Authors' objectives: To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation understand the experiences of patients, carers and staff involved in the delivery of interventions understand how different aspects of the content and delivery of interventions may influence patient outcomes. The Office for National Statistics predicts that in England the proportion of people aged 65 years and over will increase from 18.2% to 20.7% of the total population between mid-2018 and mid-2028. There has been a steady increase in the number and age of patients admitted for overnight hospital stays for planned or elective procedures, such as hip and knee replacements. Older patients are at increased risk of peri- or post-operative complications such as falls, hospital-acquired infections and cognitive decline, which can impede recovery and require additional support. The COVID-19 pandemic has had a huge impact on waiting lists for elective procedures. Prior to the pandemic, NHS hospitals were under considerable pressure to maintain or improve their provision of care and ensure the cost-effective delivery of services. These pressures have only increased. The British Medical Association suggest the number of people waiting for elective treatment has increased from 4.24 million in March 2020 to 6.84 million in July 2022. Furthermore, NHS monitoring data suggest that between December 2021 and August 2022 the number of patients facing delays in leaving hospital increased by 30%. Many hospital-led, multicomponent organisational strategies have been developed to optimise the time that older people stay in hospital after a planned admission. A recent systematic review of the effectiveness and cost-effectiveness of these interventions showed they were associated with improved clinical outcomes in terms of, for example, length of stay (LOS), readmissions, complications and mortality, or at least performed as well as standard care. However, the subsequent impact on patient outcomes, such as experience, quality of life and participation in meaningful occupations, is largely unknown. Given the ongoing crisis in hospital capacity in the United Kingdom, there is an urgent need to identify, appraise and synthesise the findings from studies considering the influence of multicomponent interventions to enhance recovery on longer-term patient outcomes. We aimed to address the following research questions: What is the impact of multicomponent interventions to enhance recovery and/or reduce LOS for older adults admitted overnight for planned procedures on patient-reported outcome measures and service utilisation? What are the experiences of patients receiving multicomponent interventions to enhance recovery and/or reduce LOS, their family and carers and staff involved with delivering care within these interventions? Which aspects of multicomponent interventions to enhance recovery and/or reduce LOS are associated with better outcomes for older adults admitted to hospital for planned procedures?

Authors' results and conclusions: Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: ‘Home as preferred environment for recovery’, ‘Feeling safe’, ‘Individualisation of structured programme’, ‘Taking responsibility’, ‘Essential care at home’ and ‘Outcomes’. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation. Implications for policy and practice Overall, interventions intended to reduce hospital LOS for older adults following planned surgery are effective, without detriment to other patient outcomes. However, our findings highlight the need to reconsider how best to evaluate patient recovery from the perspective of the patient following planned hospital admissions. Findings from the qualitative evidence and overarching synthesis may help inform policy-making regarding commissioning and delivering optimal services to support patients, carers and families before, during and after a planned admission to hospital.

Authors' methods: We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis. Data sources Methods to identify and select evidence followed best practice. We identified studies by searching bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium (HMIC) (all via Ovid), CENTRAL (via the Cochrane Library), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine Database (AMED) (both via EBSCO) and forward and backward citation-searching included studies. Bibliographic database searches were run in May 2021 and updated in April 2022. Data sources As for quantitative review, using a qualitative search filter and with the addition of searching reference lists of topically similar systematic reviews identified by the searches. Bibliographic database searches were run in June 2021. We developed a logic model representing perspectives of interventions represented in the qualitative evidence synthesis. This was used as the focus of a qualitative comparative analysis (QCA) to integrate the findings of the quantitative and qualitative systematic reviews. Fourteen quantitative studies examining LOS following lower-limb arthroplasty surgery (LLA studies) and 24 quantitative studies examining LOS following abdominal cavity surgery (i.e. combining remaining procedural groups) were allocated into successful and unsuccessful sets based on estimates of effectiveness in terms of LOS and patient-reported outcomes. These sets were used to develop three data tables showing relevant characteristics of the studies based on the logic model and their outcomes. From these, initial truth tables were created using R. A truth table displays the possible configurations of study characteristics, and which studies contain said configurations. We then developed revised truth tables, having taken a logical and considered approach to the studies and characteristics that were included and excluded from revised tables. After undertaking essential quality checks, we used our knowledge of the evidence base and discussions with stakeholders to interpret the solution.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR130576

Year Published: 2023

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/GHTY5117/

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/GHTY5117

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk