**3. Results**

Out of a population of 60.387.000 inhabitants (data updated at 2010), the incidence of color‐ ectal cancers was almost of 49.000 cases, with a prevalence of over 310.000 cases and mortali‐ ty higher than 18.000 cases (data updated at 2006). The analysis of the abovementioned three macro-areas is characterized by strong differences both in general and in particular terms.

There are considerable imbalances between the Northern, Central and Southern areas con‐ sidering their input, output and outcome.

Data in terms of distribution of population, mean age and population older than 65 years are distributed in the different macro-areas according to the distribution recorded by the Italian Institute of Statistics which depicts particular realities partially due to the industrial development and the local health level. We can differentiate in detail the following data for each Region (see Tables 1-3).


**Table 1.** Macro-area: Northern Italy

In view of the geography of the Italian territory and the distribution of the population we analyzed the data considering three macro-areas which include different regions, i.e. the re‐ gions of Northern Italy: Piedmont, Emilia Romagna, Liguria, Friuli Venetia Giulia, Veneto, Trenton Alto-Adige, Lombardy and Valle d'Aosta; the regions of Central Italy: Tuscany, Umbria, Latium, Marche, Abruzzi, Molise and Sardinia; the regions of Southern Italy: Cam‐

For each Region we considered the following indicators in order to assess a possible plan of screening campaign of colorectal cancers: global population, mean age and population older than 65 years; relationship between Gross Domestic Product (GDP) and per capita income; incidence of colorectal cancer and possible screening campaign on the territory; index of pa‐ tients' emigration and reimbursement through Diagnostic Related Group (DRG) of the path‐

The second part of the paper is the object of the article: the implement of particular method‐ ologies in order to determine which COL is cost-effective in the mass CCS programme. In this chapter a method for efficiency measurement in CCS programme has been described.

First an overview of efficiency measurements applicable is given. Calculation methods is de‐

A method to measure efficiency is proposed. This method proves to be particularly suc‐ cessful in cost-efficiency analysis, when the performance indicators are numerous and hard to aggregate. The results show that there are two cost-effective strategies after a

We performed an explorative study to efficiency measurement in CCS. To construct an effi‐ ciency measure or measures for the CCS programme, literature has been searched for differ‐ ent types of efficiency measures used in healthcare. Hence a selection of criteria and methods is made which tend to be suitable to evaluate which COL is cost-effective in the

Besides Italian CCS programme were carried out to gain understanding of the care process for CRC patients. The proper knowledge of the process it is useful to choose suitable per‐

Out of a population of 60.387.000 inhabitants (data updated at 2010), the incidence of color‐ ectal cancers was almost of 49.000 cases, with a prevalence of over 310.000 cases and mortali‐ ty higher than 18.000 cases (data updated at 2006). The analysis of the abovementioned three macro-areas is characterized by strong differences both in general and in particular terms.

There are considerable imbalances between the Northern, Central and Southern areas con‐

ology as a ratio versus the unit value represented by Italy as a system.

scribed and examples of inputs and outputs are provided.

positive FOBT: COL.

mass CCS programme.

formance indicators.

sidering their input, output and outcome.

**3. Results**

pania, Puglia, Basilicata, Calabria and Sicily.

76 Colonoscopy and Colorectal Cancer Screening - Future Directions

Piedmont is a Region with a large-size population with mean age and rate of elderly popula‐ tion higher than the Italian average. It has at its disposal a bit more resources than the Italian average and its screening campaign covers only some provinces; the incidence of the disease is lower than the Italian average; the emigration index is low and the refund of the health expenditure is a little bit higher than the national average. Emilia Romagna is a large-size population with mean age and rate of elderly persons higher than the Italian average. It has at its disposal more resources than the national average and its screening campaign covers all the provinces, the incidence of the disease is higher than the Italian average; the emigra‐ tion index is low and the refund of the health expenditure is a little bit higher than the na‐ tional average. Liguria has a middle-size population with mean age and rate of elderly definitely higher than the Italian average. It has at its disposal a little bit more resources than the Italian average and its screening campaign covers only one province; the incidence of the disease is lower than the National average; its emigration index is high and the refund of the health expenditure is on the average. Friuli Venetia Giulia Region has a middle-size pop‐ ulation with mean age and rate of elderly persons higher than the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers all the provinces with a regional plan; the incidence of the disease is higher than the national average; its emigration index is low and the refund of the health expenditure is higher than the national average.

the national average; its emigration index is intermediate and the refund of health expendi‐

**GDP/ capita index**

**Incidence colorectal cancer**

The Future of Colonoscopy: The Use of Data Envelopment Analysis (DEA) for Colorectal Cancer Screening...

61,01

78,80

52,57

67,70

42,75

43,16

54,12

69,64

Marche Region has a middle-size population with mean age and rate of elderly persons higher than the Italian average. It has at its disposal resources in line with the national aver‐ age and implements no screening campaign; the incidence of the disease is higher than the national average; its emigration index is high and the refund of health expenditure is in line

Abruzzi has a middle-size population with mean age and rate of elderly persons higher than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers only some provinces; the incidence of the disease is higher than the national average; its emigration index is high and the refund of health expenditure is in

Molise Region has a small-size population with mean age and rate of elderly higher than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers the whole Region; its emigration index is high and the refund of

**Screening plans Migration**

12 plans (100% territory)

4 plans (100% territory)

L.D. 138 2004 art. 2 bis Sof > 50 years

**Index**

http://dx.doi.org/10.5772/52310

4 plans 6,64 0,89

2007 pilot project 10,75 1

Global Regional plan 20,62 1

6 plans 10,2 1

1 plan 4,24 1

5,92 0,79

11,28 1,72


**DRG Index** 79

ture is lower than the national average.

**Population (pop)**

**Mean age**

Tuscany 3.707.818 4,3 23,3 1,09 106,5

Umbria 894.222 44,9 23,3 0,95 123,73

Lazio 5.626.710 42,6 19,2 1,22 89,06

Marche 1.569.578 44,3 22,6 1,00 109,89

Abruzzi 1.334.675 43,4 21,3 0,81 113,25

Molise 320.795 43,6 22,0 0,72 113,29

Sardinia 1.671.001 42,2 17,8 0,80 101,42

ITALY 60.387.000 42,8 19,9 1 107,8

health expenditure is in line with the national average.

**Table 2.** Macro-area: Central Italy

with the national average.

line with the national average.

**% pop ≥ 65 years**

Veneto Region has a large-size population with mean age and rate of elderly in line with the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers all the provinces; the incidence of the disease is higher than the national average, its emigration index is low and the refund of the health expendi‐ ture is higher than the national average. Trenton Alto Adige Region has a middle-size population with mean age and rate of elderly persons lower than the Italian average. It has at its disposal more resources than the national average and its screening campaign covers the whole region, the incidence of the disease is higher than the Italian average; its emigration index is high and the refund of the health expenditure is in line with the national average. Lombardy has a large-size population with mean age higher than the average and a rate of elderly slightly lower than the Italian average. It has at its disposal more resources than the national average and its screening campaign covers all its prov‐ inces, the incidence of the disease is slightly higher than the Italian average, it has a low emigration index and the refund of health expenditure is lower than the national aver‐ age. Valle d'Aosta Region has a small-size population with mean age and rate of elderly persons higher than the national average. It has at its disposal more resources than the national average, its screening campaign covers the whole Region, the incidence of the disease is lower than the national average; it has a high emigration index and the refund of health expenditure is in line with the national average.

Tuscany Region has a large-size population with mean age and rate of elderly persons high‐ er than the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers the whole territory; the incidence of the disease is lower than the national average; its emigration index is mean and the refund of health expenditure is lower than the national average. Umbria Region has a small-size population with mean age and a rate of elderly persons higher than the Italian average. It has at its disposal fewer re‐ sources than the Italian average and its screening campaign covers the whole Region; the in‐ cidence of the disease is higher than the national average; the emigration index is high and the refund of health expenditure is higher than the national average.

Lazio Region has a large-size population with mean age and a rate of elderly persons lower than the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers only some provinces; the incidence of the disease is lower than


the national average; its emigration index is intermediate and the refund of health expendi‐ ture is lower than the national average.

**Table 2.** Macro-area: Central Italy

tional average. Liguria has a middle-size population with mean age and rate of elderly definitely higher than the Italian average. It has at its disposal a little bit more resources than the Italian average and its screening campaign covers only one province; the incidence of the disease is lower than the National average; its emigration index is high and the refund of the health expenditure is on the average. Friuli Venetia Giulia Region has a middle-size pop‐ ulation with mean age and rate of elderly persons higher than the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers all the provinces with a regional plan; the incidence of the disease is higher than the national average; its emigration index is low and the refund of the health expenditure is higher than

Veneto Region has a large-size population with mean age and rate of elderly in line with the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers all the provinces; the incidence of the disease is higher than the national average, its emigration index is low and the refund of the health expendi‐ ture is higher than the national average. Trenton Alto Adige Region has a middle-size population with mean age and rate of elderly persons lower than the Italian average. It has at its disposal more resources than the national average and its screening campaign covers the whole region, the incidence of the disease is higher than the Italian average; its emigration index is high and the refund of the health expenditure is in line with the national average. Lombardy has a large-size population with mean age higher than the average and a rate of elderly slightly lower than the Italian average. It has at its disposal more resources than the national average and its screening campaign covers all its prov‐ inces, the incidence of the disease is slightly higher than the Italian average, it has a low emigration index and the refund of health expenditure is lower than the national aver‐ age. Valle d'Aosta Region has a small-size population with mean age and rate of elderly persons higher than the national average. It has at its disposal more resources than the national average, its screening campaign covers the whole Region, the incidence of the disease is lower than the national average; it has a high emigration index and the refund

Tuscany Region has a large-size population with mean age and rate of elderly persons high‐ er than the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers the whole territory; the incidence of the disease is lower than the national average; its emigration index is mean and the refund of health expenditure is lower than the national average. Umbria Region has a small-size population with mean age and a rate of elderly persons higher than the Italian average. It has at its disposal fewer re‐ sources than the Italian average and its screening campaign covers the whole Region; the in‐ cidence of the disease is higher than the national average; the emigration index is high and

Lazio Region has a large-size population with mean age and a rate of elderly persons lower than the Italian average. It has at its disposal more resources than the Italian average and its screening campaign covers only some provinces; the incidence of the disease is lower than

of health expenditure is in line with the national average.

the refund of health expenditure is higher than the national average.

the national average.

78 Colonoscopy and Colorectal Cancer Screening - Future Directions

Marche Region has a middle-size population with mean age and rate of elderly persons higher than the Italian average. It has at its disposal resources in line with the national aver‐ age and implements no screening campaign; the incidence of the disease is higher than the national average; its emigration index is high and the refund of health expenditure is in line with the national average.

Abruzzi has a middle-size population with mean age and rate of elderly persons higher than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers only some provinces; the incidence of the disease is higher than the national average; its emigration index is high and the refund of health expenditure is in line with the national average.

Molise Region has a small-size population with mean age and rate of elderly higher than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers the whole Region; its emigration index is high and the refund of health expenditure is in line with the national average.

Sardinia Region has a middle-size population with mean age and rate of elderly lower than the Italian average. It has at its disposal resources in line with the national average and its screening campaign covers only one province; the incidence of the disease is lower than the national average, its emigration index is low and the refund of health expenditure is in line with the national average.

Calabria has a middle-sized population with mean age and rate of elderly lower than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers only some provinces; the incidence of the disease in lower than the national average; its emigration index is high and the refund of health expenditure is in

The Future of Colonoscopy: The Use of Data Envelopment Analysis (DEA) for Colorectal Cancer Screening...

http://dx.doi.org/10.5772/52310

81

Sicily has a large population with mean age and rate of elderly lower than the Italian aver‐ age. It has at its disposal fewer resources than the national average and has no screening campaign; the incidence of the disease is lower than the national average, its emigration in‐ dex is intermediate and the refund of health expenditure is in line with the national average.

The average cost of colo-rectal cancer treatments in Italy has been estimated to be approxi‐ mately € 9.149,00 per patient per year including chemotherapy [27]. Some authors estimate that for the city of Ferrara the overall cost related to the introduction of a CCS programme was approximately € 1.400.000,00 (from October 2005 until March 2007 with more than 99.000 individuals invited) with a large proportion of these costs related to the implementa‐ tion and management of the programme [28]. FOBT plus COL, increase cost relative to cheapest strategy. As a consequence of screening, some individuals with low risk receive a recommendation for a follow-up COL. However follow-up colonoscopies will increase the cost consequences of introducing screening, but not the expected colorectal cancer treatment costs. The Italian Observatory on screening Practices has been collecting data on CCS since 2004 [29]. In 2007 there were 71 CRC screening programmes in Italy, covering 46,6% of the total eligible population, with a higher coverage in the North (71,6%), and in the Centre (52,1%) than in the South (7%). The majority of programmes (65) used the guaiac FOBT (gFOBT) as first-line test. Only seven programmes used the flexible sigmoidoscopy (FS), of which three used a combination of FS and gFOBT. The quality and efficacy of the screening programmes are evaluated using ad hoc indicators developed by the Italian Group for Col‐ orectal Screening (GISCoR) [28]. In 2007, on average 79,1% of the eligible population was in‐ vited for FOBT screening, with only Lombardy, Umbria, and most of the programmes in Emilia Romagna reaching the 90% target. Among the invited individuals, 46,3% underwent FOBT with significant variations across (from 26,5% in Lazio to 65% in Veneto) and within regions (from 11 to 80%). Among the people invited for the first time, the average percent‐ age of individuals with a positive test was 5,6%, while among people who were recalled it was 4%. The probability of having a positive result was higher for men than for women and increased with age. Among people with a positive test, only 78,7% underwent a COL [2]. The South and Centre had a lower rate of COL attendance than the North. Men were slight‐ ly more likely to undertake a COL after a positive FOBT than women, mainly because of the uncomfortable feeling and concern of women having a male physician performing the tests. The risk of bowel perforation and bleeding during COL was negligible. For FS, on average 66,5% of the eligible population was invited with large variations across programmes. Only 27,7% of those invited underwent FS with a slightly higher proportion among men than

line with the national average.

**4. Discussion**


**Table 3.** Macro-area: Southern Italy

Campania Region has a large-size population with mean age and rate of elderly lower than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers only some provinces; the incidence of the disease is lower than the national average; its emigration index is intermediate and the refund of health expendi‐ ture is slightly lower than the national average.

Puglia Region has a large population with mean age and rate of elderly lower than the Ital‐ ian average. It has at is disposal fewer resources than the national average and it has no screening campaign; the incidence of the disease is lower than the national average and its emigration index is intermediate. The refund of health expenditure is in line with the nation‐ al average.

Basilicata has a small-sized population with mean age and rate of elderly higher than the Italian average. It has at its disposal fewer resources than the national average and the screening campaign was discontinued in 2007, the incidence of the disease is lower than the national average, its emigration index is high and the refund of health expenditure is in line with the national average.

Calabria has a middle-sized population with mean age and rate of elderly lower than the Italian average. It has at its disposal fewer resources than the national average and its screening campaign covers only some provinces; the incidence of the disease in lower than the national average; its emigration index is high and the refund of health expenditure is in line with the national average.

Sicily has a large population with mean age and rate of elderly lower than the Italian aver‐ age. It has at its disposal fewer resources than the national average and has no screening campaign; the incidence of the disease is lower than the national average, its emigration in‐ dex is intermediate and the refund of health expenditure is in line with the national average.
