation levels)," Browne says. "We can maximize the image but minimize the dose delivered to patients. Screening may be something that we get into eventually through the medical community, especially if there is an executive group or an HMO that would like to have such a service for its members. The hospital administration has been supportive of that, but we are waiting for the facts and figures to fall out more clearly on a national level."

CT IN THE COMMUNITY

Alamance has not chosen to use a major marketing campaign to support its new technology, though the medical center did issue a press release to inform the community about the 16-slice CT's superior imaging capabilities. Response to the new CT scanner was positive, but Browne points out that most patients are not aware of how fortunate they are to have access to this technology. The facility received a greater response when it invited physicians into the department to view the 3D images created by the new technology. "Just talking to the medical community and showing physicians what the machine is capable of is often all that is necessary to bring us business, because every case seen here comes through a physician," Browne says. "Everybody in the medical community who sees the output of the new scanner is awed by it." DeAngelo adds that some physicians do not initially understand the advantages of the new technology; however, he says, "When they see the real-time, online volume rendering we can do with it, they are impressed. Consequently, we have netted a lot of referrals from area physicians."

A major selling point for Alamance has been rapid turnaround time, and Browne says that the department is very good about working in patients on short notice throughout the day. Despite the size difference between Alamance and Chapel Hill, the new technology has equalized some aspects of their radiology practices. DeAngelo notes that Alamance is not losing any referrals to Chapel Hill. "The only other competing imaging center in town has nothing near this technology," he says. "Consequently, people want their CT scans to be done at Alamance."

From a physician's standpoint, DeAngelo says that the technology is so superior that it virtually eliminates the need for many other types of imaging examinations. "The image quality is phenomenal, the speed is amazing, and multislice CT scanning gives us real-time reconstruction," he says. "This is exciting technology, and it has brought a lot of pride to our department. This latest addition is changing our CT practice altogether."

Elizabeth Finch is a contributing writer for Decisions in Imaging Economics.