Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Abstract

Background Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients. Objectives To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions. Data sources Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence. Review methods Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis. Findings A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’s d = –0.51, 95% confidence interval –0.78 to –0.24; p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’s d = –1.04, 95% confidence interval –1.55 to –0.53; p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive. Limitations Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis. Conclusions Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known. Future work Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes. Study registration This study is registered as PROSPERO CRD42017080637. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Synthesis for health services and policy: case studies in the scoping of reviews

“…38 The review was conducted between September 2017 and October 2018 and published in 2020 (with a pause of 3 months in early 2018 to address an urgent policy question) (see Case study 2: review of experiences of the 'nearest relative' provisions of the Mental Health Act 1983). 39 The scope of the review was initially discussed at a teleconference between the review team and the scientific adviser at NIHR HSDR. The aims of the meeting were to obtain a preliminary understanding of (1) the background to the decision to prioritise the topic for review, (2) the main areas of uncertainty and (3) the purpose of the proposed review.…”

“…Nunns et al 39 Systematic review, including narrative synthesis supported by tabulated data, of the comparative quantitative outcomes, after grouping studies by anatomical location of the planned procedures.…”

“…Fuller description and explanation of synthesis methods and PPI in each case study review project (continued ) Within each procedural group, the intervention and outcomes of each study was summarised visually within a table to aid comparison across multiple outcomes and intervention types. The data for each type of intervention within a procedural grouping were examined to see if any differences between the sample, intervention characteristics or study quality could be related to the effectiveness of the intervention Reproduced with permission from Nunns et al39 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/…”

Evaluation of a New Model of Postoperative Care: A Preliminary Cost-effectiveness Analysis Using Markov Modelling

“…Those studies that do address cost and effectiveness frequently including simple estimates, or formal but simple cost-effectiveness calculations [13][14][15][16][17] . One recent systematic review of interventions to reduce hospital stay concluding that, overall, the evidence base is poor, and costs are rarely dealt with effectively 18 .…”

Evaluating enhanced recovery after surgery: time to cover new ground and discover the missing patient voice

“…(mean or median age over 60) undergoing elective inpatient surgery (Nunns et al 2019). The 73 studies prioritised for synthesis represented the most relevant and highest level of evidence available, based on the following criteria: randomised controlled trials (RCTs) from any high-income country and UK-based RCTs, controlled trials and uncontrolled studies.…”