**5. Conclusions**

"large" is therefore deemed to be efficient. Region "small" is in the same situation. Howev‐ er, consider Region "medium". If we take half of Region "large" and combine it with half of Region "small", then we create a Region that processes different outputs (600 number of re‐ cruited patients, 85 number of found cancers) with just input (100 COL). This dominates "medium" (we would much rather have the virtual Region we created than Region "medi‐ um"). Region "medium" is therefore inefficient. Another way to see this is that we can scale down the inputs to "medium" (number of COL) and still have at least as much output. If we assume (and we do), that inputs are linearly scalable, then we estimate that we can get by with 63 COL. We do that by taking 0.34 times Region "small" plus 0.29 times Region "medi‐ um". The result uses 63 COL and produces at least as much as Region "medium" does. We say that Region "medium"'s efficiency rating is 0.63. Regions "small" and "large" have an

> **Region Large Middle Small**

efficiency rating of 1.

Population size Average Range Input Equivalent number of hours of physicians of general medicine Equivalent number of hours of endoscopists Equivalent number of hours of anaesthetists Equivalent number of hours of nurses Equivalent number of hours of executives Equivalent number of hours of lab physician Number of evaluations Number of endoscopies Number of histological exams Equivalent number of hours of pathologists Equivalent number of hours of technicians of pathologic anatomy Number of histological analyses Output Number of recruited patients Number of patients subject to screening Number of found cancers

86 Colonoscopy and Colorectal Cancer Screening - Future Directions

**Table 4.** Example of sustainable screening campaign.

Nowadays the Italian National Health Service is distributed on extremely diversified region‐ al realities. Needs and inefficiencies of production are inseparably correlated in the health expenditure of the Regions. In the future the issues that are now more critical will have to be adjusted: to implement screening plans, supply the Regions with the objectives related to common LEAs in view of the regional differences. According to the "National Centre for the Prevention and Control of the Diseases" (institution of coordination between Ministry of Health and Regions for the activities of surveillance, prevention and prompt response to the emergencies), it is necessary to "design the interventions of secondary prevention not as performances but rather as "paths" (profiles of care) offered to the citizen within various or‐ ganizing activities on the territory aiming at the efficiency in the practice". Only in this way the efficiencies can be optimized and the necessary budget minimized for each Region for the screening campaigns. In order to avoid the funding of squandering, a formula of analyti‐ cal calculation of the needs will be necessary [58]. A further problem in the future will be to make homogeneous the different kinds of screening currently in use on the territory to as‐ sure a higher allocative efficiency and COL will clearly has a future, which will expand even if the technology stands still. For a screening programme to be successful, multiple events have to occur, beginning with awareness and recommendation from the primary-care physi‐ cian, patient acceptance, financial coverage, risk stratification, screening test, timely diagno‐ sis, timely treatment, and appropriate follow-up. If any one of these steps is faulty or is not of high quality, the screening will fail. In this scenario we had to consider the COL as a means than an aim. In this regard DEA, which is an innovative methodology easy to be ap‐ plied especially in the health care with diversified systems as ours, can be a useful tool to calculate the regional needs in order to carry out screening campaigns.

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