Round 4 of the UK Carotid Endarterectomy Audit analysed 5,543 cases and participation has increased to involve 98% of trusts in England, Scotland, Northern Ireland and Wales ‒ making this the largest and most robust audit of carotid endarterectomy practice in the UK. The headline message is that the average delay from onset of symptoms to undergoing surgery continues to decline, demonstrating continued improvement in the quality of service.
Carotid endarterectomy is a preventative surgical procedure. It corrects narrowing in the internal carotid artery, found in the neck. Patients presenting with symptoms of stroke or transient ischaemic attack (TIA) are at increased risk of stroke and those with symptoms, such as visual loss, weakness in the face/arm/leg, who also have significant narrowing of the carotid artery are at high risk of having a more severe stroke, hence more urgent surgery is important to prevent this happening. The audit provides data about the efficiency of the pathway of care and outcomes for patients who undergo endarterectomy.
Carotid surgery is of the greatest benefit if performed quickly following the onset of symptoms and the National Institute for Clinical Excellence (NICE) and the National Stroke Strategy have set standards of 14 days and 48 hours respectively from symptom to surgery.
In round 4, the median delay between onset of symptoms and undergoing surgery was 15 days, compared to 21 days in round 3. There has also been an overall increase (from 40% to 49%) in the proportion of patients treated within 14 days from symptom to surgery as specified in NICE guidance. There is evidence that too many patients lack awareness about the need to seek urgent medical advice as soon as possible.
The audit shows that the complication rate following carotid endarterectomy is 2%. Despite the very welcome decline in delays between symptom onset and surgery (overall), round 4 found that there was still considerable variation in performance among hospitals. There are multiple reasons for this, including patient awareness and organisational structure/pathway management. Patients receive surgery more quickly in London than in all other regions. The audit demonstrated that better performing services offer 7-day clinic access and multidisciplinary team working.
Professor Ross Naylor, president of the Vascular Society and steering committee member of the UK Carotid Endarterectomy Audit, said:
This is an excellent example of how the benefits of intervening early are being translated into routine clinical practice. Britain has led the drive towards expedited surgery around the world and the latest results reflect the hard work that has gone towards achieving this for our patients.
Mr David Mitchell, the Vascular Society audit chairman and consultant vascular surgeon said:
Carotid surgery is being performed more effectively than before in the NHS and in doing so preventing more strokes and their associated misery.
The round 4 report makes several recommendations for change which include:
- clearly documented patient pathways spanning how patients access services and how they flow through to surgery if required
- agreed referral protocols for TIA and minor stroke to minimise delays in the pathway
- the availability of resources to deal with referrals on a daily basis, including the weekend.
Professor Tony Rudd, associate director, RCP Clinical Effectiveness and Evaluation Unit, and chair of the Intercollegiate Stroke Working Party said:
We are making steady progress towards achieving the standards set, but there are still too many patients who are being treated too slowly with unacceptable variability around the country. Care should be focused in centres that are well-organised and experienced in performing carotid endarterectomy surgery.
For further information, please contact Hannah Bristow, Clinical Standards communications officer, on +44 (0)20 3075 1447 / 07584 303 784 or email Hannah.Bristow@rcplondon.ac.uk
- This report is based on round 4 of the National Carotid Interventions Audit, which includes all carotid endarterectomies performed between 1 October 2010 and 30 September 2011 that were submitted to the audit by 31 December 2011.
- Download the report from the RCP website: http://www.rcplondon.ac.uk/projects/uk-carotid-interventions-audit
- Round 4 builds on progress made within round 1 (1 December 2005 ‒ 31 December 2007), round 2 (1 January 2008 ‒ 30 September 2009) and round 3 (1 October 2009 ‒ 30 September 2010).
- The audit recorded time from symptom to referral, referral to imaging and time to referral to the surgical service. Time from symptom to carotid intervention is also captured.
- Outcomes including complication rates for stroke and cranial nerve injury are captured, as well as survival while an inpatient and at 30 days post-surgery.
- The case submission rate was 93% (425/457) of eligible surgeons, reporting 90% (4849/5360) of comparable cases in England, 99% (153/154) of comparable cases in Northern Ireland and 70% (254/362) of comparable cases in Wales reported in HES in the same time period (1 October 2010 ‒ 30 September 2011).
- Patient data was submitted for Scotland, but case submission rate data are not available due to a new patient management system rolled out across a number of Scottish health boards during 2011.
About The Healthcare Quality Improvement Partnership:
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme. Its purpose is to engage clinicians across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. The programme comprises more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions.