**4. Discussion**

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

> **GDP/ capita index**

**Incidence colorectal cancer**

41,07

35,98

35,98

35,93

45,33

69,64

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‐

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‐

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

**Screening plans Migration**

Global regional plan STOP 2007

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

**Index**

4 plans 7,55 0,89


4 plans 14,82 1


24,01 1


**DRG Index**

with the national average.

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

al average.

with the national average.

**Population (pop)**

80 Colonoscopy and Colorectal Cancer Screening - Future Directions

**Mean age**

Campania 5.812.962 39,0 15,4 0,64 60,09

Puglia 4.079.702 40,7 17,4 0,66 68,89

Basilicata 590.601 42,1 20,0 0,70 104,31

Calabria 2.008.709 41,1 18,4 0,65 83,08

Sicily 5.037,799 40,7 18,0 0,66 71,15

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

ture is slightly lower than the national average.

**% pop ≥ 65 years**

> 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

women. The response rate was higher whenever FS was combined with FOBT [30]. The per‐ centage of FS successfully completed was 88%, with again a higher level among men than women; 14,3% of men and 7,6% of women were sent for a COL for further analysis and 90% of these attended the test. In 2007 overall FOBT and FS detected 20.796 adenoma of which, 2.449 were carcinomas. An additional 295 carcinomas were diagnosed in individuals who underwent further follow-up tests. Most of the adenomas identified were in Stage I, (54.5%), followed by increased widely Stages III and IV (24,9%), and then in Stage II (20,7%). The crit‐ ical points are: complications of COL (40 programs) with average perforation rate of 0,08% (2,5% operative COL) and average bleeding rate of 0,55%; low coverage and delay in South‐ ern Italy; low compliance; overload on endoscopy facilities.

staff, confirmation procedure (selection of population at risk to reduce costs); second assess‐ ment of efficacy: sensitivity, specificity, productive value; third non-invasive method: it is addressed to probably healthy subjects; latter possibility of intervention: the disease or con‐

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

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83

In the first years 2000 the Italian Government, in view of the severe unbalanced offer of screening plans, established to allocate further financial resources (52 million euro between 2004 and 2006) for interventions promoting the re-balancing of the offer and the quality of the screening plan of cervix and breast cancers and the diffusion of the screening of colorec‐ tal cancer [33]. Even though in year 2008 in oncology the plans of screening of colorectal can‐ cers had a significant increase exceeding the threshold of 50%, unfortunately they are not always able to achieve acceptable levels of efficacy. According to "The screening plans in Italy 2009", the screening campaigns for colorectal cancers carried out in the last years, showed some critical aspects: we observed a progressive increase in the compliance of the first years versus a progressive stabilization or decrease in the compliance afterwards [20]. There are extremely strong differences between Northern, Central and Southern Italy. How‐ ever, the rate of detection of cancers by using faecal occult blood and endoscopy has always

In fact, many differences are reported in relation with the ratio between regional and per capita income resulting into a three-speed Italy. This is mirrored also by the incidence of col‐ orectal cancer, which exhibits a different distribution where the highest rate is in the North‐ ern Italy and the minimum rate in the Southern Italy. According to the data of the National Screening Observatory, they are spread not uniformly throughout the territory. According to "The screening plans in Italy 2009", the real extension of colorectal screening plans (faecal occult blood plus endoscopy) for the macro-areas evidenced some critical aspects [20]. We passed from 5% in 2004 to 12% in 2005, then to 30% in 2006, which stabilized at 37% in 2007/2008 as global Italian data. Even though there were significant differences with a posi‐ tive presence in the Northern Italy versus a delay in the Central Italy and an insufficient presence in the Southern Italy, these data showed a similar annual tendency for each macroarea. However, the rate of identification of cancers by using faecal occult blood and endos‐ copy has always been lower than the acceptable minimum. After an initial enthusiasm, we observed a progressive decrease in the percentage of compliance with the plan in both mac‐ ro-areas. Regarding the emigration index, there are notable differences within the three mac‐ ro-areas, which influence the general index. The value shows that the regions of Northern Italy have more attraction power versus the regions of Southern Italy, whereas the regions

This latter parameter: the DRG index shows clear imbalances within all regions and there‐

The lack of homogeneity on the territory, moreover, is still marked with evident consequen‐ ces on mortality and morbidity [38]. The implementation of federalism poses a question: if these large differences already exist, will the situation be improved or will the disparity be‐ come even stronger? On April 29, 2010, the agreement between Government, Regions and Autonomous Provinces of Trento and Bolzano was undersigned. According to this agree‐

dition to be diagnosed should be susceptible of therapy.

been lower than the acceptable minimum.

of Central Italy have not particularly high emigration indices.

fore it is not a useful element to discriminate the different macro-areas.

The role of screening is an extremely topical question even though in the past it was already subject of discussion and until few years ago it was considered to fall within the competence of the central government [31]. Only in the last years we have observed a different interest especially in Italy due to the changed political conditions. Does a convergence really exist between federalism, screening and standard cost? The process which links the federal struc‐ ture of the nation with the screening is a thin red line which began with the promulgation of the Constitution and over the years it has been fully implemented with Act No. 42 of year 2009 with enforcement of Article 119 of the Constitution which guarantees autonomy of rev‐ enues and expenditure of municipalities, provinces, towns and regions and assure princi‐ ples of support and social cohesion [32]. In particular, it assures the funding of the essential levels of health care (which includes the practice of screening) referring to a benchmark of cost and requirements [32]. In year 2001 an agreement was made between Government and Regions for the guidelines about prevention, diagnosis and assistance in oncology, including indications for the screenings, and the promulgation of Decree of the President of the Coun‐ cil of Ministry No. 26 of November 29th 2001, which defines the Essential Levels of Care (LEA) including the plans of screening for the early diagnosis of colorectal, breast, cervix cancers [33]. Within the 2001 financial budget (law N. 388, 2000) it was decided that target population screening was free of charge [34]. In 2004 the Health Minister redistributed over‐ all € 7.000.000, a minimum of € 50.000 per region, for reducing the gaps in cancer screenings and activating the CCS programme (€ 1.750.000 specifically for CCS). This agreement made these plans to be a right for women and men. The debate about the allocation of resources in regimen of federalism is very lively, in particular regarding the costs of Health Care System. We remind that the allocation of the funds to the Health Care System for the prevention of diseases remained constant at 5% for some years [35]. The criterion of the historical expendi‐ ture will be replaced by the standard cost. The standard cost is the tool to assure the LEA funding and consists of the expenditure for the following items: staff, equipment, consuma‐ bles and general costs of the health performances of the production unit [36]. Moreover, a "direct" cost of production is predicted, i.e. a percentage to cover the general functioning costs of the equipment of the production unit [37]. The characteristics of the colorectal can‐ cers show a strong geographical variability: chronic trend, increase in the incidence and a still too high mortality rate. The increase in the prevalence should be allotted partially to the ageing of the population, but mostly to the diffusion and implementation of screening plans. The cost of the screening campaign is defined by the following factors: first costs of tests, staff, confirmation procedure (selection of population at risk to reduce costs); second assess‐ ment of efficacy: sensitivity, specificity, productive value; third non-invasive method: it is addressed to probably healthy subjects; latter possibility of intervention: the disease or con‐ dition to be diagnosed should be susceptible of therapy.

women. The response rate was higher whenever FS was combined with FOBT [30]. The per‐ centage of FS successfully completed was 88%, with again a higher level among men than women; 14,3% of men and 7,6% of women were sent for a COL for further analysis and 90% of these attended the test. In 2007 overall FOBT and FS detected 20.796 adenoma of which, 2.449 were carcinomas. An additional 295 carcinomas were diagnosed in individuals who underwent further follow-up tests. Most of the adenomas identified were in Stage I, (54.5%), followed by increased widely Stages III and IV (24,9%), and then in Stage II (20,7%). The crit‐ ical points are: complications of COL (40 programs) with average perforation rate of 0,08% (2,5% operative COL) and average bleeding rate of 0,55%; low coverage and delay in South‐

The role of screening is an extremely topical question even though in the past it was already subject of discussion and until few years ago it was considered to fall within the competence of the central government [31]. Only in the last years we have observed a different interest especially in Italy due to the changed political conditions. Does a convergence really exist between federalism, screening and standard cost? The process which links the federal struc‐ ture of the nation with the screening is a thin red line which began with the promulgation of the Constitution and over the years it has been fully implemented with Act No. 42 of year 2009 with enforcement of Article 119 of the Constitution which guarantees autonomy of rev‐ enues and expenditure of municipalities, provinces, towns and regions and assure princi‐ ples of support and social cohesion [32]. In particular, it assures the funding of the essential levels of health care (which includes the practice of screening) referring to a benchmark of cost and requirements [32]. In year 2001 an agreement was made between Government and Regions for the guidelines about prevention, diagnosis and assistance in oncology, including indications for the screenings, and the promulgation of Decree of the President of the Coun‐ cil of Ministry No. 26 of November 29th 2001, which defines the Essential Levels of Care (LEA) including the plans of screening for the early diagnosis of colorectal, breast, cervix cancers [33]. Within the 2001 financial budget (law N. 388, 2000) it was decided that target population screening was free of charge [34]. In 2004 the Health Minister redistributed over‐ all € 7.000.000, a minimum of € 50.000 per region, for reducing the gaps in cancer screenings and activating the CCS programme (€ 1.750.000 specifically for CCS). This agreement made these plans to be a right for women and men. The debate about the allocation of resources in regimen of federalism is very lively, in particular regarding the costs of Health Care System. We remind that the allocation of the funds to the Health Care System for the prevention of diseases remained constant at 5% for some years [35]. The criterion of the historical expendi‐ ture will be replaced by the standard cost. The standard cost is the tool to assure the LEA funding and consists of the expenditure for the following items: staff, equipment, consuma‐ bles and general costs of the health performances of the production unit [36]. Moreover, a "direct" cost of production is predicted, i.e. a percentage to cover the general functioning costs of the equipment of the production unit [37]. The characteristics of the colorectal can‐ cers show a strong geographical variability: chronic trend, increase in the incidence and a still too high mortality rate. The increase in the prevalence should be allotted partially to the ageing of the population, but mostly to the diffusion and implementation of screening plans. The cost of the screening campaign is defined by the following factors: first costs of tests,

ern Italy; low compliance; overload on endoscopy facilities.

82 Colonoscopy and Colorectal Cancer Screening - Future Directions

In the first years 2000 the Italian Government, in view of the severe unbalanced offer of screening plans, established to allocate further financial resources (52 million euro between 2004 and 2006) for interventions promoting the re-balancing of the offer and the quality of the screening plan of cervix and breast cancers and the diffusion of the screening of colorec‐ tal cancer [33]. Even though in year 2008 in oncology the plans of screening of colorectal can‐ cers had a significant increase exceeding the threshold of 50%, unfortunately they are not always able to achieve acceptable levels of efficacy. According to "The screening plans in Italy 2009", the screening campaigns for colorectal cancers carried out in the last years, showed some critical aspects: we observed a progressive increase in the compliance of the first years versus a progressive stabilization or decrease in the compliance afterwards [20]. There are extremely strong differences between Northern, Central and Southern Italy. How‐ ever, the rate of detection of cancers by using faecal occult blood and endoscopy has always been lower than the acceptable minimum.

In fact, many differences are reported in relation with the ratio between regional and per capita income resulting into a three-speed Italy. This is mirrored also by the incidence of col‐ orectal cancer, which exhibits a different distribution where the highest rate is in the North‐ ern Italy and the minimum rate in the Southern Italy. According to the data of the National Screening Observatory, they are spread not uniformly throughout the territory. According to "The screening plans in Italy 2009", the real extension of colorectal screening plans (faecal occult blood plus endoscopy) for the macro-areas evidenced some critical aspects [20]. We passed from 5% in 2004 to 12% in 2005, then to 30% in 2006, which stabilized at 37% in 2007/2008 as global Italian data. Even though there were significant differences with a posi‐ tive presence in the Northern Italy versus a delay in the Central Italy and an insufficient presence in the Southern Italy, these data showed a similar annual tendency for each macroarea. However, the rate of identification of cancers by using faecal occult blood and endos‐ copy has always been lower than the acceptable minimum. After an initial enthusiasm, we observed a progressive decrease in the percentage of compliance with the plan in both mac‐ ro-areas. Regarding the emigration index, there are notable differences within the three mac‐ ro-areas, which influence the general index. The value shows that the regions of Northern Italy have more attraction power versus the regions of Southern Italy, whereas the regions of Central Italy have not particularly high emigration indices.

This latter parameter: the DRG index shows clear imbalances within all regions and there‐ fore it is not a useful element to discriminate the different macro-areas.

The lack of homogeneity on the territory, moreover, is still marked with evident consequen‐ ces on mortality and morbidity [38]. The implementation of federalism poses a question: if these large differences already exist, will the situation be improved or will the disparity be‐ come even stronger? On April 29, 2010, the agreement between Government, Regions and Autonomous Provinces of Trento and Bolzano was undersigned. According to this agree‐ ment the regions are committed to implement by September 2010, the Regional Plan of Pre‐ vention to carry out the interventions established by the National Plan of Prevention: among the macro-areas of interventions there are oncologic screening programs [39]. The critical points are: complications of COL (40 programmes) with average perforation rate of 0.08% (2,5% operative COL) and average bleeding rate of 0,55%; low coverage and delay in South‐ ern Italy; low compliance; overload on endoscopy facilities.

the prices [53]. In this sense the results of non-parametric methods are objective, because they do not require prior specifications. On the other hand, however, their disadvantage is that they do not admit errors being deterministic methods; the results could be therefore in‐ fluenced. The relative efficiency of the responsibility centres is determined according to the

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

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85

Now the system of weights adopted strongly influences the efficiency, therefore through an algorithm of Charnes, Cooper and Rhodes (CCR), we try to find the optimal system of weights (among the proposed ones) in order to maximize the efficiency of the respon‐ sibility centre and the comparable ideal responsibility centre [54]. This suggests that the standard cost can be calculated in two ways: maximizing the numerator and fixing the denominator (output-oriented method – screening) or, vice versa, keeping the numerator and minimizing the denominator (input-oriented method – prevention budget) [55]. The difference is important since it determines the form of efficiency that we are assessing. Output-effective means there is no other unit that develops a larger screening with the

A productive unit is called input-effective if there is no other unit able to obtain the same

This methodology assesses the efficiency as the ratio between quality of the screening and available budget. Some weights are obviously introduced to include demographic and health characteristics of the Region. Now for each unit we can obtain the optimal budget to be allocated to the Region for the screening campaign. In this way by adding the sum of ev‐ ery single regional budget, the necessary budget of national expenditure can be obtained to

In view of the above mentioned results, we can assume an equivalent model (Table 4).

The following example of three Regions (large, middle, and small) illustrate how DEA

Each Region has exactly 10 COL (the only input), and we are be able to measure a Region CCR programme based on two outputs: number of patients subject to screening, and num‐

Region "large": 100 COL, 1000 number of recruited patients, 20 number of found cancers;

Region "medium": 100 COL, 400 number of recruited patients, 50 number of found cancers;

Now, the key to DEA is to determine whether we can create a virtual Region that is better than one or more of the real Regions. Any such dominated Region will be an inefficient Re‐ gion. Consider trying to create a virtual Region that is better than Region "large". Such a Re‐ gion would use no more inputs than a Region "large", and produce at least as much output. Clearly, no combination of Regions "medium" and "small" can possibly do that. Region

Region "small": 100 COL, 200 number of recruited patients, 150 number of found cancers.

following formula:

(*u*, *v*)=∑ *r*

*ur yr*<sup>0</sup> / <sup>∑</sup> *vixi*<sup>0</sup>

same budget for the prevention [56].

screening using a lower budget (DMUs).

carry out an effective and really sustainable screening campaign.

ber of found cancers. The data for these Regions is as follows:

**max** *u*,*v h* 0

works.

The critical limit to implement the screening campaigns of colorectal cancers is the allocation of own resources to Regions and local bodies and the overcoming of the dichotomy between legislative and administrative (on the territory) competences and derived finance (transfer from Government to territory) [40]. Up to now the Government has been engaged in fund‐ ing screening campaigns, from now on the Regions will be in charge of it [41]. Unfortunately since there is not yet an assessment of the costs of this procedure, the "promotion cam‐ paign", so far implemented, is risking to be reduced [42].

The concept of standard cost versus the historical cost is playing a crucial role in the fiscal federalism. The standard cost will contribute, in fact, to establish the "official" needs of each local body and therefore the contingent equalizing transfer to which it will have the right to in case of insufficient fiscal capacity [43].

Which approach should be used to calculate the standard costs of the federal finance?

There are two models among those currently used: micro-analytical (standard cost of each supplied performance) and macro-analytical (standard cost of easily measurable variables: demographic structure, epidemiological and social characteristics). The first approach is not very consistent with the purposes of the federalist reform (valid only as control mean) while the second model establishes a budget of expenditure resulting from merely political choices and not from the real needs of the population. What is the solution? To calculate the neces‐ sary resources the fundamental element to refer to is the efficiency [44-46]. The efficiency measures the economical employment of resources in the productive process. It is defined as the ratio between performances (screening) and resources (budget) according to the formu‐ la: efficiency= output/input [47,48].

A better approach, but for some aspects much more complex, could be the one of DEA [49]. Farrell (1957) in his preliminary work "The measurement of productive efficiency" intro‐ duced not only the well-known allocation between technique and price or allocative efficien‐ cy, but he also proposed a key to measure the comparative efficiency of the productive units which use various inputs to produce different outputs [50]. The efficiency of each unit would be equal to the ratio between real and potential output [51]. More than two decades after Charnes, Cooper and Rhodes (CCR), the idea of Farrell was developed and it was dem‐ onstrated that a linear mathematical program could be used to choose the most effective productive unit. The method, known as Data Envelopment Analysis, has been extensively used to measure the efficiency in many economical areas [52].

The analyses are non-parametric and its characteristic is that it can evaluate the relative effi‐ ciency of decisional units, and the like, through linear programming techniques without specifying whether the relative importance of the different factors of production or that of the prices [53]. In this sense the results of non-parametric methods are objective, because they do not require prior specifications. On the other hand, however, their disadvantage is that they do not admit errors being deterministic methods; the results could be therefore in‐ fluenced. The relative efficiency of the responsibility centres is determined according to the following formula:

**max** *u*,*v h* 0 (*u*, *v*)=∑ *r ur yr*<sup>0</sup> / <sup>∑</sup> *vixi*<sup>0</sup>

ment the regions are committed to implement by September 2010, the Regional Plan of Pre‐ vention to carry out the interventions established by the National Plan of Prevention: among the macro-areas of interventions there are oncologic screening programs [39]. The critical points are: complications of COL (40 programmes) with average perforation rate of 0.08% (2,5% operative COL) and average bleeding rate of 0,55%; low coverage and delay in South‐

The critical limit to implement the screening campaigns of colorectal cancers is the allocation of own resources to Regions and local bodies and the overcoming of the dichotomy between legislative and administrative (on the territory) competences and derived finance (transfer from Government to territory) [40]. Up to now the Government has been engaged in fund‐ ing screening campaigns, from now on the Regions will be in charge of it [41]. Unfortunately since there is not yet an assessment of the costs of this procedure, the "promotion cam‐

The concept of standard cost versus the historical cost is playing a crucial role in the fiscal federalism. The standard cost will contribute, in fact, to establish the "official" needs of each local body and therefore the contingent equalizing transfer to which it will have the right to

There are two models among those currently used: micro-analytical (standard cost of each supplied performance) and macro-analytical (standard cost of easily measurable variables: demographic structure, epidemiological and social characteristics). The first approach is not very consistent with the purposes of the federalist reform (valid only as control mean) while the second model establishes a budget of expenditure resulting from merely political choices and not from the real needs of the population. What is the solution? To calculate the neces‐ sary resources the fundamental element to refer to is the efficiency [44-46]. The efficiency measures the economical employment of resources in the productive process. It is defined as the ratio between performances (screening) and resources (budget) according to the formu‐

A better approach, but for some aspects much more complex, could be the one of DEA [49]. Farrell (1957) in his preliminary work "The measurement of productive efficiency" intro‐ duced not only the well-known allocation between technique and price or allocative efficien‐ cy, but he also proposed a key to measure the comparative efficiency of the productive units which use various inputs to produce different outputs [50]. The efficiency of each unit would be equal to the ratio between real and potential output [51]. More than two decades after Charnes, Cooper and Rhodes (CCR), the idea of Farrell was developed and it was dem‐ onstrated that a linear mathematical program could be used to choose the most effective productive unit. The method, known as Data Envelopment Analysis, has been extensively

The analyses are non-parametric and its characteristic is that it can evaluate the relative effi‐ ciency of decisional units, and the like, through linear programming techniques without specifying whether the relative importance of the different factors of production or that of

Which approach should be used to calculate the standard costs of the federal finance?

ern Italy; low compliance; overload on endoscopy facilities.

84 Colonoscopy and Colorectal Cancer Screening - Future Directions

paign", so far implemented, is risking to be reduced [42].

used to measure the efficiency in many economical areas [52].

in case of insufficient fiscal capacity [43].

la: efficiency= output/input [47,48].

Now the system of weights adopted strongly influences the efficiency, therefore through an algorithm of Charnes, Cooper and Rhodes (CCR), we try to find the optimal system of weights (among the proposed ones) in order to maximize the efficiency of the respon‐ sibility centre and the comparable ideal responsibility centre [54]. This suggests that the standard cost can be calculated in two ways: maximizing the numerator and fixing the denominator (output-oriented method – screening) or, vice versa, keeping the numerator and minimizing the denominator (input-oriented method – prevention budget) [55]. The difference is important since it determines the form of efficiency that we are assessing. Output-effective means there is no other unit that develops a larger screening with the same budget for the prevention [56].

A productive unit is called input-effective if there is no other unit able to obtain the same screening using a lower budget (DMUs).

This methodology assesses the efficiency as the ratio between quality of the screening and available budget. Some weights are obviously introduced to include demographic and health characteristics of the Region. Now for each unit we can obtain the optimal budget to be allocated to the Region for the screening campaign. In this way by adding the sum of ev‐ ery single regional budget, the necessary budget of national expenditure can be obtained to carry out an effective and really sustainable screening campaign.

In view of the above mentioned results, we can assume an equivalent model (Table 4).

The following example of three Regions (large, middle, and small) illustrate how DEA works.

Each Region has exactly 10 COL (the only input), and we are be able to measure a Region CCR programme based on two outputs: number of patients subject to screening, and num‐ ber of found cancers. The data for these Regions is as follows:

Region "large": 100 COL, 1000 number of recruited patients, 20 number of found cancers;

Region "medium": 100 COL, 400 number of recruited patients, 50 number of found cancers;

Region "small": 100 COL, 200 number of recruited patients, 150 number of found cancers.

Now, the key to DEA is to determine whether we can create a virtual Region that is better than one or more of the real Regions. Any such dominated Region will be an inefficient Re‐ gion. Consider trying to create a virtual Region that is better than Region "large". Such a Re‐ gion would use no more inputs than a Region "large", and produce at least as much output. Clearly, no combination of Regions "medium" and "small" can possibly do that. Region "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 efficiency rating of 1.

After the definition of the population size and the observed input and output to assess the screening unit (DMUs), it is possible to calculate the index of efficiency by using the abovementioned formula. This index can be referred to the single Regions or to the system Italy as

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87

In many states, a larger question may be whether the overwhelming use of COL as the

Determination of the appropriateness of an indication for COL has been advanced as a means to help rationalize the use of endoscopic resources. Current guidelines regarding the appropriateness of COL are relatively inefficient in excluding a clinically meaningful CRC risk for patients, in whom COL is generally not indicated, raising serious concerns about

A tailored navigation approach, which determines the particular concerns and barriers of an eligible individual and matches them with the strengths and weaknesses of each strategy to find the one most suitable, may be the optimal way to maximize the number of people who

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‐

In the end, a test can only provide benefit if it is actually done [57].

a whole.

screening method is the appropriate choice.

their applicability to clinical practice.

can benefit from COL.

**5. Conclusions**


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

After the definition of the population size and the observed input and output to assess the screening unit (DMUs), it is possible to calculate the index of efficiency by using the abovementioned formula. This index can be referred to the single Regions or to the system Italy as a whole.

In many states, a larger question may be whether the overwhelming use of COL as the screening method is the appropriate choice.

Determination of the appropriateness of an indication for COL has been advanced as a means to help rationalize the use of endoscopic resources. Current guidelines regarding the appropriateness of COL are relatively inefficient in excluding a clinically meaningful CRC risk for patients, in whom COL is generally not indicated, raising serious concerns about their applicability to clinical practice.

A tailored navigation approach, which determines the particular concerns and barriers of an eligible individual and matches them with the strengths and weaknesses of each strategy to find the one most suitable, may be the optimal way to maximize the number of people who can benefit from COL.

In the end, a test can only provide benefit if it is actually done [57].
