DISCUSSION
Day-case ESS activity in England has risen substantially over the last 20 years with a greater than four-fold increase in day-case rates; from 15.5% in 2000-0112 to nearly 80% in 2018-19. We provide evidence that day-case ESS is safe. There was no evidence that outcomes were better for patients with overnight stay. Generally better outcomes for patients undergoing day-case surgery are likely to be due, in part, to confounding factors not fully adjusted for through modelling, most obviously disease severity. Our comparison of trusts with high and low rates of day-case surgery attempts to overcome this residual confounding, since presentation is unlikely to vary between the two groups of trusts in a way that would substantially bias our findings. In this analysis there was no significant difference between the two groups. It is also interesting that, despite a substantial increase in the proportion of patients undergoing day-case ESS over the five-year, outcomes were relatively stable over time.
Most previous studies on the safety of day-case ESS are relatively small. A study of outcomes from 909 rhinology procedures published in 2021 reported no difference in readmission rate between outpatient (day-case) and inpatient groups.13 The authors noted higher complication rates in those with overnight stay, highlighting differences in patient selection criteria for day-case surgery.13 Nevertheless, the conversion rate from day-case to overnight stay was less than 5%. A single surgeon study of 181 patients (both day-case and overnight stay) from New Zealand concluded that day-case sinonasal surgery was safe and acceptable to patients.14 An earlier case note review involving 105 day-case ESS patients drew similar conclusions and suggested important factors in successful implementation of day-case ESS were careful patient selection and dedicated day-case infrastructure.15 A French study focussing on patient reported outcomes for endoscopic ethmoidectomy reported no readmission and no major complications in their series of 74 patients. SNOT-22 scores decreased on average by 56% post-operatively, demonstrating good surgical outcomes in day-case ESS.16
One of the reasons often cited for the need to have an overnight observation following ESS, other than patient co-morbidities, is the risk of post-operative haemorrhage.12 However, advances in ESS techniques have led to reduced morbidity associated with the procedure. Furthermore, the utilisation of topical vasoconstrictor agents, antifibrinolytic medications and hypotensive anaesthetic practice have contributed to reduced intra-operative and post-operative bleeding, supporting a day-case model.17,18 We found relatively low rates of haemorrhage during the index procedure (0.5% (day-case) and 4.3% (overnight stay)) compared to an earlier large prospective cohort study of ESS in England and Wales that reported excessive perioperative bleeding rates of 5% and post-operative haemorrhage rates of 1%.19 Some of these differences may be due to differences in data collection (coded events vs surgeon reported). The indication for overnight stay for many patients is likely to have been excessive perioperative or immediate post-operative haemorrhage, explaining the higher haemorrhage rate in this group. Recent increases in the use of absorbable packing also enables patients to be discharged with nasal packing still in situ if post-operative minor haemorrhage is a concern.20,21
There remains substantial variation between NHS hospital trusts in England in rates of day-case ESS. In the last full financial year prior to the COVID-19 pandemic a number of trusts still had overnight stay for the majority of patients. The barriers to day-case ESS can be cultural as well as practical. Surgical preference and trust policy can hinder attempts to create an effective day surgery pathway. Careful theatre management that takes into account operation timing and case-mix will help optimise day-case surgery potential.13 The proximity of the patient’s home address need not be an absolute contraindication to day-case surgery. In France, non-medical accommodation has been offered to patients travelling a long distance for their surgery.13 Such provision is substantially less costly that a hospital bed. Day-case surgery can support more cost-effective and resource-efficient provision of surgical services by preventing unnecessary bed occupation14 and reducing risks of hospital acquired infection and deconditioning.22
A further consideration that will impact the surgical management of sinonasal disease is the emergence of balloon sinuplasty which can be performed under local anaesthetic, and therefore as a day-case or out-patient office procedure.23 Complication risks are similar to those of conventional ESS.24 Although not indicated for all patients, identifying patients that would benefit from this procedure may help reduce ESS waiting lists.25
The ability to track patients across hospitals in England and the comprehensiveness of the HES database are strengths of our study. However, the lack of data relating to some aspects of clinical presentation limited the extent to which we could adjust for this. Some data entry inconsistencies between trusts have been noted, mostly with regard to differences in clinical coding practice across trusts.5 However, coding for ESS is relatively uncomplicated and so may be less prone to such errors. Data on patient quality of life and other patient reported outcomes were not available and would have added markedly to the depth of our findings.