**The Future of Colonoscopy: The Use of Data Envelopment Analysis (DEA) for Colorectal Cancer Screening — Italian Experience**

Alberto Vannelli, Michel Zanardo, Valerio Basilico, Baldovino Griffa, Fabrizio Rossi, Massimo Buongiorno, Luigi Battaglia, Vincenzo Pruiti, Sara De Dosso and Giulio Capriata

Additional information is available at the end of the chapter

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

**1. Introduction**

René Descartes (1596-1650) in the published Discourse on Method, wrote: "…And because the actions of life often brook no delay, it is certainly very true that, when it is not in our power to determine the truest opinions, we ought to follow the most probable ones, and even when we see no difference in probability among this group of truths or that one, never‐ theless, we have to decide on some for ourselves and then to consider them, not as some‐ thing doubtful with regard to the practical matter at hand, but as manifestly true and very certain, because the reason which made us choose them has these qualities". [1] Colonosco‐ py (COL) issues this doubt.

Everybody known the effect of COL on colorectal cancer (CRC) until 2009, when an observa‐ tional case–control study did not identify a reasonable explanation for COL: much less effec‐ tive in preventing death from colorectal cancer (CRC) of the right colon compared with the left colon [2]. Moreover to prevent one cancer death, 1,250 colonoscopies need to be per‐ formed, but perforation of the colon occurs at a rate of about 1 in 1000 procedures [3].

Since polyps often take 10 to 15 years to transform into cancer, in someone at average risk of colorectal cancer, guidelines recommend 10 years after a normal screening COL before the next COL. [4,5]. By removing premalignant adenomas and detecting early cancer, COL should lower colorectal cancer mortality. Although gastroenterologists strongly believe that

COL lowers colorectal cancer mortality, evidence in support of this belief is indirect. Robert S. Sandler in 2010 wrote: "The mortality from colorectal cancer has actually been decreasing steadily since 1980, long before widespread use of COL or any other screening, and before use of effective adjuvant therapy for cancer" [6].

However the high cost of biological therapy for advanced CRC, and the high risk of CRC in low-income population are likely to affect the cost-effectiveness of COL in the future [7,8].

In Italy CRC rank third for incidence among male (second among female) and second among the most frequent causes of tumour death for both men and women [9]. The cur‐ rent trend of the incidence shows a slow-down among male patients and stabilization among women. Mortality seems to be in decrease in particular in the population under 50 years old. In Southern Italy and in the Italian islands the incidence is lower (like mor‐ tality), but its trend is less favourable than in central-northern Italy. In the Southern Italy trends on the increase are reported both among men and women. The success of Color‐ ectal cancer screening (CCS) is the success of COL. However there are critical points: complications of COL programmes; low coverage; low compliance; overload on endos‐ copy facilities. Faecal occult blood screening (FOBT) for CRC in men and women aged 50 to 74 is the Italian and European Union recommendation [10]. CCS is widely accepted as a public health policy in Italy [11]. On the contrary few regions have adopted wide‐ spread CCS programmes, although some are inching their way to that goal [12]. The rea‐ son, is the burden that extensive CCS places on COL services [13]. Behind every CCS test, no matter what kind, is the potential need for a COL, who can detect and remove adenomas, and detect asymptomatic cancers [14-19].

**Figure 1.** Italian Network of Cancer Registries: red actived, white not yet actived.

On the other hand, especially in the South of Italy, cancer registration has remarkably ex‐ panded in recent years with several new registries, which provide a more detailed and de‐ scriptive dataset of the oncologic illnesses in this area of Italy. Figure 1 shows the proportion of the resident population covered by cancer registries according to region and geographic macroareas (Northwest, Northeast, Centre, and South). Regional coverage varies from 0% in several southern regions (Puglia, Basilicata, Abruzzi, Molise), as well as Val d'Aosta, to 100% (e.g., Umbria, Friuli Venetia Giulia, Trento, and Bolzano). Nevertheless, Southern Italy reported an increase in cancer reporting. Today more than a third of the Italian population lives in an area with an active cancer registry. This proportion differs between areas (37% in the Northwest, 68% in the Northeast, 26% in the Centre, and 18% in South). Overall, AIR‐ TUM Registries involve more than 19.000.000 subjects, or 34% of the entire Italian resident population. The importance of AIRTUM, is supported by the growing number of accredited registries contributing to the centralized dataset, thus improving representation at the na‐ tional level. Furthermore, the presence of historic registries, operating since the 1980s, has helped calculate 20-year incidence trends, and stable, robust prevalence estimates. Ccm is to liaise between the Ministry of health on the one side, and regional governments on the other as regards surveillance, prevention and promptly responding to emergencies [23-25]. Over the years, Ccm has acquired a specific identity, which makes it unique within the frame‐ work of Italian public health; its main features are: analyze health hazards implementation in prevention secondary and tertiary prevention. The Centre is a bridge between the world of research and health facilities on the one hand, and the best practices and entities being developed on the other, by activating institutional partnerships and professional collabora‐

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

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73

The social and economical impact of CRC is such, to warrant the decisions of the Italian gov‐ ernment to implement the screening as a form of prevention. According to the Italian gov‐ ernment agreements, on September 30th 2010, the Italian Regions should have implemented the Plan of National Prevention and transformed it into Plan of Regional Prevention: April 24th 2010 agreement between Government, Regions and Autonomous Provinces of Trento and Bolzano: "… the regions are committed to implement by September 30, 2010, the Re‐ gional Plan of Prevention to carry out the interventions established by the National Plan of Prevention …" [20].

Two authorities coordinate activities and research projects for both general and specific, population. The Italian Network of Cancer Registries (AIRTUM), and the National Centre for Disease Prevention and Control (Ccm) [21,22].

AIRTUM, called AIRT until 2006, was born in 1997, in 2005, AIRTUM created a central‐ ized database where data from Cancer Registries are stored and, after checked for quali‐ ty and completeness, used for collaborative studies on cancer epidemiology in Italy [14]. Cancer registration in Italy began in the 1970s with a steady increase in experiences and coverage of an increasing proportion of the Italian resident population. The density of registries is greater in northern Italy, especially in the North-east, compared with Central and Southern Italy (Figure 1).

**Figure 1.** Italian Network of Cancer Registries: red actived, white not yet actived.

COL lowers colorectal cancer mortality, evidence in support of this belief is indirect. Robert S. Sandler in 2010 wrote: "The mortality from colorectal cancer has actually been decreasing steadily since 1980, long before widespread use of COL or any other screening, and before

However the high cost of biological therapy for advanced CRC, and the high risk of CRC in low-income population are likely to affect the cost-effectiveness of COL in the future [7,8].

In Italy CRC rank third for incidence among male (second among female) and second among the most frequent causes of tumour death for both men and women [9]. The cur‐ rent trend of the incidence shows a slow-down among male patients and stabilization among women. Mortality seems to be in decrease in particular in the population under 50 years old. In Southern Italy and in the Italian islands the incidence is lower (like mor‐ tality), but its trend is less favourable than in central-northern Italy. In the Southern Italy trends on the increase are reported both among men and women. The success of Color‐ ectal cancer screening (CCS) is the success of COL. However there are critical points: complications of COL programmes; low coverage; low compliance; overload on endos‐ copy facilities. Faecal occult blood screening (FOBT) for CRC in men and women aged 50 to 74 is the Italian and European Union recommendation [10]. CCS is widely accepted as a public health policy in Italy [11]. On the contrary few regions have adopted wide‐ spread CCS programmes, although some are inching their way to that goal [12]. The rea‐ son, is the burden that extensive CCS places on COL services [13]. Behind every CCS test, no matter what kind, is the potential need for a COL, who can detect and remove

The social and economical impact of CRC is such, to warrant the decisions of the Italian gov‐ ernment to implement the screening as a form of prevention. According to the Italian gov‐ ernment agreements, on September 30th 2010, the Italian Regions should have implemented the Plan of National Prevention and transformed it into Plan of Regional Prevention: April 24th 2010 agreement between Government, Regions and Autonomous Provinces of Trento and Bolzano: "… the regions are committed to implement by September 30, 2010, the Re‐ gional Plan of Prevention to carry out the interventions established by the National Plan of

Two authorities coordinate activities and research projects for both general and specific, population. The Italian Network of Cancer Registries (AIRTUM), and the National Centre

AIRTUM, called AIRT until 2006, was born in 1997, in 2005, AIRTUM created a central‐ ized database where data from Cancer Registries are stored and, after checked for quali‐ ty and completeness, used for collaborative studies on cancer epidemiology in Italy [14]. Cancer registration in Italy began in the 1970s with a steady increase in experiences and coverage of an increasing proportion of the Italian resident population. The density of registries is greater in northern Italy, especially in the North-east, compared with Central

use of effective adjuvant therapy for cancer" [6].

72 Colonoscopy and Colorectal Cancer Screening - Future Directions

adenomas, and detect asymptomatic cancers [14-19].

for Disease Prevention and Control (Ccm) [21,22].

Prevention …" [20].

and Southern Italy (Figure 1).

On the other hand, especially in the South of Italy, cancer registration has remarkably ex‐ panded in recent years with several new registries, which provide a more detailed and de‐ scriptive dataset of the oncologic illnesses in this area of Italy. Figure 1 shows the proportion of the resident population covered by cancer registries according to region and geographic macroareas (Northwest, Northeast, Centre, and South). Regional coverage varies from 0% in several southern regions (Puglia, Basilicata, Abruzzi, Molise), as well as Val d'Aosta, to 100% (e.g., Umbria, Friuli Venetia Giulia, Trento, and Bolzano). Nevertheless, Southern Italy reported an increase in cancer reporting. Today more than a third of the Italian population lives in an area with an active cancer registry. This proportion differs between areas (37% in the Northwest, 68% in the Northeast, 26% in the Centre, and 18% in South). Overall, AIR‐ TUM Registries involve more than 19.000.000 subjects, or 34% of the entire Italian resident population. The importance of AIRTUM, is supported by the growing number of accredited registries contributing to the centralized dataset, thus improving representation at the na‐ tional level. Furthermore, the presence of historic registries, operating since the 1980s, has helped calculate 20-year incidence trends, and stable, robust prevalence estimates. Ccm is to liaise between the Ministry of health on the one side, and regional governments on the other as regards surveillance, prevention and promptly responding to emergencies [23-25]. Over the years, Ccm has acquired a specific identity, which makes it unique within the frame‐ work of Italian public health; its main features are: analyze health hazards implementation in prevention secondary and tertiary prevention. The Centre is a bridge between the world of research and health facilities on the one hand, and the best practices and entities being developed on the other, by activating institutional partnerships and professional collabora‐ 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‐ gions.(Figure 2).

DEA is applied by the management control to evaluate the relative efficiency of human re‐ sources, the results are related to the cost of diagnostic procedures, standardized by the case-mix, and both scatter plot and cluster analysis are produced to find out related area of performance and to plan a strategy for the continuous quality improvement. The objective of this study therefore, is to propose one model of study of the costs in the strategy of CCS

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

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

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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

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,

we compared them with the screening tests available in each Region.

produces and distributes information that describes National Health Service.

supporting the benefits of COL using DEA model.

**2. Materials and methods**

**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 and projects of CCS.

At the present days, no studies are ongoing to define the cause-effect relationship between costs, CCS programme, and COL.

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 Analysis" (DEA).

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‐ tiple outputs.

DEA is applied by the management control to evaluate the relative efficiency of human re‐ sources, the results are related to the cost of diagnostic procedures, standardized by the case-mix, and both scatter plot and cluster analysis are produced to find out related area of performance and to plan a strategy for the continuous quality improvement. The objective of this study therefore, is to propose one model of study of the costs in the strategy of CCS supporting the benefits of COL using DEA model.
