Are Hospital-Led Interventions Reducing LOS for High-Risk Populations?

A systematic review published in JAMA Network Open revealed inconsistent findings on the effectiveness associated with interventions to reduce hospital length of stay (LOS) across all high-risk populations, underscoring important evidence gaps and the need for further research.

LOS is often used as a proxy for efficient hospital management, while reductions in LOS help improve bed turnover. This allows hospitals to match demand with capacity for elective and emergent admissions, intensive care unit (ICU) care, and interhospital transfers, researchers explained.

Numerous strategies to reduce LOS have been developed; however, a paucity of evidence exists when it comes to the effectiveness of interventions in unplanned hospitalizations, as opposed to elective admissions. This is especially true for populations at-risk for poor outcomes, including those with heart failure or older or medically complex patients.

To identify interventions aimed at reducing LOS among those at high risk of prolonged LOS, researchers conducted a systematic review of MEDLINE, PubMed, Embase, CINAHL, the Cochrane Library, and gray literature sources for studies published between 2010 to 2021. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study.

A total of 19 systematic reviews were included, of which 10 included a mix of study designs, 8 included only randomized clinical trials, and 1 included only retrospective cohort studies. Eight strategies to reduce LOS in high-risk populations were assessed: 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, often those who were frail (9 studies), or patients with heart failure,” authors wrote, while “there were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk.” These could have included patients with housing instability, social isolation, limited English proficiency, or other factors.

Reviews also did not assess LOS interventions among those with substance use disorder or common chronic diseases.

Although analyses did find that for patients with heart failure, clinical pathways and case management were linked with reduced LOS , due to the heterogeneity across studies included, authors underscored the important roles local contexts and resources may play in streamlining care.

In addition, they found that “for patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations.”

Overall, this review showed no single intervention consistently reduced LOS in all high-risk populations.

“Future research assessing interventions for LOS reduction in high-risk populations or subpopulations should also consider implementation science measures to inform local adaption,” researchers concluded.