| Summary: | Following the publication of two large-scale randomised controlled trials in the early 1990s, little doubt remains about the efficacy of carotid endarterectomy as a means of preventing stroke in selected sub-groups of patients. However, the effectiveness and cost-effectiveness of this intervention as a stroke prevention strategy are uncertain, as are the public health implications when this strategy is applied to a population. This thesis focuses on the effectiveness and cost-effectiveness of carotid endarterectomy as a stroke prevention strategy in the Scottish population. The variation in uptake of carotid endarterectomy by hospital and region between 1981 - 1996 is described by analysing a unique set of patient linked data on hospital use and outcome following carotid surgery for 2892 patients. Stroke-free survival and overall survival before and after the publication of the trial results for this cohort are also assessed. A systematic overview of studies addressing the costs and benefits of carotid endarterectomy is conducted by critically appraising the methodology and interpretation of previous cost and cost-effectiveness estimates. Unlike previous studies, this thesis considers the resource implications of carotid endarterectomy by estimating not only the procedure cost of carotid endarterectomy but also the overall NHS work-up costs for a large cohort of patients with transient ischaemic attack referred to a Scottish teaching hospital for carotid endarterectomy assessment, investigation and surgery. Finally, as part of the analysis of cost-effectiveness estimates for Scottish patients, a novel use of the European Carotid Surgery Trial data has enabled assessment of the transferability of efficacy results obtained in a randomised controlled trial to a setting outside trial conditions.
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