Agency for Healthcare Research and Quality.

Key Points Question 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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Stereotactic body radiation therapy (SBRT) is derived from the techniques of stereotactic radiosurgery used to treat lesions in the brain and spine. It combines multiple finely collimated radiation beams and stereotaxy to deliver a high dose of radiation to an extracranial target in the body in a single dose or a few fractions. This review provides a broad overview of the current state of SBRT for solid malignant tumors. Reviewers identified a total of 124 relevant studies. To our knowledge, no published comparative studies address the relative effectiveness and safety of SBRT versus other forms of external-beam radiation therapy. Stereotactic body radiation therapy seems to be widely diffused as a treatment of various types of cancer, although most studies have focused only on its use for treating thoracic tumors. Comparative studies are needed to provide evidence that the theoretical advantages of SBRT over other radiation therapies actually occur in the clinical setting; this area is currently being studied in only 1 small trial.

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.