AN EPIDEMIOLOGIC NEEDS ASSESSMENT OF CAROTID ENDARTERECTOMY IN AN ENGLISH HEALTH REGION - IS THE NEED BEING MET

Objective: To compare the level of provision of carotid endarterectomy (an intervention of proved efficacy for prevention of stroke in patie nts with symptomatic high grade carotid artery stenosis) with estimate s of need. Design: Comparison of regional, district, and age-sex speci fic operation rates derived from hospital episode statistics with esti mates of need based on demographic and epidemiological data; interview s with regional vascular surgeons and a joint provider-purchaser works hop to discuss implications. Setting: Former Wessex Regional Health Au thority, 1991-2 to 1995-6. Subjects: All residents covered by wessex r egion treated for carotid artery reconstruction. Main outcome measures : Regional, district, and age-sex operation rates as three year averag e 1993-6 (use) compared with respective estimates of need for carotid endarterectomy among those who presented with symptomatic carotid dise ase-transient ischaemic attack or minor stroke. Results: The operation rate more than doubled between 1991-2 and 1995-6, from 35 to 89 per m illion population, compared with an estimated level of need in the reg ion's general population of 153 per million population (transient isch aemic attack 77, minor stroke 76). The ratio of use to need was 0.47 ( 95% confidence interval 0.4 to 0.54); district ratios were 0.28 (0.19- 0.38) to 0.81 (0.62 to 1.06). The annual use:need ratio rose over the three years 1993-6 from 0.38 to 0.59. Use:need ratios were lower in el derly and female patients. Providers were keen to develop guidelines f or referral and to increase access to diagnostic facilities; purchaser s were more reluctant, given the limited impact of this intervention o n the incidence of stroke and the relatively high cost of the operatio n. Conclusion: Although treatment rates increased in Wessex there is s till unmet need. Further research is needed to determine the referral pathways of patients with symptomatic carotid disease for diagnosis an d operation and to evaluate strategies to improve access to diagnostic facilities.