Education And Debate

Controversies in Management: Purchasers need a broader perspective

BMJ 1995; 310 doi: (Published 04 February 1995) Cite this as: BMJ 1995;310:317
  1. Mark Lambert, registrar in public health medicinea
  1. a Wakefield Health Authority, White Rose House, Wakefield WF1 1LT

    Stroke is one of the leading causes of premature death and disability in the United Kingdom,1 and district health authorities have an important responsibility for purchasing appropriate services to meet this challenge. Is carotid endarterectomy such an appropriate service? To answer this question, we need to examine the benefits to the individual from the procedure and then to try to extrapolate this effect to a population.

    Benefits to individuals

    Two comparable multicentre randomised controlled trials have measured the outcome of carotid endartarectomy in people with severe symptomatic carotid artery stenosis. The reduction in the absolute risk of a disabling or fatal stroke (the outcome with probably the greatest public health significance) was estimated at 5% in the European trial2 and 10% in the North American study.3 Both studies used experienced surgeons with a good operative record. These figures provide compelling evidence of the benefit to individuals from surgery, which should not be ignored. Of course, people in this risk group often die of other causes, but the absolute benefit of endarterectomy remains, even when such deaths are taken into account.

    This measure of benefit, however, omits the morbidity experienced by the many people who have cerebral angiography. Depending on the investigation protocol …

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