interventions to reduce hospital length of stay in high

Original Investigation | Health Policy

Interventions to Reduce Hospital Length of Stay in High-risk PopulationsA Systematic ReviewShazia Mehmood Siddique, MD, MSHP; Kelley Tipton, MPH; Brian Leas, MS; S. Ryan Greysen, MD, MS; Nikhil K. Mull, MD; Meghan Lane-Fall, MD, MSHP;Kristina McShea, MSLIS; Amy Y. Tsou, MD, MSc

Abstract

IMPORTANCE Many strategies to reduce hospital length of stay (LOS) have been implemented, butfew studies have evaluated hospital-led interventions focused on high-risk populations. The Agencyfor Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this studyto further evaluate system-level interventions for LOS reduction.

OBJECTIVE To identify and synthesize evidence regarding potential systems-level strategies toreduce LOS for patients at high risk for prolonged LOS.

EVIDENCE REVIEW Multiple databases, including MEDLINE and Embase, were searched forEnglish-language systematic reviews from January 1, 2010, through September 30, 2020, withupdated searches through January 19, 2021. The scope of the protocol was determined with inputfrom AHRQ Key Informants. Systematic reviews were included if they reported on hospital-ledinterventions intended to decrease LOS for high-risk populations, defined as those with high-riskmedical conditions or socioeconomically vulnerable populations (eg, patients with high levels ofsocioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency,or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteriaincluded interventions that were conducted outside of the hospital setting, including communityhealth programs. Data extraction was conducted independently, with extraction of strength ofevidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using theAHRQ Evidence-Based Practice Center methods guide.

FINDINGS Our searches yielded 4432 potential studies. We included 19 systematic reviews reportedin 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: dischargeplanning, geriatric assessment, medication management, clinical pathways, interdisciplinary ormultidisciplinary care, case management, hospitalist services, and telehealth. Interventions weremost frequently designed for older patients, often those who were frail (9 studies), or patients withheart failure. There were notable evidence gaps, as there were no systematic reviews studyinginterventions for patients with socioeconomic risk. For patients with medically complex conditions,discharge planning, medication management, and interdisciplinary care teams were associated withinconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heartfailure, clinical pathways and case management were associated with reduced length of stay (clinicalpathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: meandifference reduction, 1.28 [95% CI, 0.52 to 2.04] days).

CONCLUSIONS AND RELEVANCE This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, thatare often widely used by health systems. This systematic review highlights important evidence gaps,

(continued)

Key PointsQuestion Which hospital-led

interventions are associated with

reducing length of stay (LOS) for high-

risk populations?

Findings In this systematic review

including 19 systematic reviews, 8

strategies for reducing LOS in high-risk

populations were identified: discharge

planning, geriatric assessment,

medication management, clinical

pathways, interdisciplinary or

multidisciplinary care, case

management, hospitalist services, and

telehealth. Interventions were most

frequently designed for older patients or

patients with heart failure and were

often associated with inconsistent

outcomes in LOS, readmissions, and

mortality across populations.

Meaning This systematic review found

that across all high-risk populations,

there are inconsistent results on the

effectiveness associated with

interventions to reduce LOS, such as

discharge planning, which are often

widely used by health systems.

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JAMA Network Open. 2021;4(9):e2125846. doi:10.1001/jamanetworkopen.2021.25846 (Reprinted) September 20, 2021 1/13

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Abstract (continued)

such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors,and the need for further research.

JAMA Network Open. 2021;4(9):e2125846. doi:10.1001/jamanetworkopen.2021.25846

Introduction

Hospital length of stay (LOS) is a quality metric health systems use as a proxy of efficient hospitalmanagement. Reduction in LOS improves bed turnover, allowing hospitals to match demand withcapacity for elective and emergent admissions, intensive care unit (ICU) care, and interhospitaltransfers.1,2 When demand exceeds capacity, emergency department crowding, ICU strain, and wardstrain occur, all of which are associated with worse outcomes, including mortality.3-9 Classifyingpatient hospital stays into diagnosis-related groups with fixed reimbursements further incentivizeshospitals to improve LOS to maintain operating margins.10 However, important potential trade-offsbetween LOS reduction and postdischarge adverse outcomes (eg, readmissions, mortality) exist.Furthermore, prolonged LOS may be associated with negative patient and staff experience, as wellas increased inpatient complications (eg, hospital acquired infections, falls), many of which may bepreventable.11 Therefore, many hospitals aim to implement systems-level approaches to provideoptimal care and a safe discharge while avoiding prolonged hospital stays.

Many strategies to reduce hospital LOS have been developed, including some targetingdifferent aspects of patient management, such as clinical care (eg, enhanced recovery programs andearly mobility programs12-15), and others focusing on staffing models16,17 and logistics of carecoordination.18-22 Although evidence is limited, some interventions, such as enhanced recovery aftersurgery programs, have focused on elective admissions and have been reported as consistentlyassociated with improved LOS for planned, scheduled surgeries.23 In contrast to elective admissions,much less is known about the effectiveness of interventions in unplanned hospitalizations, especiallyamong populations at-risk for poor outcomes. This includes patients who are medically complex,such as older adults, patients with heart failure, or patients with other chronic comorbidities who areat increased risk for prolonged LOS. Similarly, such interventions may be less generalizable topatients with socioeconomic risk factors more likely to be affected by health care disparities and atincreased risk for adverse events related to hospitalization24 and unnecessary delays indischarge.25-27 Furthermore, many hospitals within Learning Health Systems, including safety-nethospitals, serve populations at disproportionately high risk for prolonged LOS and often struggle tomaintain operating margins as a result. Long-term financial viability of these hospitals is crucial toensuring access to care for underserved populations.5 Therefore, the Agency for HealthcareResearch and Quality (AHRQ) Learning Health System Panel identified a need to identify broadsystem-level interventions to reduce LOS among patients with high risk of prolonged LOS.28 Toaddress this need, we performed an overview of systematic reviews to identify interventionsintended to reduce LOS for high-risk populations and identify evidence gaps. In this systematicreview, we summarize existing evidence, with a specific focus on hospitalized older adults andpatients with heart failure.

Methods

This systematic review is based on a technical brief performed by the ECRI-Penn Medicine Evidence-based Practice Center for the AHRQ. The protocol and final report are available elsewhere.29 Weinterviewed 7 key informants with expertise in health systems, health care delivery processes, high-risk populations, care model transformation, and hospital quality and safety and incorporated input

JAMA Network Open | Health Policy Interventions to Reduce Hospital Length of Stay in High-risk Populations




to refine scope and aims. This report follows the Preferred Reporting Items for Systematic Reviewsand Meta-analyses (PRISMA) reporting guideline for systematic reviews.

Data Sources and Search StrategyMedical librarians searched MEDLINE, PubMed, Embase, CINAHL, the Cochrane Library, and grayliterature sources, including from government agencies and relevant stakeholder organizations, fromJanuary 1, 2010, through September 30, 2020, with updated searches through January 19, 2021.Search terms are provided in eTable 1 in the Supplement. The full search strategy is available in the fullreport, published elsewhere.29

Study SelectionAbstracts and full-text articles were screened in duplicate by a methodologist and a clinician usingDistillerSR (Evidence Partners) using predetermined criteria (Table 1). Based on input from keyinformants, we focused on 2 populations at high-risk for prolonged LOS: patients with socioeconomicrisk factors (eg, underinsured or uninsured) and patients who are medically complex (eg, with frailtyor multimorbidity) (Table 1). Systematic reviews were included if they examined acute unplannedhospitalizations in the United States, evaluated hospital-initiated interventions (such as case

Table 1. Populations, Interventions, Comparators, Outcomes, Timing, Settings, and Inclusion and Exclusion Criteria

Category CriteriaPopulation Include hospitalized children and adults (including pregnant women) with ≥1 of the following risk

factors for prolonged LOS, harms, or adverse outcomes:• High levels of socioeconomic risk (eg, housing instability, social isolation, social vulnerability,

social mobility, lack of social network, lack of social support, limited access to health careservices or social services, rural settings)

• Medically uninsured, underinsured• Hospitalization at safety-net, tertiary, or quaternary care institution• Limited English proficiency• Patients who are medically complex, including those with comorbid psychiatric or behavioral

health conditions, comorbid substance use disorder, frailty, multimorbidity (≥2 chronic healthconditions), and high-volume chronic disease conditions with significant risk of exacerbation orcomplications (including chronic kidney disease, diabetes, congestive heart failure, and chronicobstructive pulmonary disease)

Exclude patients undergoing nonemergent or elective proceduresInterventions Include interventions that are

• Initiated within the hospital• Designed (at least in part) to evaluate LOS• Examples include but are not limited to clinical pathways, enhanced recovery programs,

discharge planning, case management, and multidisciplinary teamsExclude interventions that are• Initiated, managed, or implemented by entities wholly external to the hospital setting• Are not intended or expected to reduce LOS• Examples include but are not limited to ambulatory clinic follow-up visits, community-based

support resources, regulatory policies, and third-party reimbursement programsComparators Include: Usual care, any comparison, or other active intervention

Outcomes Include:1. Primary:

• LOS• LOS index

2. Secondary:• Readmission• Patient harms, such as mortality, hospital-acquired conditions• Patient experience or satisfaction• Patient functional return• Clinician or staff satisfaction• Resource use, including patient flow and discharge disposition

Exclude• Only describe cost-related outcomes without reporting LOS• Cost-related outcomes that do not quantify valuations of both comparisons or alternative

interventions (including usual or standard care) and both of their associated outcomesTiming Include: All

Setting Include• Acute care hospitalizations in general or pediatric hospitals• Reviews of studies conducted in the United StatesExclude• Reviews focused solely on intensive care unit stays, emergency departments, or observation

units• Specialty hospitals (eg, psychiatric, ophthalmologic, orthopedic, cancer, rehabilitation,

long-term acute care)• Reviews of studies conducted solely outside the US Abbreviation: LOS, length of stay.




http://www.equator-network.org/reporting-guidelines/prisma/


management or multidisciplinary team models), aimed to reduce hospital LOS, reported on LOS as aprimary outcome, and were published in English. We also required systematic reviews to provideexplicit search criteria and inclusion and exclusion criteria and assess risk of bias (ROB) for includedstudies. We excluded systematic reviews focused on admission for nonemergent electiveprocedures, utilizing interventions not initiated within hospital settings (eg, community-basedprograms or ambulatory care visits after discharge), or including more than 50% of studies fromoutside of the United States.

Data Extraction and Quality AssessmentA standardized data extraction form was used to collect patient population, hospital and interventioncharacteristics, comparators, and outcomes assessed. Included systematic reviews were required tomeet several thresholds for quality, including explicit search strategies, inclusion and exclusioncriteria, and ROB assessment; therefore, independent quality assessment of included reviews wasnot performed. LOS was extracted as the primary outcome, with associated balancing measures assecondary outcomes, including readmission and mortality rates. For each outcome, when available,we extracted strength of evidence (SOE) ratings provided by systematic reviews. If not provided,we assessed SOE using AHRQ Evidence-based Practice Center guidance.30

Data SynthesisWe narratively summarized evidence for heart failure and older populations and developed anevidence map to summarize the direction of association, volume, and quality of existing data forinterventions across key outcomes (ie, LOS, readmission, and mortality). We also highlightedimportant knowledge gaps in the evidence base.

Results

Of 4432 potentially relevant studies, we included 19 systematic reviews in 20 publications, 1 of whichwas identified in our gray literature search.20,31-49 The most common reason for exclusion was thatthe systematic review did not describe a hospital-led intervention. Study selection is shown in theFigure. Characteristics of included systematic reviews are shown in eTable 2 in the Supplement.

Of 19 systematic reviews analyzed, 10 included a mix of study designs (eg, randomized clinicaltrials [RCTs], observational cohort studies),31-41 8 included only RCTs,20,42-48 and 1 included onlyretrospective cohort studies.49

Included systematic reviews addressed 8 types of systems-level hospital or health systeminterventions: discharge planning,20,37,38,43,46 geriatric assessment or consultation,33,39,44,47,49

medication management,31,34,45 clinical pathways,36,42 interdisciplinary or multidisciplinarycare,40,48 case management,35 hospitalist services,41 and telehealth.32 There was an overlap of 10individual studies across 8 systematic reviews evaluating discharge planning, geriatric assessment, ormultidisciplinary care.20,37-39,42-44,46,49 The description and distribution of these categories is shownin Table 2, and individual study overlap is presented in eTable 2 in the Supplement.

The clinical conditions reported included patients with heart failure and other patient groups,such as patients with acute stroke, pregnant women at high risk, and infants. Some systematicreviews synthesized data quantitatively for the LOS outcome, while others presented either anarrative synthesis or data from individual studies on reported LOS. Included reviews evaluated olderadults and those with chronic conditions and quantitatively synthesized LOS and other outcomes(Table 2). Results from included systematic reviews are shown in eTable 1 in the Supplement, andthose performing meta-analysis for LOS are presented in eTable 3 in the Supplement.

Systematic reviews reported limited information on the setting of included studies. There were13 reviews that described interventions conducted in multiple types of hospitals, including academicmedical centers, community hospitals, and, less frequently, Department of Veterans Affairs hospitals.Only 1 systematic review focused on trauma centers, and 6 reviews did not report hospital type. Only








5 reviews reported whether all included studies were conducted in urban, suburban, or rural settings:3 included both urban and rural hospitals, 1 was limited to urban settings, and 1 included only ruralhospitals. Few reviews reported hospital bed size or affiliation with a health system.

Evidence MapTable 3 summarizes quantitative findings from systematic reviews for the outcomes of LOS,readmissions, and mortality in an evidence map. The map provides an overview of direction ofassociation, SOE, size and study designs contributing to the evidence base, and patient populationsaddressed. For most interventions, evidence for LOS reduction was inconsistent.

Evidence GapsWe found notable evidence gaps for high-risk populations. No systematic reviews focused onpatients with socioeconomic risk factors (eg, housing instability, social isolation, no medical insuranceor underinsuance, social mobility, lack of social network, lack of social support, limited access tohealth care services or social services, rural settings), limited English proficiency, or hospitalization ata safety-net or tertiary or quaternary care hospital. Furthermore, although systematic reviews didaddress certain populations of patients who were medically complex (including patients with chronicdiseases, infants with high risk, and pregnant women with high risk), no systematic reviews assessedinterventions for other key medically complex populations, such as patients with substance usedisorder, comorbid psychiatric or behavioral health problems, or common chronic diseases, such aschronic kidney disease and chronic obstructive pulmonary disease.

Figure. Diagram of Included Systematic Reviews

4432 Articles identified through databaseand gray literature searches

1227 Articles excluded at title level

2782 Articles excluded at abstract level1379 Intervention not relevant530 No intervention, eg, risk factor study291 Narrative review or limited to uncontrolled studies263 Patient population not relevant150 Care setting not relevant93 Does not address Guiding Questions45 Key outcomes not reported15 All included studies not conducted in the US16 Other

19 Included systematic reviews in 20 publications

403 Articles excluded at full-text level116 All or majority studies not conducted in US30 Narrative review56 Systematic review with no risk of bias assessment55 Care setting not relevant37 Key outcomes not reported37 Patient population not relevant34 Intervention not relevant15 Duplicate, redundant, or superseded by

other reviews11 Full-text not available or not published in English12 Other

3205 Abstracts assessed

423 Full-text articles assessed




Older PatientsThere were 9 systematic reviews (in 10 publications) that included older patients,33,37-39,43,44,46-49

with 4 systematic reviews focused on elderly patients who were frail. Of these, 5 systematic reviewsperformed quantitative synthesis of LOS and assessed discharge planning interventions (3systematic reviews) and geriatric assessment or consultation (2 systematic reviews).

Discharge planning interventions (eg, early assessment of discharge suitability, establishingdischarge plan and follow-up) had mixed results among older patients (Table 2). One systematicreview by Mabire et al37,38 included 4 RCTs, 1 pre-post study, and 1 cohort study (including 2370patients) assessing nursing-led discharge planning interventions, and found the intervention wasassociated with increased hospital LOS (weighted mean difference, 0.29 [95% CI, 0.24 to 0.35] days;low SOE). Although LOS increased, discharge planning was associated with improved readmissionrates (odds ratio [OR], 0.57 [95% CI, 0.40 to 0.81]; P = .01), although a subanalysis specific totransitional care did not find an association with improvement (OR, 0.70 [95% CI, 0.38 to 1.27]).Another review by Goncalves-Bradley et al46 examined transitional care programs run by clinicalnurse specialists across 12 RCTs (including 2193 patients) and found a decrease in LOS (meandifference, −0.73 [95% CI, −1.33 to −0.12] days; moderate SOE). A subgroup analysis focused on oldersurgical patients, including 2 RCTs (including 184 patients), found no change in LOS (mean difference,−0.06 [95% CI, −1.23 to 1.11] days). The third review by Bryant-Lukosius et al43 also evaluated a

Table 2. Description of Interventions to Reduce Length of Stay

Intervention Included systematic reviews Description of interventionGeriatric assessment Bakker et al,33 2011 Multidisciplinary team with geriatrics

consultation at various stages of patient care,including comanagement with surgical teams forpreoperative optimization

Patel et al,39 2020

Ellis et al,44 2017

Van Craen et al,47 2010

Eagles et al,49 2020

Discharge planning Zhu et al,20 2015 Included an assessment of suitability fordischarge, planning, implementation, and/orpost-discharge follow-up. Follow-up careinvolved a phone call within 24 h of discharge,scheduling outpatient visits, home visits, and/oron-call services.

Mabire et al,37 2018


Bryant-Lukosius et al,43 2015

Goncalves-Bradley et al,46 2010

Medication management Austin et al,31 2020 Often targeted for high-risk medications, such asanticoagulants or antibiotics, with known adverseeffects. Interventions included computerizedentry systems, clinical decision support tools,dashboard utilization, pharmacist-ledanticoagulation consultation services, andsystematic education and feedback programs forpatients.

Gillaizeau et al,34 2013

Frazer et al,45 2019

Clinical pathways Kul et al,36 2012 Included studies on multicomponentinterventions, such as quality-improvementinitiatives, including inpatient clinical pathwayfor heart failure management, standardizedadmission orders, education for staff andpatients, or telephone surveillance afterdischarge

Agarwal et al,42 2019

Multidisciplinary care Pannick et al,40 2015 Team coordination with inclusion of specialistsduring rounds, communication strategies, andtask delegation for implementation ofconsultative recommendations

Zhang et al,48 2013

Case management Huntley et al,35 2016 Directed by nurse case managers and includedvarious strategies, such as medication review,family conferencing, education, homeenvironment assessment, or referral to otherservices

Hospitalist service White et al,41 2011 Utilization of hospitalist physician staffingevaluated based on assessments of physicianperformance on quality of care

Telehealth Baratloo et al,32 2018 Hospital-based telehealth services for patientswith stroke, linking hospital-based clinicians tooutside clinical care teams




nurse-led intervention in 3 RCTs (including 396 patients) and found no difference in LOS (meandifference, −0.69 [95% CI, −1.95 to 0.56] days; low SOE).

There were 2 systematic reviews that quantitatively assessed outcomes associated withgeriatric assessment or consultation interventions and also found mixed LOS outcomes. Eagleset al49 evaluated geriatric assessment performed by a geriatrician for reducing LOS for patients aged65 years or older admitted to a trauma center. Based on 2 retrospective cohort studies (including5414 patients), Eagles et al49 found that compared with standard care, geriatric assessment wasassociated with reduced LOS (mean difference, −1.11 [95% CI, −1.43 to −0.79] days; moderate SOE).49

Pre-post studies (including 7408 patients) from the systematic review by Eagles et al49 did not showimprovement in mortality (unadjusted OR, 0.91 [95% CI, 0.70 to 1.18]), but cohort data comparinggeriatric trauma consultation with standard of care (including 482 patients) did show improvementassociated with consultation in inpatient mortality (unadjusted OR, 0.24 [95% CI, 0.12 to 0.52];I2 = 0%; moderate SOE). In contrast, another review by Van Craen et al47 included 7 RCTs (including4759 patients) and found no difference in LOS (mean reduction, 0.07 [95% CI, −0.11 to 0.26] days)or mortality at 12 months (relative risk [RR], 0.97 [95% CI, 0.88 to 1.08]; high SOE). Notably, thereview by Van Craen et al47 focused on elderly patients who were frail, which may have representeda higher-risk population than other studies. Van Craen et al47 noted that the components andimplementation of the intervention (geriatric evaluation and treatment unit) across included studieswas heterogeneous.

Heart FailureWe found 4 systematic reviews assessing 3 interventions (ie, discharge planning, clinical pathways,and case management) in patients with heart failure. However, only 2 of 4 systematic reviews meta-analyzed outcomes for LOS. One systematic review did not provide quantitative synthesis for LOS

Table 3. Evidence Map of Systematic Reviews With Quantitative Synthesisa

Patient population Intervention Systematic review(s)Study designs(No. of included patients)b

Outcome (strength of evidence)c

LOS Readmissions MortalityOlder adults Discharge planning Mabire et al,37 2018 4 RCTs, 1 pre-post study, 1 cohort

(2370)↑ (L) ↓ (M) NR


Goncalves-Bradley et al,46 2016 12 RCTs (2193) ↓ (M) ↓ (M) NR

Bryant-Lukosius et al,43 2015 3 RCTs (396) ↔ (L) NR ↔ (L)

Geriatric assessment Eagles et al,49 2020 2 retrospective cohort studies(5414)

↓ (M) NR ↓ (M)

Van Craen et al,47 2010 7 RCTs (4759) ↔ (H) ↔ (M) ↔ (H)

Ellis et al,44 2017 11 RCTs (4346) NR NR ↔ (H)

Patients with heartfailure

Discharge planning Bryant-Lukosius et al,43 2015 2 RCTs (495) NR ↔ (L) ↔ (L)

Clinical pathways Kul et al,36 2012 1 RCT and 4 observational studies(2095)

↓ (L) ↓ (M) ↓ (M)

Case management Huntley et al,35 2016 8 RCTs and 1 observational study(1765)

↓ (M) ↓ (M) NR

Patients with chronicconditions

Discharge planning Zhu et al,20 2015 5 RCTs (1912) ↔ (M) ↓ (M) ↓ (H)

Medicationmanagement

Gillaizeau et al,34 2013 8 RCTs and 1 observational study(n = 18 507)

↔ (L) NR NR

Interdisciplinary care Pannick et al,40 2015 2 RCTs, 2 non-RCT cluster studies,2 before/after studies (NR)

↔ (M) ↑ (L) ↔ (M)

Infants Discharge planning Bryant-Lukosius et al,43 2015 2 RCTs (495) NR ↔ (L) NR

Pregnant women Discharge planning Bryant-Lukosius et al,43 2015 2 RCTs (15) ↓ (M) NR NR

Patients with stroke Telehealth Baratloo et al,32 2018 1 RCT, 2 prospective controlledstudies, 6 retrospective controlledstudies (2850)

↓ (M) NR ↔ (M)

Abbreviations: L, low or very low; H, high; LOS, length of stay; M, moderate; NR, notreported; RCT, randomized clinical trial.a All reviews reported LOS data. NR in the LOS column indicates that the authors

reported a narrative synthesis or results from individual trials instead of a quantitativesynthesis. Narrative syntheses are not included here.

b Number of patients included in quantitative synthesis for LOS. If LOS was notquantitatively synthesized, the number of patients for the outcome depicted withquantitative synthesis is reported.

c Direction of association is indicated by arrows, with ↑ indicating increase; ↓, decrease;and ↔, inconclusive.




but found no difference in readmission (defined as unplanned readmission at 90 days) or mortality,although the intervention was associated with improved patient satisfaction.43

One systematic review performed a quantitative assessment of LOS for clinical pathwayinterventions. Kul et al36 included 1 RCT and 4 observational studies (including 2095 patients) andfound that clinical pathway utilization was associated with reduced LOS (mean difference reduction,1.89 [95% CI, 1.33 to 2.44] days; I2 = 42%; low SOE). There was also a reduction in readmission rate(RR, 0.81 [95% CI, 0.66 to 0.99]; I2 = 16%; moderate SOE) and inpatient mortality (RR, 0.45 [95% CI,0.21 to 0.94]; I2 = 73%; low SOE).

A single systematic review by Huntley et al35 examined case management interventions.Huntley et al35 included 8 RCTs and 1 observational study (including 1765 patients) and found anassociation with decreased LOS (mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days;I2 = 63%; moderate SOE). Additionally, a sensitivity analysis excluding studies at high ROB found amean reduction of 1.76 (95% CI, 1.23-2.29) days (I2 = 14%). Regarding readmission, Huntley et al35

found that case management interventions studied in 12 RCTs and 1 observational study (including3346 patients) were associated with reduced readmission rates (RR, 0.74 [95% CI, 0.60 to 0.92];moderate SOE) with increased heterogeneity (I2 = 69%), with similar results when high ROB studieswere excluded (RR, 0.77 [95% CI, 0.61 to 0.96]; I2 = 68%).

A review by Bryant-Lukosius et al43 evaluated discharge planning interventions across multiplepatient populations aged in their early to mid-70s, including patients with heart failure (2 RCTs with495 patients). Although the systematic review did not perform quantitative synthesis of LOS forpatients with heart failure, Bryant-Lukosius et al43 found no difference in readmission rates, definedas unplanned readmission at 90 days (RR, 0.81 [95% CI, 0.57 to 1.13]), and no difference in mortality(including 345 patients; RR, 0.76 [95% CI, 0.41 to 1.42]). However, the intervention was associatedwith improved patient satisfaction (including 403 patients; mean difference, 6.09 [95% CI, 3.55 to8.63]; P < .001; moderate SOE).

Discussion

This systematic review identified evidence for 8 hospital-based interventions targeting high-riskpatient populations: discharge planning,20,37,38,43,46 geriatric assessment or consultation,33,39,44,47,49

medication management,31,34,45 clinical pathways,36,42 interdisciplinary or multidisciplinarycare,40,48 case management,35 hospitalist services,41 and telehealth.32 As shown Table 3, aside frominterventions for patients with heart failure, interventions were not consistently associated withreduced hospital LOS for medically complex populations. It is important to note that patients who aremedically complex do not exist in silos, as older patients may also have chronic conditions, such asheart failure; therefore, identifying interventions that could reduce LOS across populations isimportant.

For patients with heart failure, clinical pathways and case management interventions were bothassociated with reduced LOS, readmission rates, and mortality.36 These findings are notable, sinceprior research has shown that interventions may improve LOS but worsen readmission rates ormortality.50 However, it is important to recognize the significant heterogeneity across studies in thesystematic review by Kul et al36; similarly, another included narrative review on clinical pathways didnot perform meta-analysis owing to increased heterogeneity.42 This suggests local context andresources (eg, team dynamics, hospital priorities, processes and staffing resources, andadministrative support) are likely important factors in how successful interventions, such as clinicalpathways or case management, are in streamlining care.36,51,52

Hospitalized older patients often have increased costs, complications, worse outcomes,53,54

and longer LOS compared with younger patients. For example, a study by Freeman et al53 estimatedthat compared with younger patients (aged 18-44 years), older adults (aged 65-84 years) hadhospital stays that were a mean of 1.4 days longer. However, no intervention was consistentlyassociated with reduced LOS for older patients. While 1 review found discharge planning was




associated with a 0.73-day reduction in LOS in older patients,46 others found no association withreduced LOS, or even found an association with increased LOS.37,38,43 Inpatient geriatric assessmentinterventions also yielded inconsistent results. The largest review on this topic was unable to meta-analyze results owing to heterogeneity in study designs and settings across 11 RCTs.44 Studies’settings included academic medical centers as well as community hospitals, and interventioncomponents varied across studies. Thus, the variable associations with LOS across studies mayreflect organizational differences, as LOS may vary depending on hospital factors, such as patienttransfers, bed capacity, and demand. Future studies are needed to identify if interventions wouldprovide more consistent benefits for particular types of hospitals or wards.

LimitationsThis systematic review has several important limitations. First, we used systematic reviews insteadof primary studies to characterize interventions. Using systematic reviews facilitated searching forevidence across a broad range of populations and interventions and supported identification ofevidence gaps. However, systematic reviews rarely reported key aspects of local environments (eg,demographic data on patient volume, bed size, payer mix, or other organizational capacity), whichindividual studies may have reported and would provide valuable context for health systems gaugingfeasibility and likelihood of success. Future systematic reviews assessing hospital LOS shouldcertainly highlight these factors. Second, as systematic reviews inherently lag behind primaryresearch, our evidence base may have missed interventions not yet captured in a published review.However, a targeted search of RCTs through January 19, 2021, identified no additional relevantstudies pertinent to older or heart failure populations. Third, we did not formally assess systematicreview quality; however, because systematic reviews were required to meet certain methodologicalstandards for inclusion (ie, explicit search strategies, inclusion and exclusion criteria, and ROBassessment), all included systematic reviews met this threshold for quality.

Conclusions

In this systematic review, we found 19 systematic reviews that identified 8 strategies for reducingLOS in high-risk populations: discharge planning, geriatric assessment; medication management;clinical pathways; inter- or multidisciplinary care; case management; hospitalist services; andtelehealth. Identifying hospital-initiated interventions to reduce LOS without increasingreadmissions or mortality is of interest to most hospitals and health systems. While many hospitalsare searching for a one-size-fits-all solution to streamline care, our systematic review found that nosingle intervention was consistently associated with reduced LOS across all high-risk populations. A2011 study by Hansen et al55 found that no single intervention was associated with reducedreadmissions across broad populations. Since then, national initiatives have resulted in developmentof multifaceted approaches that include a range or combination of interventions that can be adaptedfor local context.56 Our findings suggest that efforts to reduce LOS, particularly for high-riskpopulations, could benefit from a similar approach. Future research assessing interventions for LOSreduction in high-risk populations or subpopulations should also consider implementation sciencemeasures to inform local adaption.

ARTICLE INFORMATIONAccepted for Publication: July 18, 2021.

Published: September 20, 2021. doi:10.1001/jamanetworkopen.2021.25846

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Siddique SMet al. JAMA Network Open.





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Corresponding Author: Shazia Mehmood Siddique, MD, MSHP, Division of Gastroenterology, University ofPennsylvania, 3400 Civic Center Blvd, 7th Floor, Philadelphia, PA 19104 ([email protected]).

Author Affiliations: Division of Gastroenterology, University of Pennsylvania, Philadelphia (Siddique); LeonardDavis Institute of Health Economics, University of Pennsylvania, Philadelphia (Siddique, Greysen, Lane-Fall);Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia (Siddique, Leas,Greysen, Mull, Lane-Fall); ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines,Plymouth Meeting, Pennsylvania (Tipton, McShea, Tsou); Division of General Internal Medicine, University ofPennsylvania, Philadelphia (Greysen, Mull); Department of Anesthesiology and Critical Care, University ofPennsylvania, Philadelphia (Lane-Fall); Division of Neurology, Michael J. Crescenz Veterans Affairs Medical Center,Philadelphia, Pennsylvania (Tsou).

Author Contributions: Dr Siddique and Ms Tipton had full access to all of the data in the study and takeresponsibility for the integrity of the data and the accuracy of the data analysis. Dr Siddique and Ms Tipton areco–first authors.

Concept and design: Siddique, Tipton, Leas, Mull, Lane-Fall, Tsou.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Siddique, Tipton, Leas, McShea.

Critical revision of the manuscript for important intellectual content: Siddique, Tipton, Leas, Greysen, Mull, Lane-Fall, Tsou.

Statistical analysis: Leas.

Obtained funding: Siddique, Leas, Tsou.

Administrative, technical, or material support: Tipton, Leas, Mull, Lane-Fall, Tsou.

Supervision: Leas, Greysen, Mull, Tsou.

Conflict of Interest Disclosures: Dr Leas reported receiving grants from the Agency for Healthcare Research andQuality (AHRQ) outside the submitted work. No other disclosures were reported.

Funding/Support: This work was funded by the Agency for Healthcare Research and Quality (AHRQ), USDepartment of Health and Human Services, through the Evidence-based Practice Center (grant No.75Q80120D00002; task order No. 75Q80120F32001). The manuscript preparation was also supported in part bythe National Institutes of Health (grant No. NIDDK-K08DK120902-02; for Dr Siddique).

Role of the Funder/Sponsor: An AHRQ representative served as a contracting officer for the nominator (AHRQLearning Health System panel) and provided technical assistance and feedback during the conduct of the evidencereport, and reviewed the contract deliverables for adherence to contract requirements and quality. AHRQ did notdirectly participate and the National Institutes of Health had no role in the design and conduct of the study;collection, management, analysis, and interpretation of the data; preparation, review, or approval of themanuscript; and decision to submit the manuscript for publication.

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SUPPLEMENT.eTable 1. Embase and MEDLINE Search Terms in Embase SyntaxeTable 2. Characteristics of Systematic Reviews on Reducing Length of Hospital StayeTable 3. Summary of Findings for Length of Stay Meta-analyses




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interventions to reduce hospital length of stay in high

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