The goals of this Technical Brief are to (1) categorize and evaluate current knowledge regarding strategies to reduce length of stay (LOS) for medically complex, high-risk, or vulnerable patients at increased risk of extended LOS; (2) examine contextual factors (e.g., resources, costs, staffing, technology) that affect implementation of LOS-focused interventions; (3) identify emerging concepts or initiatives that may merit future research; and (4) develop a series of evidence maps to inform health systems’ strategic efforts for LOS reduction in these populations.
- Few studies have evaluated system-level interventions focused on medically complex, high-risk, or vulnerable patient populations, including frail elderly patients and those with complex chronic illness. Strategies assessed in multiple systematic reviews include geriatric consultation services and early specialized discharge planning.
- Substantial research gaps need to be addressed, including interventions for socially or economically vulnerable populations and patients with psychiatric or substance use disorders, contextual factors affecting feasibility of implementation, and the resources and potential savings associated with interventions to reduce LOS.
- Hospital administrative leaders, researchers, and policymakers can work to reduce LOS by improving research practice, developing targeted health system interventions, and collaboratively addressing the social care needs of medically complex and vulnerable patient populations.
- Two interventions (clinical pathways and case management) improved key outcomes for patients with heart failure. Clinical pathways reduced LOS, readmission, and mortality (low to moderate quality evidence from a single systematic review). Similarly, case management decreased LOS and readmissions (moderate quality evidence from a single systematic review). More research is needed to confirm these findings.
- For other interventions, evidence for LOS reduction was inconsistent. Only limited evidence was available for other post-discharge adverse outcomes (hospital readmission, mortality).
- The evidence base examining strategies for reducing LOS is large but focuses primarily on average-risk patients undergoing elective surgery or specialized procedures, who were not the focus of this Technical Brief.
Background. Timely discharge of hospitalized patients can prevent patient harm, improve patient satisfaction and quality of life, and reduce costs. Numerous strategies have been tested to improve the efficiency and safety of patient recovery and discharge, but hospitals continue to face challenges.
Purpose. This Technical Brief aimed to identify and synthesize current knowledge and emerging concepts regarding systematic strategies that hospitals and health systems can implement to reduce length of stay (LOS), with emphasis on medically complex or vulnerable patients at high risk for prolonged LOS due to clinical, social, or economic barriers to timely discharge.
Methods. We conducted a structured search for published and unpublished studies and conducted interviews with Key Informants representing vulnerable patients, hospitals, health systems, and clinicians. The interviews provided guidance on our research protocol, search strategy, and analysis. Due to the large and diverse evidence base, we limited our evaluation to systematic reviews of interventions to decrease hospital LOS for patients at potentially higher risk for delayed discharge; primary research studies were not included, and searches were restricted to reviews published since 2010. We cataloged the characteristics of relevant interventions and assessed evidence of their effectiveness.
Findings. Our searches yielded 4,364 potential studies. After screening, we included 19 systematic reviews reported in 20 articles. The reviews described eight strategies for reducing LOS: discharge planning; geriatric assessment or consultation; medication management; clinical pathways; inter- or multidisciplinary care; case management; hospitalist services; and telehealth. All reviews included adult patients, and two reviews also included children. Interventions were frequently designed for older (often frail) patients or patients with chronic illness. One review included pregnant women at high risk for premature delivery. No reviews focused on factors linking patient vulnerability with social determinants of health.
The reviews reported few details about hospital setting, context, or resources associated with the interventions studied. Evidence for effectiveness of interventions was generally not robust and often inconsistent—for example, we identified six reviews of discharge planning; three found no effect on LOS, two found LOS decreased, and one reported an increase. Many reviews also reported patient readmission rates and mortality but with similarly inconsistent results.
Conclusions. A broad range of strategies have been employed to reduce LOS, but rigorous systematic reviews have not consistently demonstrated effectiveness within medically complex, high-risk, and vulnerable populations. Health system leaders, researchers, and policymakers must collaborate to address these needs.
Siddique SM, Tipton K, Leas B, et al. Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review. JAMA Netw Open. 2021;4(9):e2125846. DOI: 10.1001/jamanetworkopen.2021.25846
Tipton K, Leas BF, Mull NK, Siddique SM, Greysen SR, Lane-Fall MB, Tsou AY. Interventions To Decrease Hospital Length of Stay. Technical Brief No. 40. (Prepared by the ECRI–Penn Medicine Evidence-based Practice Center under Contract No. 75Q80120D00002.) AHRQ Publication No. 21-EHC015. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. DOI: 10.23970/AHRQEPCTB40. Posted final reports are located on the Effective Health Care Program search page.