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Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review Michael Nunnso ,1* Liz Shawo ,1 Simon Briscoeo ,1 Jo Thompson Coono ,1 Anthony Hemsleyo ,2 John S McGratho ,1,3 Christopher J Lovegroveo ,3,4 David Thomaso 3 and Rob Andersono 1 1Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK 2Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK 3Royal Devon & Exeter NHS Foundation Trust, Exeter, UK 4School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK *Corresponding author m.p.nunns@exeter.ac.uk 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 DOI: 10.3310/hsdr07400 HEALTH SERVICES AND DELIVERY RESEARCH 2019 VOL. 7 NO. 40 © Queen’s Printer and Controller of HMSO 2019. This work was produced by Nunns et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v 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, healthcare 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. ABSTRACT NIHR Journals Library www.journalslibrary.nihr.ac.uk vi