**2. Materials and methods**

tions: its aim is to build an Italian prevention network. The goal of Ccm is to optimise the national prevention Plan checking surveillance plans and active prevention with the Re‐

**Figure 2.** Regional colorectal cancer screening: red actived, white not yet actived, red and white partial actived.

The cooperation with these two authorities introduced design standards and evaluation cri‐ teria, as part of an active collaboration relationship between AIRTUM, CCM and the part‐ ners with which it has agreements, both in the design and monitoring phase of programmes

At the present days, no studies are ongoing to define the cause-effect relationship between

In this paper we show how both the choice of specific constraints on output weights (CCS programme) can affect the measurement of COL efficiency using the "Data Envelopment

In their originating study, Charnes, Cooper, and Rhodes on 1978, described DEA as a "mathematical programming model applied to observational data [that] provides a new way of obtaining empirical estimates of relations - such as the production functions and/or efficient production possibility surfaces – that are cornerstones of modern economics" [27].

DEA is a relatively new "data oriented" approach for evaluating the performance of a set of peer entities called Decision Making Units (DMUs) which convert multiple inputs into mul‐

gions.(Figure 2).

74 Colonoscopy and Colorectal Cancer Screening - Future Directions

and projects of CCS.

Analysis" (DEA).

tiple outputs.

costs, CCS programme, and COL.

The absence in the literature of previous experience or analogous models can makes difficult to create a logistic model. At the present days, there are many studies to define the causeeffect relationship between costs, and CCS programme, or between costs and COL. The ob‐ jective of this study is to propose one model of study of the costs in the strategy of CCS supporting the benefits of COL using DEA model. Since the incidence of colorectal cancer shows a geographical variability, we considered the epidemiological data in the light of the different Italian cancer records, which are often referred to provincial or regional results and we compared them with the screening tests available in each Region.

In the first part of the paper, we calculated the global population in Italy and the number of current colorectal cancer cases using the historical archive of ISTAT (Italian National Insti‐ tute of Statistics). The ISTAT produces and distributes information that describes the social, economic and environmental conditions of the Country, and the changes taking place with‐ in it, in strict compliance with legal provisions on confidentiality. As the main producer of national statistics, it provides data and releases information to European statistical authori‐ ties and international organizations. We then evaluated the economical impact considering every single available regional result obtained from the archives of Age.Na.S. (Italian Agen‐ cies for Regional Health Care Services), AIRTUM, and CCM, and comparing them with the available Italian data obtained from the Italian Ministry of Health and the statistical registers of INAIL (Italian institute for insurance against industrial accident) and INPS (Italian Insti‐ tute of social insurance). The Age.Na.S. is a public agency founded in 1993. In the Italian healthcare service the Agency plays as a technical body supporting the Ministry of Labour, Health and Social Services and Regions. The Agency also coordinates health research pro‐ grams financed by the Ministry of Labour, Health and Social Services or by the Regions. The National Fund against Accidents created on 1883, took the name of INAIL on 1933. INAIL took up the management of compulsory insurance against occupational diseases in the in‐ dustrial and agricultural sector, diseases caused by X-rays and radioactive substances; com‐ pulsory insurance has also been extended to "housewives". It produces and distributes information on occupational diseases. The INPS, established in 1933, is the large Italian pub‐ lic body that pays out old-age pensions to workers, after receiving contributions from them throughout their working lives, and manages the types of assistance provided for by the "social state", sickness, maternity and unemployment benefits, invalidity payments and so‐ cial payments for citizens who are in need. INPS is one of the biggest public body in Europe, produces and distributes information that describes National Health Service.

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‐ pania, Puglia, Basilicata, Calabria and Sicily.

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

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

**GDP/ capita index** **Incidence colorectal cancer**

64,11

82,86

82,5

95,52

83,94

76,14

74,5

60,04

69,64

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‐

**Screening plans Migration**

4 plans sigmoidoscopy

11 plans (100% territory)

Global regional plan TRENTO

> 15 plans (100% territory)

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

**Index**

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

1 plan 11,19 1

17 plans 5,31 1,17

Global regional plan 6,4 1,22

Global regional plan 22,17 1

8,43 1,01

6,31 1,06

10,56 1

3,9 0,81


**DRG Index** 77

each Region (see Tables 1-3).

Friuli-Venetia Giulia

Trenton Alto-Adige

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

**Population (pop)**

**Mean age**

Piedmont 4.432.571 44,9 22,6 1,09 90,79

Emilia Romagna 4.337.979 45,0 22,8 1,21 139,58

Liguria 1.615.064 47,3 26,7 1,03 104,16

Veneto 4.885.548 42,9 19,3 1,15 124,02

Lombardy 9.742.676 43,0 19,6 1,30 107,93

Valle d'Aosta 127.065 43,6 20,3 1,32 82,83

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

**% pop ≥ 65 years**

1.230.936 45,4 22,7 1,11 140,17

1.018.657 41,3 17,8 1,25 113,60

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

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‐ scribed and examples of inputs and outputs are provided.

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 positive FOBT: COL.

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 mass CCS programme.

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‐ formance indicators.
