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.