Interventions to Decrease Hospital Length of Stay

In 2014, there were 35.4 million inpatient hospital stays in the U.S.: 3.9 million neonatal; 4.1 million maternity-related admissions; 7 million surgical; and 17 million medical.¹ Unnecessary days in the hospital may lead to patient complications (e.g., healthcare-associated infections, falls) and increased costs. In addition, length of hospitalization may impact negatively both patient and staff experience.² Delays in hospital discharge may be related to unnecessary waiting, poor organization of care, delays in decision-making, or difficulties related to discharge planning.^2,3

A broad array of interventions have been developed to reduce length of stay (LOS), and they differ in design, intent, and focal point. While some interventions primarily aim at improving clinical care (ERAS,^4-6 clinical pathways,7 and early patient mobility programs⁸) other approaches address logistical factors (care coordination, transition and discharge planning,^9-11 case management,12 medication management,¹³ or specialized units for high-risk populations^14,15). Other interventions target the workforce, such as multidisciplinary care teams¹⁶ or redesigned staffing models.¹⁷

Interventions have the potential to create trade-offs between outcomes. Reducing LOS might increase concerns for risk of readmission or shifting costs of care.² Conversely, interventions might be ineffective in reducing LOS, but yield significant improvements in other patient-centered outcomes, such as patient satisfaction. Further, treatment for exacerbation of a complex chronic condition may differently prioritize interventions to reduce LOS, compared with treatment of an acute illness or a surgical procedure.

Particular patient populations, such as patients who are socially or economically vulnerable or with medically-complex needs, may be at increased risk for unnecessary delays in discharge.^18-20 These patients are typically at greater risk for adverse events during and after hospitalization.²¹ Interventions that focus on addressing the challenging LOS reduction needs of these populations might increase the efficiency of patient throughput while improving the delivery of safe and effective care.

Successful hospital-based interventions may significantly depend on environmental factors including the unique resources, personnel, leadership, and infrastructure specific to each setting. A hospital or health system-based approach could therefore address the multiple factors contributing to unnecessary delays in hospital discharge.² The goals of this Technical Brief (TB) are to: (1) categorize and evaluate current knowledge regarding the multitude of strategies to reduce LOS; (2) examine contextual factors (e.g., resources, costs, staffing, and technology) that affect implementation of 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.

GQ 1: What are the characteristics of interventions to decrease length of hospital stay and how do they vary?

GQ 2: What are the contextual factors (e.g., resources, staffing, technology) that impact implementation of interventions to decrease hospital length of stay?

GQ 3: What is the current evidence addressing interventions to decrease hospital length of stay?

GQ 4: What future research is needed to close evidence gaps regarding interventions to decrease length of hospital stay?

1. Data Collection

A. Discussions With Key Informants

We will interview 6–9 Key Informants (KIs) with expertise in one or more of the following areas: health system leadership, healthcare quality improvement and patient safety, regulation, social determinants of health, payment and delivery system transformation, and chronic conditions associated with long LOS. KIs will be queried on key priority areas for health systems, characteristics of medically complex patients and vulnerable populations, interventions specific and/or different to reducing LOS in these at risk populations, and outcomes important to a system, care team, and/or patients. They will also be asked to identify important characteristics to support assessments about feasibility of implementation and the challenges encountered. Patient advocates will also be recruited as KIs, to ensure that the patient perspective is represented.

KI input will help inform GQ 1, 2, and 4. KI input will also be used to refine the systematic literature search, identify grey literature resources, provide information about ongoing research, confirm evidence limitations, recommend approaches to help fill these gaps, and provide input on the potential design, focus, and audience for the evidence maps that will be featured in this TB. Table 1 presents potential questions that KIs will be asked.

Table 1. Potential KI Questions

What clinical conditions are top priorities for you when thinking about efforts to reduce LOS? How do you decide on prioritization for these efforts?
Based on national admissions and LOS data, some of the chronic conditions for specific focus include: acute exacerbations of chronic COPD, acute exacerbations of chronic CHF.
1. Are there other chronic conditions with frequent decompensations often requiring inpatient admission missing from this list that are of particular interest?
Can you describe characteristics of medically complex patients for which interventions to reduce LOS would be particularly helpful?
How would you describe vulnerable populations within a hospital setting as it relates to LOS?
1. Are there interventions of interest that would be specific and/or different to LOS in these at risk populations?
How would you define a hospital or health system-based organizational intervention to reduce LOS? What are the most important elements of such interventions?
What characteristics of interventions are important for you to know or understand so that you can judge feasibility of implementation? (e.g. staffing requirements, infrastructure, resource utilization)
1. How do emerging or existing payment models affect approaches to operationalizing or prioritizing LOS interventions?
The information about interventions we glean from studies will be presented in evidence maps. For example, https://www.ncbi.nlm.nih.gov/books/NBK379312/figure/findings.f7/?report=objectonly
1. What are your thoughts about 2 or 3 key variables that would be most helpful for you to see graphically presented?
2. What types of categories of interventions or conditions would be useful to highlight or group together?
What outcomes other than LOS, including potential positive or negative effects to a system or care team are of particular interest for interventions to decrease LOS? What outcomes are important to patients?
Where do you think are the most important gaps in current knowledge, and can you recommend approaches to help fill and/or identify these gaps?
In addition to published literature, what unpublished resources could help inform our analysis?

B. Gray Literature Search

Gray literature sources and retrieval will include websites of relevant stakeholder organizations (e.g., American Hospital Association, Institute for Healthcare Improvement, The Joint Commission), healthcare consulting firms (e.g., Premier, Vizient, Socially Determined), and government agencies (e.g., ClinicalTrials.gov, the Agency for Healthcare Research and Quality [AHRQ], The Centers for Medicare and Medicaid [CMS]). Also, we will search for evidence in non-medical resources that often address healthcare management, such as Modern Healthcare and Harvard Business Review. Input from the KIs will be used to identify other grey literature sources.

C. Published Literature Search

Published literature will be used to answer GQ 3. Literature searches will be performed by Medical Librarians within the Evidence-based Practice Center (EPC) Information Center, and will follow established systematic review protocols. We will search the following databases using controlled vocabulary and text words: MEDLINE, PubMed (unprocessed records only), EMBASE, CINAHL, and the Cochrane Library to identify systematic reviews (SRs) with and without meta-analysis. Searches will cover the literature published since January 1, 2010. Search dates may be adjusted based on the quantity and quality of the available literature. Appendix 1 presents a sample search strategy.

Literature screening will be performed in duplicate using the database Distiller SR (Evidence Partners, Ottawa, Canada). Literature search results will initially be screened for relevancy. Selected abstracts will be screened in duplicate. Studies that appear to fit the scope of the brief will be retrieved in full and screened again in duplicate. All disagreements will be resolved by consensus discussion among the two original screeners. The literature searches will be updated during the Peer Review process, before finalization of the review.

D. Inclusion of Published Literature

This TB will focus on evaluating existing English-language systematic reviews (SRs) of published studies. SRs will be included if they meet the inclusion criteria listed in Table 2. We will consider SRs of both randomized and non-randomized primary studies. We will limit inclusion of SRs to those meeting certain methodological standards, such as providing search criteria, explicit inclusion/exclusion criteria, and risk-of-bias assessment. Where available, we will abstract and use strength of evidence (SOE) ratings provided by SRs; including the methods used to assess SOE; if not provided, we will use AHRQ EPC guidance to appraise SOE. We will note if the SRs' conclusions for a given intervention had different SOE ratings. We will supplement our searches with the results of exploratory searches for randomized controlled trials (RCTs) on topics not covered in the SRs in order to assess the need for future SRs or primary studies. We will apply the same inclusion and exclusion criteria to the results of the exploratory search for RCTs.

We will exclude SRs focused on patients undergoing non-emergent elective procedures or focused solely on intensive care units, emergency department visits, observation units, or specialty hospitals. We will also exclude SRs of interventions initiated, managed, or implemented by entities external to the hospital setting, such as community organizations. Interventions not intended or expected to reduce LOS will not be evaluated. SRs will also be excluded if they only describe cost-related outcomes without reporting LOS. Finally, we will exclude SRs of primary studies that were conducted solely outside the United States.

Table 2. Inclusion and Exclusion Criteria

Category	Criteria
Population	Include hospitalized children and adults (including pregnant women) with one or more of the following risk factors for prolonged LOS, harms, or adverse outcomes: Vulnerable populations: high levels of socioeconomic risk (e.g., housing instability, social isolation, social vulnerability, social mobility, lack of social network, lack of social support, limited access to healthcare services or social services, rural settings) medically uninsured, underinsured hospitalization at safety-net, tertiary, or quaternary care institution limited English proficiency Medically complex patients: comorbid psychiatric or behavioral health conditions comorbid substance use disorder frailty multimorbidity (≥2 chronic health conditions) high volume chronic disease conditions with significant risk of exacerbation or complications, including chronic kidney disease, diabetes, congestive heart failure, and chronic obstructive pulmonary disease Exclude patients undergoing non-emergent elective procedures
Interventions	Include interventions that are: initiated within the hospital; and designed (at least in part) to evaluate LOS Examples include but are not limited to: clinical pathways, ERAS, discharge planning, case management, multidisciplinary teams Exclude interventions that are: initiated, managed, or implemented by entities wholly external to the hospital setting; or 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, third-party reimbursement programs
Comparators	Include: Usual care; any comparison; other active intervention
Outcomes	Include Primary: Length of stay, length of stay index Secondary: Readmission Patient harms, such as hospital-acquired conditions and medical errors Patient experience/satisfaction Patient functional return Clinician/staff satisfaction Resource use including patient flow and discharge disposition Exclude studies that only describe cost-related outcomes without reporting LOS, exclude cost related outcomes that do not quantify valuations of both comparisons or alternative interventions (including usual or standard of care) and both of their associated outcomes
Timing	Include: All
Setting	Include acute care hospitalizations in general or pediatric hospitals reviews of studies conducted in the United States Exclude reviews focused solely on ICU stays, emergency departments, or observation units specialty hospitals (e.g., psychiatric, ophthalmologic, orthopedic, cancer, rehabilitation, long-term acute care) reviews of studies conducted solely outside the U.S.

2. Data Organization and Presentation

A. Information Management

Descriptive characteristics will be abstracted from published SRs and tabled. Factors to be abstracted will include:

Patient population (age; sex; primary language; primary diagnosis and comorbidities; medical insurance or lack of coverage; housing type; other measures of social isolation and/or vulnerability as reported by SRs)
Hospital characteristics (adult/pediatric; bed size; location [urban, rural, etc.]; type of hospital [academic medical center, community hospital]; health system affiliation or standalone hospital)
Intervention characteristics (description of intervention; resources needed; implementation factors including durability, if described)
Comparators (description of comparison group, including models of care for controlled trials or cohort studies, or preexisting hospital care factors for pre-post studies)
Outcomes (LOS or LOS index; sustainment of LOS changes; readmission rates; measures of hospital-related harms as reported in SRs; patient functional status and time to functional return; patient satisfaction/experience; clinician/staff experience; resource use; patient throughput)

B. Data Presentation

Data that are abstracted will be presented in searchable evidence tables. To optimize usability of the findings we will design a series of visual evidence maps that broadly summarize the volume and quality of existing research for each intervention category, and describe their effects on LOS. We will also highlight the current state of knowledge regarding implementation of interventions and important evidence gaps (e.g., qualitatively summarize relevant results from the exploratory searches for randomized controlled trials) that require further study and assessment using data visualization approaches as appropriate. Finally, significant perspectives and insights gathered from the KIs will be summarized narratively.

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In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

Within the Technical Brief process, Key Informants serve as a resource to offer insight into the clinical context of the technology/intervention, how it works, how it is currently used or might be used, and which features may be important from a patient of policy standpoint. They may include clinical experts, patients, manufacturers, researchers, payers, or other perspectives, depending on the technology/intervention in question. Differing viewpoints are expected, and all statements are crosschecked against available literature and statements from other Key Informants. Information gained from Key Informant interviews is identified as such in the report. Key Informants do not do analysis of any kind nor contribute to the writing of the report and will not review the report, except as given the opportunity to do so through the public review mechanism.

Key Informants must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as Key Informants and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodologic expertise. Peer review comments on the draft report are considered by the EPC in preparation of the final report. Peer reviewers do not participate in writing or editing of the final report or other products. The synthesis of the scientific literature presented in the final report does not necessarily represent the views of individual reviewers. The dispositions of the peer review comments are documented and may be published three months after the publication of the evidence report.

Potential Reviewers must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not have any financial conflict of interest greater than $5,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.

EPC core team members must disclose any financial conflicts of interest greater than $1,000 and any other relevant business or professional conflicts of interest. Related financial conflicts of interest that cumulatively total greater than $1,000 will usually disqualify EPC core team investigators.

This project is funded under Contract No. 75Q80120D00002 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The AHRQ Task Order Officer will review contract deliverables for adherence to contract requirements and quality. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Set Number	Concept	Search Statement
1	Length of Stay –	'length of stay'/exp OR ('hospital discharge'/exp AND 'time factor'/exp)
2	Length of Stay – keywords in title, abstract	(“LOS” OR (length NEXT/3 stay) OR “bed days” OR (length NEAR/3 hospital) OR ((inpatient OR patient OR short) NEAR/1 (stay OR throughput OR flow)) OR ((Discharge OR stay) NEAR/4 (delay* OR timely OR timeliness OR fast OR faster OR sooner OR quick* OR haste* OR rapid* OR early OR earlier OR reduc* OR decrease OR lessen)) OR (fast NEXT/1 track)):ti,ab
3	Combine sets: LOS	#1 OR #2
4	Vulnerable populations – social – controlled terms	'vulnerable population'/exp OR 'frail elderly'/exp OR 'homelessness'/exp OR 'homeless person'/exp OR 'poverty'/exp OR 'sexual and gender minority'/exp OR 'minority group'/exp OR 'household economic status'/exp OR 'lowest income group'/exp OR 'social status'/exp OR 'health disparity'/exp OR 'health equity'/exp OR 'income group'/exp OR 'safety net hospital'/exp OR 'medically uninsured'/exp OR 'health literacy'/exp OR 'educational status'/exp OR 'literacy'/exp OR 'employment'/exp OR 'employment status'/exp OR 'veteran'/exp OR 'veterans health'/exp OR 'migrant'/exp OR 'English as a second language'/exp OR 'limited English proficiency'/exp OR 'language ability'/exp OR 'prisoner'/exp OR ‘social environment’/exp OR 'health care access'/exp OR 'socioeconomics'/de OR ‘social isolation’/exp
5	Vulnerable populations – social – keywords in title, abstract	(((vulnerable OR marginalized) NEAR/2 (population* OR patient* OR person)):ti,ab) OR homeless:ti,ab OR poverty:ti,ab OR ((poor NEAR/3 (people OR persons)):ti,ab) OR 'low income':ti,ab OR (((sexual OR gender OR ethnic OR racial) NEAR/3 minorit):ti,ab) OR socioeconomic:ti,ab OR ((social NEAR/2 (class OR health* OR status OR support OR mobility OR isolation)):ti,ab) OR ((health* NEAR/4 (disparit* OR equit* OR inequalit* OR literacy OR illiteracy OR literate OR illiterate* OR inequit* OR access)):ti,ab) OR ((('safety net' OR 'safety-net') NEAR/3 (provider OR hospital)):ti,ab) OR uninsured:ti,ab OR 'un insured':ti,ab OR 'under insured':ti,ab OR 'under-insured':ti,ab OR underinsured:ti,ab OR ((without NEXT/3 insurance):ti,ab) OR unemploy:ti,ab OR underemploy:ti,ab OR 'working poor':ti,ab OR veteran:ti,ab OR immigrant:ti,ab OR migrant:ti,ab OR refugee:ti,ab OR ((english NEAR/3 (proficien OR second)):ti,ab) OR (((language OR communication) NEAR/3 barrier):ti,ab) OR prison:ti,ab OR incarcerat:ti,ab OR jail:ti,ab
6	Combine sets: vulnerable populations - social	#4 OR #5
7	Vulnerable populations – diseases/conditions –controlled terms	'disabled person'/exp OR 'disability'/exp OR 'developmental disorder'/exp OR 'mental disease'/exp OR 'communication barrier'/exp OR 'drug dependence'/exp OR 'multiple chronic conditions'/exp OR 'rare disease'/exp OR 'chronic disease'/exp OR 'substance use'/de OR 'alcohol consumption'/exp OR 'cannabis use'/exp OR 'addiction'/de OR 'chronic obstructive lung disease'/exp OR 'heart failure'/exp OR 'dementia'/exp OR 'diabetes mellitus'/exp OR 'chronic kidney failure'/exp OR cormobidity/exp/mj
8	Vulnerable populations – diseases/conditions –keywords	frail:ti,ab OR frailty:ti,ab OR disabilities:ti,ab OR disabled:ti,ab OR multimorbid:ti,ab OR ((multi NEXT/1 morbid):ti,ab) OR alcoholic:ti,ab OR (((alcohol OR substance OR drug OR drugs OR opiate* OR opioid* OR narcotic) NEAR/3 (abuse OR misuse OR addict OR disorder* OR users)):ti,ab) OR (((rare OR chronic) NEAR/2 (disease* OR disorder)):ti,ab) OR ((chronic NEAR/2 (multisymptom OR 'multi symptom')):ti,ab) OR ((multiple NEAR/3 (comorbid* OR morbid)):ti,ab) OR (((mental OR developmental OR behavioral) NEAR/3 (illness OR disorder* OR delay)):ti,ab) OR ((chronic NEXT/1 obstruct NEXT/2 (lung* OR pulmonary)):ti,ab) OR copd:ti,ab OR (((heart OR cardio* OR cardiac OR cardiogen) NEAR/2 (failure OR shock OR death OR infarc OR arrest)):ti,ab) OR dementia:ti,ab OR alzheimer:ti,ab OR diabetes:ti,ab OR diabetic:ti,ab OR chronic:ti,ab OR (('end stage' NEAR/3 kidney):ti,ab) OR renal:ti,ab OR esrd:ti,ab OR ckd:ti,ab OR (complex NEAR/2 patient*)
9	Combine sets – vulnerable populations – disease/conditions -	#7 OR #8
10	Combine sets – all vulnerable populations	#6 OR #9
12	Combine sets – LOS plus population	#3 AND #10
13	Remove unwanted study types	#12 NOT (abstract:nc OR annual:nc OR book/de OR 'case report'/de OR 'case study'/de OR conference:nc OR 'conference abstract':it OR 'conference paper'/de OR 'conference paper':it OR 'conference proceeding':pt OR 'conference review':it OR congress:nc OR editorial/de OR editorial:it OR erratum/de OR letter:it OR note/de OR note:it OR meeting:nc OR sessions:nc OR 'short survey'/de OR symposium:nc)
14	Limit to SRs/MAs	#13 AND ('systematic review'/de OR 'meta analysis'/de OR (systematic* NEAR/2 review*) OR metaanalysis OR 'meta analysis' OR Cochrane)
15	Limit	Limit to English, human, py:2010-2020
Broad search for Length of Stay – no PICO limits applied
16	LOS – major concepts, title words	'length of stay'/exp/mj OR ('hospital discharge'/exp/mj AND 'time factor'/exp/mj) OR 'los':ti OR ((length NEXT/3 stay):ti) OR 'bed days':ti OR ((length NEAR/3 hospital):ti) OR (((inpatient OR patient OR short) NEAR/1 (stay OR throughput OR flow)):ti) OR (((discharge OR stay) NEAR/4 (delay* OR timely OR timeliness OR fast OR faster OR sooner OR quick* OR haste* OR rapid* OR early OR earlier OR reduc* OR decrease OR lessen)):ti) OR ((fast NEXT/1 track):ti)
17	Remove unwanted publication types	#16 NOT (abstract:nc OR annual:nc OR book/de OR 'case report'/de OR 'case study'/de OR conference:nc OR 'conference abstract':it OR 'conference paper'/de OR 'conference paper':it OR 'conference proceeding':pt OR 'conference review':it OR congress:nc OR editorial/de OR editorial:it OR erratum/de OR letter:it OR note/de OR note:it OR meeting:nc OR sessions:nc OR 'short survey'/de OR symposium:nc)
18	Limit to SRs/MAs	#17 AND ('systematic review'/de OR 'meta analysis'/de OR (systematic* NEAR/2 review*) OR metaanalysis OR 'meta analysis' OR Cochrane)
19	Limit to English, PY	Limit #18 to English, human, py:2010-2020
20	LOS – major concept, title, abstract	'length of stay'/exp/mj OR 'los':ti,ab OR ((length NEXT/3 stay):ti,ab) OR 'bed days':ti,ab OR ((length NEAR/3 hospital*):ti,ab)
21	Organizational interventions – controlled terms	'health program'/exp/mj OR 'care coordination'/exp/mj OR 'case management'/exp/mj OR 'interdisciplinary communication'/exp/mj OR 'hospital policy'/exp/mj OR 'clinical decision making'/exp/mj OR 'hospital readmission reduction program'/exp/mj OR 'clinical pathway'/exp/mj OR 'personnel management'/exp/mj OR 'hospital personnel'/exp/mj OR 'care bundle'/exp/mj OR 'health care quality'/exp/mj OR 'multidisciplinary team'/exp/mj OR 'patient care'/exp/mj
22	Organizational interventions - keywords	“case management”:ti,ab OR ((interdisciplin* OR multdisciplin) NEAR/3 (rounds OR rounding OR communicat)):ti,ab OR ((organization* OR hospital) NEAR/5 (policy OR policies OR program OR intervention)):ti,ab OR (staff OR staffing OR bundl OR model* OR pathway*):ti,ab OR (“system level” OR “hospital wide”):ti,ab
23	Specific organizational interventions	('lean process' OR 'eras' OR ((enhanced NEXT/1 recovery):ti,ab) OR 'hospital elder life program' OR 'goal-directed achievement through geographic location' OR gagl OR 'older people assessment liason' OR opal OR 'early supported discharge' OR 'early home supported discharge'):ti,ab OR (six NEXT/1 sigma):ti,ab OR (OASIS NEXT/4 framework*):ti,ab
24	Combine sets – LOS organizational interventions	#20 AND (#21 OR #22 OR #23)
25	Remove unwanted publication types	#24 NOT (abstract:nc OR annual:nc OR book/de OR 'case report'/de OR 'case study'/de OR conference:nc OR 'conference abstract':it OR 'conference paper'/de OR 'conference paper':it OR 'conference proceeding':pt OR 'conference review':it OR congress:nc OR editorial/de OR editorial:it OR erratum/de OR letter:it OR note/de OR note:it OR meeting:nc OR sessions:nc OR 'short survey'/de OR symposium:nc)
26	Remove unwanted publication types	#25 AND ('systematic review'/de OR 'meta analysis'/de OR (systematic* NEAR/2 review*) OR metaanalysis OR 'meta analysis' OR Cochrane)
27	Remove unwanted publication types	#26 to English, human, py:2010-2020
28	Combine sets	#15 OR #19 OR #27

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