Plans are to centralize all cervical cancer screening in just two Alberta medical laboratories
Ongoing efforts to further consolidate clinical laboratory testing in the Canadian Province of Alberta caused local pathologists earlier this year to go on record to specifically oppose a proposed consolidation of Pap Smear testing. Over the past 15 years, the Alberta government has never been timid in its efforts to use consolidation of clinical pathology laboratory testing as a way to achieve cost savings.
During the past winter, more than 30 pathologists in Alberta signed letters to Health Minister Gene Zwozdesky to protest the consolidation of all the province’s Pap Smear testing into just two clinical laboratories—one in Edmonton and one in Calgary. As a result of the government’s decision to consolidate this medical laboratory testing service, cytology laboratories in Lethbridge, Medicine Hat, Red Deer, and the University of Alberta Hospital would no longer perform Pap smear testing.
For pathologists and clinical laboratory executives familiar with the centralization of Pap testing in Ireland over the past three years, certain aspects of the Alberta Pap testing consolidation proposal will be similar in important ways. Even if motivations of the health bureaucrats in both nations are different, the end result is that fewer local laboratories will be allowed to perform Pap tests on behalf of patients living in their communities.
In Alberta, pathologists protesting this action by the provincial health system argued that the move would delay diagnostic tests results and make clinical decisions more difficult. It would also put patients at risk and would cost the system more.
In defense of the lab test consolidation project, Tammy Hofer, Acting Vice President of Pathology Services for Alberta Health Services, the agency responsible for this reorganization, said consolidation of Pap testing offers the most affordable way to give all women in Alberta access to a more accurate test for cervical cancer.
The original decision to consolidate Pap Smear testing was made in 2009 by former health minister Ron Liepert. Infrastructure issues have delayed implementation.
According to Hofer, the Pap Smear dispute stems from the decentralized decision-making that existed prior to 2008. Two years ago, Alberta combined its nine regional health authorities into the province-wide Alberta Health Services. Before that consolidation, some of the regions invested in the newer liquid-based cytology (LBC) method for preserving and analyzing cervical cells. Others stuck with the conventional and less expensive Pap smear.
“Now that we are one health service, we want to standardize quality and access to care across the province,” Hofer explained. With Alberta Health Services facing a C$1.3 billion deficit, its Health Superboard must find the least expensive way to do that, she said.
Since liquid-based cytology is more expensive than conventional Pap smear testing, the most budget-effective way to offer the technology was to consolidate all testing at the two labs. “My own hospital (University of Alberta Hospital) will lose 30,000 Pap smears a year,” Hofer explained. Those tests are currently mailed into the lab from surrounding cities. In the future, they will go to one of the two laboratories that offer liquid-based cytology testing.
“The [consolidated] lab where they will be going does 250,000 tests each year and can absorb the additional volume at very little increased cost,” stated Hofer. “It’s a test that lends itself to consolidation. It doesn’t need to be done locally.”
Pathologists, however, are concerned that loss of the test will mean loss of cytotechnologists and the expertise they offer to community hospitals. That loss would very likely affect other health services. Hofer acknowledges that some medical laboratory technologist positions will likely be eliminated due to consolidation of cervical cancer screening tests.
“When more than 80% of clinical decision-making is based on laboratory testing, it is incomprehensible that such testing will not be available on site at a hospital of this size (at the University of Alberta Hospital) and with this level of acuity,” reads a letter signed by a group of pathologists and sent to Health Minister Zwozdesky.
The letter went on to say, “One particular issue of concern is that results of the Pap test and results of the subsequent colposcopic biopsies will end up in two different laboratories whose information systems are incompatible. It will be difficult, if not impossible, for pathologists to correlate the results of the Pap tests with the biopsies. This will compromise patient care, and may result in additional unnecessary testing and or procedures.”
The position of these pathologists is supported by Alberta New Democratic Party (NDP) leader Brian Mason, who said the health minister should listen to the pathologists’ concerns and scrap plans to centralize laboratory services.
“You don’t experiment with people’s lives,” declared Mason. “You have to trust the experts who have studied and worked in this field for many years, and when they say it’s more expensive, there are more risks to the patient, and they can’t get timely results, then I think we have to accept that this [laboratory consolidation] is a very serious concern.”
Zwozdesky said he planned to meet with pathologists and staff to deal with the issue.
Hofer said that the move to provide equal access likely would bring new clinical laboratory tests to the community hospitals, even as it removes existing Pap smear work. One such test is the Beta Natriuretic Peptide (BNP) cardiac marker test currently available only in about half of Alberta. It is not a test that can be consolidated at central labs, and Alberta Health Services has plans to begin offering that test province-wide, as soon as funds are available. With the deficit of C$1.3 billion deficit that is expected this year, Hofer does not know when plans to introduce BNP and similar tests into local hospital laboratories will become a reality.
Consolidation of pathology and clinical laboratory testing is widely recognized as one approach to achieve economies of scale, and thus deliver a lower average cost per test. That is the goal in Alberta’s efforts to consolidate the province’s cervical cancer testing into just two clinical laboratories. However, consolidation and centralization of laboratory testing can also compromise patient care if turnaround times lengthen or because local physicians lose immediate access to knowledgeable pathologists and laboratory scientists in their community.
Alberta provides a useful case study in the consolidation of clinical laboratory testing. In the mid-1990s, its government health system aggressively consolidated pathology testing throughout the province, in a manner that proved disruptive to clinical care. Over the past 15 years, there have been additional rounds of laboratory restructuring. So the latest move to centralize and consolidate cervical cancer screening is consistent with government health service policies for quite some time.