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a lack of physicians in the healthcare system has resulted in fewer healthcare practitioners screening women with a Pap smear, as well as a reduced probability that women will be screened frequently. This issue is particularly problematic in remote and northern communities. Moreover, there is an expected shortage of cytotechnologists (laboratory screeners) in the future, which will extend waiting times for results. Currently, Pap tests are performed at seven private and public laboratories, and minimal HPV testing is conducted for research purposes only. There is no one facility for centralized testing. Similar to other fiscally challenged jurisdictions across Canada, Manitoba Health has been considering the ways in which newer screening platforms could impact on the net costs and savings of delivering cervical screening services on a province-wide basis.

The objective of this article is to report the findings of a comparative cost analysis for the implementation of new cervical cancer screening technology models. Manitoba is a province of 396,635 women aged 15–69 (Statistics Canada 2007). Approximately 195,000 cervical screening tests are performed annually, and 45 women are diagnosed with cervical cancer each year (CancerCare Manitoba n.d.).

There were two main goals of the costing exercise. The first was to develop a framework of models for the delivery of cervical screening in the province based on a literature review of economic costing models. This exercise generated eight models, which were subsequently costed out. The second task was to find the least costly of the eight models, using a practical cost-minimization technique that focused on the public budget aspects of health-care resource use. The cost analysis was built on a baseline model of cervical screening, the traditional Pap smear test. The direct healthcare costs in the baseline model were compared with the estimates of two newer technology platforms, LBC (a cellular test) and HPV testing (a viral test), in eight models.

A substantive literature review identified key variables that would have an impact on the marginal costs of cervical screening platforms compared with the conventional Pap test (Canfell et al. 2008; Insinga et al. 2004; Moss et al. 2003; Raab et al. 1998). In gathering data for the cost calculations, the eight models were estimated with a focus on these key cost drivers:

• Lengthofroutinescreeningintervals• Thelabourmix,includingchangesinworkloadandproduc-

tivity of labour• Capitalexpendituresandmarginalcostsofconsumables• Impactonrepeatcytologyfrommarginalchangesinsensitivity

and specificity• Impactontherateofcolposcopyreferrals frommarginal

changes in sensitivity and specificity (Colposcopy is a more detailed examination of the cervix using an operative micro-scope and some simple stains.)

• Therateofspecimensthataredeemedunsatisfactoryforevaluation

• Impactofmodelchangesontheincidenceofcervicalcancerrequiring hospital treatment

The importance of this study is its contribution to an empirical literature, which suggests that recent advancements in cervical cancer screening technologies present opportunities for the integration of HPV testing as a prevention strategy for the reduc-tion of cervical cancer incidence, as well as enhancing women’s health outcomes. In a fiscal climate of doing more with less, the analysis has better informed public policy decision-makers of the direct healthcare costs associated with cervical disease detection.

Methods and Eight Comparative Models of Service Delivery Eight proposed models for the delivery of cervical cancer screening were estimated in terms of assessing the least-cost model. Table 1 lists the main variables that frame the methodological assump-tions. The study specifically focused on the marginal costs of newer technology platforms compared with the baseline model. The methodological implication of exclusively focusing on marginal cost changes of direct government expenditures was the omission of a societal perspective for the analysis, potentially resulting in an understatement of the cost savings of the newer technologies. Moreover, the inclusion of additional upstream (e.g., prevention/education costs) and downstream costs (e.g., patient impact/treatment) was beyond the scope of this analysis. The goal of the study was a narrow one that emphasized a practical and program context–specific, value-for-money technique.

“ The main policy challenge in Manitoba is that the current laboratory system for routine cervical cancer screening is outdated, deteriorating and unsustainable over the longer term.”

The cost categories were estimated in 2009 Canadian dollars over a period of five years. We selected this time period for the analysis due to the incremental nature of the implementation plan for two of the eight models. Annual inflation of 2% was applied to capital costs (Bank of Canada 2010). Salary-related cost-of-living allowance was based on collective agreements of technologist and cytopathologist positions. No inflation factor was applied to fee tariffs or consumables since these costs were expected to remain relatively constant over the period of analysis. Depreciation and salvage value of capital equipment were excluded from the analysis since these estimates were immaterial in value.

Comparative Models of Cervical Cancer Screening in Manitoba Linda DeRiviere et al.

Aggregated data were obtained from the provincial database at the Manitoba Cervical Cancer Screening Program, as well as the trajectories of care following cervical screening results, which are classified into categories of cellular changes using the Bethesda Classification System. The reader should refer to Boronow (1998) for more information on the algorithms of care for abnormal results. We gathered cost data from published physician fee tariffs. Collective agreements were provided by Manitoba Health. Though the current model of cervical screening in the province is

composed of both public and private laboratory services, we deter-mined that any newly proposed model would be estimated based on service delivery in a public laboratory setting. In addition, the methodological decisions included the following:

• IncreasedsensitivityofHPVtesting(97%)comparedwiththe

Pap test (51%) • ReducedfrequencyofscreeningofqualifyingwomenforHPV

testing from every one to two years to once in three years

Linda DeRiviere et al. Comparative Models of Cervical Cancer Screening in Manitoba

Model Test Characteristics

Implementation Schedule

Screening Intervals

Age Range Consumables* Labour Intensity†

Capital Equipment Intensity‡

1. Baseline – CC Traditional Pap test (cellular test)

Baseline model is the current screening strategy

1–2 years on average

All women who present for screening

Low marginal costs of slide preparation

2 6 – microscopes, 10-year replacement interval

2. LBC, using ThinPrep technology

Cellular test as primary screening

Year 1; concurrent testing with CC for a period of 6 months

Same as baseline Same as baseline ThinPrep consumables

3 2 – processors, stainers, automated imaging

3. LBC, using SurePath technology

Same as model 2 Same as model 2 Same as baseline Same as baseline SurePath consumables

4 1 – processors, stainers, automated imaging

4. LBC, primary screening; HPV triage to assess low-grade results

Cellular test for primary screening, triaged with a viral test

Same as model 2 Same as baseline Same as baseline; HPV triage of low-grade results

ThinPrep consumables; Qiagen’s hc2 detection technology

1 3 – processors, stainers, automated imaging

5. HPV and LBC Viral and cellular testing

Year 1, HPV as primary screening for some women

3 years for HPV-tested women

Age 30+ years:HPV testing;<30 years: LBC

hc2 for HPV testing; ThinPrep for LBC testing

7 5 – processors, stainers, automated imaging

6. HPV and LBC Same as model 5 Gradual implementation over a 5-year period

Same as model 5 Same as model 5 Same as model 5 6 4 – processors, stainers, automated imaging

7. HPV and CC Same as model 5 Year 1, HPV as primary screening for some women

Same as model 5 Same as model 5 hc2 test; conversion kit; CC – same as model 1

8 7 – microscopes; 10-year replacement interval

8. HPV and CC Same as model 5 Gradual implementation over a 5-year period

Same as model 5 Same as model 5 Same as model 7 5 8 – microscopes; 10-year replacement interval

TABLE 1. Methodological assumptions for models 1–8

CC = conventional cytology; hc2 = Hybrid Capture 2; HPV = human papillomavirus; LBC = liquid-based cytology; Pap = Papanicolaou.

*Consumables include slides, stains and other sample collection devices. We assumed minimal transportation costs of slides in all eight models. All models assume delivery in a public laboratory system.†1 = highest use; 8 = lowest use.‡1 = highest; 8 = lowest.