Are Variations in the Use of Carotid Endarterectomy Explained by Population Need? A Study of Health Service Utilisation in Two English Health Regions

Abstract

Objectives:to describe variation in utilisation of carotid endarterectomy (CEA) within two English health regions and explore relationships between use, need and proximity to services.Design:consecutive case series of operations. Comparison at a population level with district stroke mortality, hospital admissions and material deprivation.Main outcome measures:standardised utilisation rates for CEA and measures of inter-district variability. Spearman's rank correlation coefficients for associations between variables.Results:variation in utilisation rates was considerable (14-fold difference across district populations). More individuals had bilateral surgery in the Yorkshire region than in the Northern (11.7% vs. 5.5%, p=0.002). There was no association between utilisation rates for CEA and district stroke mortality (r=−0.06, 95% CI −0.41 to 0.30) or admission rates for stroke (r=0.17, 95% CI −0.2 to 0.49). There was a strong relationship between residence in districts where services were located and higher utilisation. Rates of CEA were lowest in the regions» most affluent wards.Conclusion:use of CEA varies widely, depending on area of residence. Variation is not a consequence of differences in need, but reflects clinical practice and supply of services. There is evidence to suggest unmet need for CEA.