More patients are getting rapid access to carotid endarterectomy, but variation remains

BMJ 2013; 347 doi: (Published 23 October 2013) Cite this as: BMJ 2013;347:f6373
  1. Zosia Kmietowicz
  1. 1BMJ

More than half the patients in the United Kingdom who need a carotid endarterectomy have surgery within 14 days of experiencing symptoms of stroke or transient ischaemic attack, an audit has found.

The fifth report of the national carotid endarterectomy audit, carried out by the Royal College of Surgeons of England and the Vascular Society of Great Britain and Ireland, looked at 5723 operations carried out between 1 October 2011 and 30 September 2012. It found that 56% of patients who needed carotid endarterectomy were meeting the guideline target set by the National Institute of Health and Care Excellence to have surgery within two weeks of presenting with symptoms.1

The median time to surgery was 13 days, an improvement of 10 days since the third audit, which looked at cases between October 2009 and March 2010 and found that the median time to surgery was 23 days.

However, despite the progress, the audit found variation across the UK, with delays between presentation of symptoms and referral to stroke specialists and on to surgery. While some hospitals averaged five days from symptom presentation to surgery, in others patients were waiting up to three months for their operation.

Most delays related to presentation or referral (or both). Of the patients who did not meet the 14 day target, 65% were found to have had a slow diagnosis, either because they didn’t call 999, go to a hospital emergency department, or visit a GP (27% of the total) or because they weren’t quickly referred to a specialist stroke centre (38%). Lesser reasons for delays were cancelled operations because patients were not fit or because they decided against surgery (18%) and lack of operating time (12%).

In a foreword to the report, David Mitchell, chairman of the Vascular Society’s audit and quality improvement committee and a consultant vascular surgeon, said that having fewer centres with a faster throughout of patients could help deliver surgery more quickly to more patients. In London the number of stroke services has dropped from 17 to 11, and the average delay from symptom presentation to surgery has fallen from 12 days in 2009 to eight in 2012.

Mitchell said, “Discussions with high performing centres indicate that a focus on a facilitated pathway of referral, seven day TIA [transient ischaemic attack] clinic access, and working in teams (as opposed to the traditional consultant firm approach) are the keys to improving access to treatment for patients.”

The audit results also showed that stroke and other complications after carotid surgery remain low. For the first time the report included comparative outcome information on outcomes at trust level. After these were adjusted for risk, in all trusts the rates of death or stroke within 30 days were within the expected range for the number of procedures they performed.

Mitchell concluded, “Carotid surgery is being performed more effectively than ever before in the NHS. What is required now is for clinical teams to work hard on managing their pathways of care to treat all patients within the NICE target.”

The report makes 10 recommendations, including checking performance against NICE guidance, making sure clinicians contribute to the national audit with accurate coding, and having a clearly documented pathway of care. Clinicians should also make sure they have agreed protocols to minimise delays and that referrals to surgery or interventional radiology are not made to individual doctors but to a central point, which is open every day, including weekends.

Stroke teams should also publicise their services to primary care and the public and highlight the importance of amaurosis fugox, because this is associated with significantly greater delays in the pathway, says the report.


Cite this as: BMJ 2013;347:f6373


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