Regarding: “Timing of postcarotid complications: A guide to safe discharge planning”☆☆☆★★★
Article Outline
Ambulatory carotid surgery: Caveat emptor
In this month's issue of the Journal, Sheehan et al have taken reductionism in carotid surgery one step further, by raising the possibility of ambulatory carotid endarterectomy. This is the continuing evolution of a process that began by questioning the need for preoperative carotid angiography1 and examining the role of the intensive care unit in postoperative monitoring2 and has extended to refining techniques of anesthetic management and completion imaging and reducing the length of postoperative hospitalization. I agree with the authors' contention that disciplined scrutiny of carotid endarterectomy by the vascular surgical community has streamlined the performance of the operation without compromising, and perhaps improving, outcomes. However, one must wonder whether we have come to, and perhaps surpassed, the limits of what we can or should expect to accomplish. Although their experience clearly indicates that same-day discharge is feasible, one must ask whether it should become “standard of care” and what purpose that would serve.
The authors have reported on a subgroup of patients who were considered eligible for same-day discharge because they had no need for postoperative anticoagulation or concomitant operations. In this subgroup (which included 92% of their total experience) they report noncardiac complications potentially requiring operation in 62 cases (8%). These are honestly reported results from a center recognized for expertise in carotid surgery, and they serve to remind us that carotid endarterectomy remains an operation with significant perioperative morbidity, even in experienced hands. The incidence of cardiac complications was not the focus of this article and was not reported, but it is reasonable to assume that it would approximate 2% of their cohort. Therefore, in the practice of an experienced group of surgeons in a tertiary care center, 8% of patients would not be eligible for this algorithm because of preoperative comorbidities, and an additional 10% might be expected to have some complication that would preclude same-day discharge. Although this still leaves 80% of patients eligible for same-day discharge after carotid endarterectomy, one must look at the consequences of adopting this as a routine practice.
It is concerning that 7.7% of neurologic deficits were recognized on the day after surgery. In both cases the authors intimate that, with the benefit of hindsight, some signs of these events might have been recognized within the 8-hour window they suggest for observation. However, one of the consequences of continuing to shorten the period of observation after a surgical procedure is to decrease rather than increase the vigilance of the observer, who tends to view the procedure as “minor” with a low likelihood of problems. In many outpatient procedures, while patients are seen by the operating surgeon before discharge, the patient is actually discharged after review by a nurse, an anesthesiologist, or a surgical resident. Certainly a program of same-day discharge after endarterectomy would require monitoring in an area other than the standard ambulatory unit and an 8-hour review by an experienced clinician, in this case the operating surgeon. The medicolegal consequence of an error would be devastating. One need only imagine the perception of a family returning their loved one, operated on at noon and discharged at 10 PM the day before, to the emergency department because of a stroke or hematoma.
This raises the second major question: what is gained by same-day discharge? As the authors note in their discussion, it is not practical to discharge many patients on the day of surgery for social reasons (distance, lack of a satisfactory home environment). This is a real consideration in a patient population whose mean age is older than 70. To be practical, same-day carotid endarterectomy would need to be completed at the latest by early afternoon, to avoid discharge after 10 PM . Late-evening discharges from a hospital bed are not likely to reduce hospital cost because they will not affect staffing patterns and very few resources are consumed by an overnight stay per se. Although one might be able to address this by never admitting a patient for carotid surgery unless a complication develops, this would require extended staffing of the ambulatory unit and the inevitable scramble for a bed late in the evening when a complication arose. It would also mean arguing with the third-party payer about the necessity of admission, which would be required in at least a quarter of cases. In my opinion this is “a long run for a short slide.”
The likely consequence of adopting such a policy would simply be a reduction in hospital reimbursement for carotid endarterectomy by payers. If past experience were any guide, the hospital would begin to lose money on this procedure under more restrictive reimbursement rules. This is likely to benefit no one other than medical insurers and exposes the patient, hospital, and physician to increased risk.
The authors suggest that their algorithm may make endarterectomy more “fiscally attractive” when compared with carotid angioplasty. Unfortunately, carotid angioplasty continues to gain ground despite the fact that in its current state of development it has been shown to be more expensive and less effective than endarterectomy. The drive toward or away from carotid angioplasty is not likely to be based on its cost relative to endarterectomy, but rather on patient preference and the incentive of hospitals and physicians to increase their market share.
I think the authors have done an excellent analysis and, as is typical of their group, raised a number of controversial and interesting questions for further debate. However, it is my considered opinion that their thesis moves us beyond the point of diminishing returns. This operation, one of the most closely scrutinized of all surgical procedures, bases its efficacy on the proven ability of the surgeon and health care team to keep complication rates at a minimum. Any approach that even marginally increases these rates by reducing an already streamlined algorithm of postoperative observation must be viewed with extreme caution. In my mind the benefits of such a proposal are ephemeral, and the risks are real. Any operation where the real risks are stroke, myocardial infarction, and death certainly merits an overnight hospital stay.
References
☆ Competition of interest: nil.
☆☆ J Vasc Surg 2001;34:178-9.
★ Reprint requests: John J. Ricotta, MD, SUNY at Stony Brook, University Hospital and Medical Center, Stony Brook, NY 11794-8191 (e-mail: ricotta@surg.som.sunysb.edu ).
★★ Please see the related article by Sheehan et al on pages 13-6 .
PII: S0741-5214(01)79286-5
doi:10.1067/mva.2001.116105
© 2001 Society for Vascular Surgery and The American Association for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Timing of postcarotid complications: A guide to safe discharge planning
