Ärztliche Versorgung von Pflegeheimbewohnern

Hospitalizations, emergency medical care utilization, and contacts with the regional on-call medical services among nursing home residents in Germany: a cross-sectional study in 44 nursing homes

BACKGROUND

Nursing home residents frequently utilize medical care, but there lacks a complete picture of their acute medical care utilization. We quantified hospitalizations, emergency medical care utilization, and contacts with the regional on-call medical services among nursing home residents, and investigated individual characteristics that may be associated with the utilization of these medical care types.

METHODS

Cross-sectional data from the "Needs-based provision of medical care to nursing home residents" (MVP-STAT) study were analyzed, which were collected in 44 German nursing homes from 442 residents in 2018/2019. Proportions of residents with at least one hospitalization, emergency medical care utilization (via the nationwide phone number 112), and contact with an on-call medical service (nationwide via 116117) over the previous 12 months were determined. Associations between individual characteristics and the utilization of the three medical care types were examined using multivariable logistic regressions.

RESULTS

Of the analyzed residents, 45.8% were hospitalized, 23.2% utilized emergency medical care, and 12.1% had contact with an on-call medical service at least once in the previous 12 months. Hospitalizations were positively associated with male vs. female sex (adjusted odds ratio 1.99 [95% confidence interval 1.22-3.26]), age group 85 + vs. 60-74 years (2.15 [1.12-4.13]), long-term care grades 4/5 vs. 1/2 (2.78 [1.48-5.21]), 6 + vs. 0-1 Elixhauser diseases (2.58 [1.01-6.62]), and the risk or presence of vs. no malnutrition (3.10 [1.52-6.35] and 2.01 [1.26-3.21]); and not associated with years of residence in the respective nursing home. Emergency medical care utilization was positively associated with age group 85 + vs. 60-74 years (2.58 [1.14-5.84]) and long-term care grades 3 and 4/5 vs. 1/2 (2.65 [1.07-6.55], 6.31 [2.60-15.35]); negatively associated with 5 + vs. 1- < 3 years of residence (0.46 [0.24-0.86]); and not associated with sex, the number of Elixhauser diseases, and nutritional status. No associations were found with on-call medical services.

CONCLUSIONS

Hospitalizations and emergency medical care utilization were more frequent among nursing home residents than contacts with on-call medical services. Future studies should investigate whether the frequent hospitalizations and emergency medical care utilization among nursing home residents are justified, or whether they can be reduced by strengthening medical care provision by on-call doctors and other professionals.

TRIAL REGISTRATION

DRKS00012383 [2017/12/06].

[Geriatric assessment in dentistry : A review of chewing function tests]

Due to increasing life expectancy and the associated demographic changes, more and more people are dependent on care. To identify a possible need for dental treatment, chewing function tests as assessment instruments have proven their effectiveness. In this article, the reader is given an overview of existing chewing function tests and their implementation. It is important that a patient with pain should be presented to a dentist immediately, regardless of whether a chewing function test is performed. Furthermore, chewing function tests are not a substitute for routine dental examinations, but they could provide information to (dental) laypersons as to whether an appointment should be arranged in a dental practice or whether a dental consultation is necessary.

Use of indwelling urinary catheters in nursing home residents: results from a cross-sectional study in 21 German nursing homes

BACKGROUND

Indwelling urinary catheters often lead to complications such as symptomatic urinary tract infections. In nursing home residents, catheter prevalence is high, but prevalence differences by sociodemographic characteristics, comorbidities, and health services use have rarely been investigated. The purpose of this work was to describe the use of indwelling urinary catheters in nursing home residents and to examine whether catheter use is associated with individual characteristics.

METHODS

Cross-sectional data of the "Inappropriate Medication in patients with REnal insufficiency in Nursing homes" (IMREN) study conducted in 21 German nursing homes between October 2014 and April 2015 were analyzed. For all residents of the involved care units, nurses of the participating institutions completed an anonymous questionnaire including the Modified Rankin Scale to assess physical impairments. The proportion of nursing home residents with indwelling urinary catheter was determined. Associations between catheter use and individual characteristics were investigated via cluster-adjusted multivariable logistic regression.

RESULTS

Of 852 residents (76.5% female; mean age 83.5 years), 13.4% had an indwelling urinary catheter. The adjusted odds ratios for catheter use for men vs. women was 2.86 (95% confidence interval 1.82-4.50). For residents with "moderate" disability vs. those with "no to slight" disability it was 3.27 (1.36-7.85), for individuals with "moderately severe" disability vs. the reference group it was 9.03 (3.40-23.97), and for those with "severe" disability vs. the reference group it was 26.73 (8.60-83.14). For residents who had been hospitalized within the last 12 months vs. those without a hospitalization it was 1.97 (1.01-3.87). For age, dementia, overweight/obesity, other indwelling devices, and long-term medications no significant associations were found.

CONCLUSIONS

Male nursing home residents, residents with a higher degree of physical impairment, and those who had been hospitalized within the last 12 months were more likely to use an indwelling urinary catheter than their counterparts. Data on circumstances of and indications for catheters, catheter types, and duration of catheterization are needed to evaluate the appropriateness of catheter use in nursing home residents and the need for interventions.

[Frequency and characteristics of interventions by community paramedics on people in need of care : Analysis of 2,410 deployment protocols for people aged 65+ years]

BACKGROUND

The aim of this study was to obtain a differentiated view of interventions delivered by community paramedics (Gemeindenotfallsanitäter, G‑NFS) in older people in need of care living in nursing homes and at home.

MATERIALS AND METHODS

A retrospective analysis of G‑NFS documentation from 2021 with a focus on patients aged ≥65 years was performed. Data were grouped into callouts to nursing homes or private homes. Interventions, urgency, transport, and further recommendations were analyzed descriptively.

RESULTS

Of 5,900 G-NFS protocols, 43.0% (n = 2,410) were related to elderly people (mean age 80.8 years, 49.7% female). A total of 20.6% of these callouts involved nursing home residents, 38.4% (n = 926) were homecare patients, and 41% (n = 988) of callouts were to persons who did not rely on care. No specific interventions except advice were given to 48.4% of nursing home residents, and to even 82.1% of those in homecare and 83.7% of those without care needs. About 60% of the G‑NFS interventions were classified as non-urgent. Transport was waived for 63.1% of nursing home residents, for 58.1% in homecare, and for 60.6% of persons without care needs. A visit to the emergency department was recommended to 29.4% of nursing home residents, 37.6% of homecare patients, and 33.6% of persons without need of care. Measures related to urine catheters were documented much more often in nursing homes (38.5%) than in patients in homecare (15.1%) or without need of care (9.3%).

CONCLUSION

Community paramedics perform primary care tasks and can contribute to a reduction in unnecessary transport. It should be discussed whether the emergency medical service is responsible for such interventions and how older people in need of care can be cared for according to their needs in the future.

Prevalence of indwelling urinary catheters in nursing home residents: Systematic review

BACKGROUND

This systematic review examines the prevalence of indwelling urinary catheters in nursing home residents.

METHODS

MEDLINE via PubMed, CINAHL, and EMBASE were searched from inception to 9 August 2022. Cross-sectional studies and longitudinal studies with cross-sectional analyses reporting catheter prevalence in nursing home residents were identified and summarized descriptively. Study quality was assessed using the Joanna Briggs Institute's tool.

RESULTS

Sixty-seven studies (92.5 % cross-sectional) were included. The reported number of included residents ranged from 73 to 110,656. The median catheter prevalence was 7.3 % (interquartile range 4.3-10.1 %; n = 65 studies). It was higher in Germany (10.2 % [9.7-12.8 %]; n = 15) than in the United States of America (9.3 % [6.3-11.9 %]; n = 9), United Kingdom (6.9 % [4.8-8.5 %]; n = 7), and Sweden (7.3 % [6.4-7.9 %]; n = 6). Furthermore, it was higher among men (17.0 % [16.0-26.0 %]) than among women (5.3 % [4.0-9.5 %]) (n = 9). Only one study investigated differences by age. The prevalence was higher for transurethral (5.7 % [5.6-7.2 %]; n = 12) than for suprapubic (1.2 % [0.6-2.5 %]; n = 13) catheters. Most catheterized residents were long-term catheterized (n = 6) and had their catheter changed within 3 months (n = 2). Symptomatic urinary tract infections were more common among catheterized than among non-catheterized residents (n = 4).

DISCUSSION

Catheter prevalence in nursing home residents varies between studies and countries. Prevalence differences by sex, age, and catheter type as well as duration of catheterization, catheter change intervals, and catheter-associated urinary tract infections are rarely reported because most studies do not primarily focus on catheters. Future studies should focus on the circumstances of urinary catheter use and care in nursing home residents.

REGISTRATION AND FUNDING

PROSPERO (29 August 2022; CRD42022354358); no funding.

Dental care utilization among home care recipients, nursing home residents, and older adults not in need of long-term care: An observational study based on German insurance claims data

OBJECTIVES

To describe and compare dental care utilization (DCU) among home care recipients, nursing home residents, and older adults not in need of long-term care (LTC).

METHODS

Using nationwide claims data of 8 German statutory health and LTC insurance funds, proportions of home care recipients (n = 68,137), nursing home residents (n = 21,167), and non-LTC dependents (n = 632,205) aged 65+ years with DCU in 2017 were determined and compared. Associations between DCU and individual characteristics and setting were investigated via multivariable logistic regression. The proportions of individuals with DCU one year before and after transition to (a) home care (n = 23,590) and (b) nursing home care (n = 6,583) were compared.

RESULTS

Proportions of home care recipients and nursing home residents with DCU were lower compared to non-LTC dependents (51.9, 53.1, and 73.2%, respectively). Adjusted odds ratios for DCU for home care recipients vs. non-LTC dependents ranged from 0.55 (LTC grades 1/2; 95% confidence interval 0.54-0.56) to 0.38 (LTC grades 4/5; 0.36-0.40). For nursing home residents vs. non-LTC dependents they ranged from 0.69 (3; 0.65-0.72) to 0.67 (4/5; 0.63-0.71). Women, older individuals, those with 0-1 diseases of the Elixhauser comorbidity index, dementia, and those from West Germany were also less likely to utilize dental care than their counterparts. Utilization decreased after transition to home care (60.0 vs. 55.6%) and increased after transition to nursing homes (46.1 vs. 53.5%).

CONCLUSIONS

Nursing home residents and especially home care recipients utilized dental care less frequently than older non-LTC dependents. Organizational barriers for dental care utilization and ways to remove them should be investigated.

CLINICAL SIGNIFICANCE

Dental care utilization among LTC dependents is low and should be improved in both the home care and nursing home setting.

Health services in older psoriasis patients before and after nursing home admission : A retrospective analysis of health insurance data

BACKGROUND AND OBJECTIVE

Demographic change confers significance to healthcare management of chronic diseases like psoriasis. There are few studies on the care of older people with psoriasis, particularly for the nursing home setting. It was investigated whether the number of psoriasis patients with specialist contact changes before vs. after nursing home admission.

MATERIAL AND METHODS

We analyzed claims data of a German health insurance company including a cohort of newly admitted nursing home residents aged 65 years and older between 2011 and 2014, who received a diagnosis of psoriasis 1 year before nursing home admission. Outpatient care was compared between the years before vs. after nursing home admission. We conducted a multivariate regression analysis for identifying predictors for dermatological care.

RESULTS

The study cohort included 718 insured persons (Ø83 years). Proportion of patients who had contact to a dermatologist significantly decreased after nursing home entry (44.6% before vs. 40.1% after nursing home entry). Strongest predictors for dermatological care after entry were a previously existing dermatological contact (odds ratio, OR 3.87, 95% confidence interval, CI 2.70-5.54) and prescription for topical steroids (OR 1.61, 95% CI 1.14-2.28).

CONCLUSION

The analysis of health insurance data showed a pertinent decrease in the use of outpatient dermatological care after institutionalization. The evaluation of the adequacy of care is difficult due to the used database without clinical information. As long as no further investigations of this vulnerable patient group are available, the care of psoriasis patients of old age should be closely monitored. Dermatological knowledge of the skin in old age is an essential prerequisite for this.

[Dermatological care of elderly people with psoriasis before and after entering a nursing home : A qualitative analysis from the perspective of medical providers]

Hintergrund

Demografische Veränderungen bewirken einen steilen Anstieg der Anzahl der über 65-Jährigen. Damit verbunden ist die Zunahme der Anzahl pflegebedürftiger, multimorbid Erkrankter. National wie auch international gibt es keine Informationen insbesondere zur Versorgung von Psoriasiserkrankten im Setting Pflegeheim und zur Frage, wie diese durch den Eintritt in ein Pflegeheim beeinflusst wird.

Fragestellung

Ziel war es, anhand von Interviews bzw. Fokusgruppen die Ergebnisse vorausgehender Routinedatenanalysen zur Versorgung Psoriasiserkrankter in Pflegeheimen mit medizinischen Versorgern (Dermatologen, Allgemeinmediziner, Pflegedienstleitungen und Pflegekräfte) zu diskutieren, Schwierigkeiten der Versorgung aufzudecken und abschließend Handlungsempfehlungen für eine zukunftsfähige gerontodermatologische Versorgung abzuleiten.

Material und Methoden

Durchgeführt wurden qualitative Leitfaden-gestützte Interviews und Fokusgruppen mit Dermatologen (n = 5), Allgemeinmedizinern (n = 7), Pflegekräften (n = 7) und Pflegedienstleitungen (n = 2). Die Daten wurden inhaltsanalytisch ausgewertet.

Ergebnisse

Die Auswertung ergab insgesamt 344 Aussagen, die insgesamt 14 Hauptkategorien zugeordnet werden konnten. Die Ergebnisse zeigen, dass für die Versorgungsqualität von Menschen mit Hautkrankheiten, insbesondere Psoriasis, in Pflegeinrichtungen ein Verbesserungsbedarf besteht. Dieser zeigt sich sowohl auf ärztlicher als auch auf pflegerischer Ebene. Laut der Versorger (N = 21) kann dies insbesondere durch eine verstärkte digitale Versorgung, dermatologische Schulungen für Hausärzte und Pflegefachkräfte sowie engere Kooperationen zwischen den einzelnen Disziplinen adressiert werden.

Schlussfolgerung

Digitale Pflegekonsile, aber auch eine spezifische Leitlinie zur „Haut des alternden Menschen“ können von Nutzen sein, um die dermatologische Versorgungssituation im Pflegeheim zu verbessern und somit das Wohlbefinden der Betroffenen zu steigern.

Contacts with general practitioners, dentists, and medical specialists among nursing home residents: a cross-sectional study in 44 German nursing homes

Background

Nursing home residents have high medical care needs. Their medical care utilization is, however, lower compared to community-dwelling elderly and varies widely among nursing homes. This study quantified the utilization of general practitioners (GPs), dentists, and medical specialists among nursing homes and residents, and investigated whether dentist utilization is associated with individual and nursing home characteristics.

Methods

Forty-four nursing homes invited 2124 residents to participate in a cross-sectional study. For 10 medical specialties, data on contacts in nursing homes, practices, and by telephone in the last 12 months were assessed at individual and nursing home level. The proportion of nursing homes and residents with any form of contact, and the median number and interquartile range (IQR) of contacts among individuals with contact were determined. Using multilevel logistic regression, associations between the probability of individual dental care utilization and sex, age, LTC grade, years of residence, sponsorship, number of nursing home beds, and transport and medical escort services for consultations at a practice were investigated.

Results

The proportion of nursing homes with any form of contact with physicians ranged from 100% for GPs, dentists, and urologists to 76.7% for gynecologists and orthopedists. Among the nursing homes, 442 residents participated (20.8% response). The proportion of residents with any contact varied from 97.8% for GPs, 38.5% for neurologists/psychiatrists, and 32.3% for dentists to 3.0% for gynecologists. Only for GPs, neurologists/psychiatrists, dentists, otorhinolaryngologists, urologists, and dermatologists, the proportion was higher for nursing home contacts than for practice and telephone contacts. Among residents with any contact, the median number of contacts was highest for GPs (11.0 [IQR 7.0-16.0]), urologists (4.0 [IQR 2.0-7.0]), and neurologists/psychiatrists (3.0 [IQR 2.0-5.0]). Dentist utilization varied widely among nursing homes (median odds ratio 2.5) and was associated with higher age.

Conclusions

Almost all residents had regular contact to GPs, but only one third had contact with dentists. Lower proportions with contact were found for medical specialists, except for neurologists/psychiatrists. Reasons for the large variations in dental care utilization among nursing homes should be identified.

Trial registration

DRKS00012383 [2017/12/06].

[Care of older patients by community emergency paramedics : Comparison of community-dwellers and nursing home residents]

Hintergrund

Notaufnahmen und Rettungsdienste werden zunehmend durch nicht vital bedrohlich erkrankte Patienten belastet. Ein großer Anteil der Rettungsdiensteinsätze entfällt auf ältere Menschen. Um eine unnötige Disponierung höherwertiger Rettungsmittel zu reduzieren, wurde das Modellprojekt Gemeindenotfallsanitäter (G-NFS) entwickelt.

Ziel der Arbeit

Ziel dieser Arbeit war es herauszufinden, ob sich spezifische Einsatzschwerpunkte des G‑NFS in der Versorgung älterer Menschen in häuslicher Umgebung und im Pflegeheim zeigen.

Material und Methoden

Es handelt sich um eine retrospektive Beobachtungsstudie auf Basis der Einsatzdokumentation vom 01.07.2019 bis zum 30.06.2020. Es wurden G‑NFS Einsätze bei älteren Menschen (≥ 65 Jahre) analysiert, unterteilt nach den Einsatzorten Pflegeheim oder Häuslichkeit.

Ergebnisse

Es wurden 2358 Protokolle ausgewertet (Durchschnittsalter: 80,8 Jahre; 52,9 % weiblich). Vor Ort wurden 55 % der Patienten versorgt. Die durchgeführten Maßnahmen umfassten Beratungsgespräche (79,4 %), Hilfe bei Selbstmedikation (16,7 %) und Medikamentengabe (23,2 %). Auf Pflegeheimbewohner entfielen 329 (14,0 %) Einsätze. Maßnahmen in Bezug auf Urindauerkatheter wurden häufiger bei Pflegeheimbewohnern als in der Häuslichkeit durchgeführt (32,2 % bzw. 5,7 % aller Einsätze). Bei Patienten mit Katheterproblemen erfolgte im Vergleich zu anderen Einsätzen nahezu immer eine Versorgung vor Ort (84,3 % bzw. 52,2 %).

Diskussion

Durch G‑NFS können die Mehrzahl der älteren Patienten ambulant versorgt und andere Ressourcen entlastet werden. Allerdings führen G‑NFS auch Maßnahmen durch, die im Verantwortungsbereich der hausärztlichen Versorgung liegen, und gleichen somit strukturelle Defizite in der medizinisch-pflegerischen Versorgung aus.

Zusatzmaterial online

Die Onlineversion dieses Beitrags (10.1007/s00063-021-00863-8) enthält die Tabellen S1–S3.

Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study

Background

Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce.

Aims

The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer.

Methods

We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively.

Results

Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3–83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%).

Discussion

Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences.

Conclusion

Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01751-5) contains supplementary material, which is available to authorized users.

[Medical specialist undertreatment in nursing home residents-Prevalence and extrapolation]

Hintergrund

Bisherige Studien deuten darauf hin, dass Pflegebedürftige eine geringere fachärztliche Versorgung aufweisen als Nichtpflegebedürftige. Insbesondere im stationären Setting ist die fachärztliche Versorgungsintensität gering. Aus den bestehenden quantitativen Versorgungsunterschieden lässt sich bislang jedoch nicht ableiten, inwieweit von einer Unterversorgung bei Pflegebedürftigen ausgegangen werden muss. Für die Versorgungsbereiche Sehfähigkeit, Hörfähigkeit, Mundgesundheit und Parkinson-Syndrom wird geprüft, inwieweit Heimbewohner fachärztlich unterversorgt sind.

Material und Methoden

In 44 Pflegeheimen in Bremen und Niedersachsen wurde der Gesundheitszustand von 409 Pflegebedürftigen mittels standardisierter Assessments und Befragungen erhoben; zusätzlich wurden Diagnosen und die medizinische Versorgung aus der Pflegedokumentation ausgewertet. Ärzteteams beurteilten auf dieser Grundlage für jeden Pflegebedürftigen, inwieweit eine bedarfsgerechte fachärztliche Versorgung vorlag oder nicht.

Ergebnisse

Gemäß ärztlichem Urteil zeigt sich bei 45 % (Sehfähigkeit), 19 % (Parkinson-Syndrom), 16 % (Mundgesundheit) und 15 % (Hörfähigkeit) der Bewohner mit entsprechendem Versorgungsbedarf eine fachärztliche Unterversorgung. Bei 27 % aller Bewohner zeigt sich in mindestens einem der 4 Versorgungsbereiche eine fachärztliche Unterversorgung. Hochgerechnet entspricht dies bis zu 205.000 fachärztlich unterversorgten Pflegeheimbewohnern in Deutschland.

Diskussion

Die Studie liefert für ausgewählte Versorgungsbereiche die ersten empirischen Belege über das Ausmaß fachärztlicher Unterversorgung von Pflegeheimbewohnern. Daher erscheint es notwendig, entsprechende Interventionen zur Reduktion der Unterversorgung zu entwickeln und zu erproben.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00391-021-01865-z) enthält eine detaillierte Erklärung zur Methodik der Datenerhebung sowie 6 Tabellen mit weiterführenden Analysen. Beitrag und Zusatzmaterial stehen Ihnen im elektronischen Volltextarchiv auf https://www.springermedizin.de/link/10.1007/10.1007/s0391-021-01865-z zur Verfügung. Sie finden das Video am Beitragsende unter „Supplementary Material“.

Home care recipients have poorer oral health than nursing home residents: Results from two German studies

OBJECTIVES

To describe and compare the objective and subjective oral health of older nursing home residents and home care recipients, and to investigate whether oral health is associated with sociodemographic characteristics and the long-term care (LTC) setting.

METHODS

In two German studies, the oral health of 246 nursing home residents and 90 home care recipients aged ≥60 years was assessed objectively using the Oral Health Assessment Tool (OHAT) and subjectively using the Oral Health Impact Profile (OHIP). OHAT and OHIP scores were compared between both settings. Multivariable logistic regressions were applied to investigate whether oral health is associated with sex, age group, LTC grade, and LTC setting.

RESULTS

OHAT and OHIP mean scores in the home care setting were higher compared to the nursing home setting (OHAT: 3.13 vs. 1.28, p < .0001; OHIP: 7.81 vs. 2.15, p < .0001). The adjusted odds ratios for poor objective and subjective oral health for home care recipients vs. nursing home residents were 6.71 (95 % confidence interval 3.29-13.69) and 4.92 (2.77-8.76). No significant associations with sociodemographic characteristics were found.

CONCLUSIONS

Oral health was poor in both settings, but home care recipients were more likely to have poor oral health than nursing home residents. Interventions to improve oral health are needed in the nursing home setting and, even more importantly, in the home care setting.

CLINICAL SIGNIFICANCE

Oral health among older people in need of LTC is poor and should be improved. From a health policy perspective, home care recipients may need more attention.

Are there changes in medical specialist contacts after transition to a nursing home? an analysis of German claims data

BACKGROUND

Provision of ambulatory care by medical specialists for nursing home residents (NHR) is discussed to be inadequate in Germany, however with only incomplete evidence on this topic. We wanted to know whether the transition to a nursing home is associated with a general decrease in medical specialist care and therefore compared contact rates before and after institutionalization.

METHODS

Claims data of 18,779 newly admitted NHR in 2013 were followed for the whole year prior to and up to two years after admission. The frequencies of contacts to specialists were assessed and stratified by sex, age, care level, dementia diagnosis and chronic conditions. Multivariate analyses were conducted to identify predictors for contacts to specialists.

RESULTS

One year after institutionalization the most pronounced decrease was found in contacts with ophthalmologists (38.4% vs. 30.6%) whereas with most other specialties only small changes were found. The only specialty with a large increase were neurologists and psychiatrists (27.2% vs. 43.0%). Differences depending on sex and age were rather small while NHR with dementia or a higher care level had lower contact rates after institutionalization. Before institutionalization most patients were referred to a specialist by a general practitioner (61.7-73.9%) while thereafter this proportion decreased substantially (27.8-58.6%). The strongest predictor for a specialist contact after admission to a nursing home was a contact to a specialist before (OR 8.8, CI 7.96-9.72 for contacts to neurologists or psychiatrists). A higher nursing care level and a higher age were also predictors for specialist contacts.

CONCLUSIONS

Relevant decreases of ambulatory specialist care utilization after institutionalization are restricted to ophthalmologists. NHR of higher age and higher nursing care level had a lower chance for a specialist contact. The assessment of the adequacy of the provided care after institutionalization remains inconclusive due to little investigated but assumable changes in care needs of NHR. The decreased coordination of care by general practitioners after institutionalization conflicts with health policy goals.

Claims data analysis of medical specialist utilization among nursing home residents and community-dwelling older people

BACKGROUND

Most older people, and especially those in need of long-term care, suffer from one or more chronic diseases. Consequently, older people have an increased need of medical care, including specialist care. There is little evidence as yet whether older people with greater medical care needs obtain adequate medical care because existing studies do not sufficiently control for differences in morbidity. In this study we investigate whether differences in medical specialist utilization exist between older people with and without assessed long-term care need in line with Book XI of the German Social Code, while at the same time controlling for individual differences in morbidity.

METHODS

We used data from the 11 German AOK Statutory Health and Long-term Care Insurance funds of 100,000 members aged 60 years or over. Zero-inflated Poisson regression analyses were applied to investigate whether the need for long-term care and the long-term care setting are associated with the probability and number of specialist visits. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner (GP) utilization.

RESULTS

Older people in need of long-term care are more likely to have no specialist visit than people without the need for long-term care. This applies to nearly all medical specialties and for both care settings. Yet, despite these differences in utilization probability the number of specialist medical care visits between older people with and without the need for long-term care is similar.

CONCLUSION

Older people in need of long-term care might face access barriers to specialist care. Once a contact is established, however, utilization does not differ considerably between those who need long-term care and those who don't; this indicates the importance of securing an initial contact.

Nutritional status and quality of nutrition in chronic wound patients

Malnutrition is a negative confounding factor influencing wound healing. The prevalence of malnutrition increases with age, as do chronic wounds. The aim of this prospective study was to analyse the nutritional status of patients with chronic wounds. Data collection of sociodemographic and nutritional parameters was based on an inter‐professionally developed questionnaire as well as the Mini Nutritional Assessment (MNA). A total of 90 patients with chronic wounds of different aetiologies were included. Pain and dental health were found to be significant factors: Patients with malnutrition or the risk of malnutrition had significantly lower tooth and oral health scores (rs = −0.218, P = .039), and higher pain levels at rest (rs = 0.339, P < .001), while dressing (rs = 0.268, P = .014), and upon exercising (rs = 0.303, P = .005). Our data address the impact of nutrition on chronic wounds and confirm the relationship between pain, dental health, and nutritional status. Clinicians should be aware of adequate pain management and dental health care in chronic wound patients. Further studies, particularly on characterisation of preventive and therapeutic measures in the nutrition of chronic wound patients, are of great importance.

Needs and availability of medical specialists' and allied health professionals' visits in German nursing homes: a cross-sectional study of nursing home staff

BACKGROUND

The medical care for nursing home residents is estimated to be partly inadequate in Germany. The aim of this study is to investigate the needs and utilization of general practitioners (GPs), medical specialists and allied health professionals.

METHODS

A survey was sent to a nationwide random sample of 1069 nursing homes in Germany in January 2019. Nursing staff managers were asked about medical care. Regular nursing home visits by medical specialists and allied health professionals were defined as at least one contact per year to at least one nursing home resident.

RESULTS

A total of 486 persons responded (45.5%). On average, nursing homes have contact to 8.6 (interquartile range: 4-10) different GPs. Almost 70% of respondents agreed that residents' medical care should be coordinated by GPs. However, only 46.0% stated that specialist treatment should require GP referral. A high need was seen for care from physiotherapists (91.0%), neurologists or psychiatrists (89.3%), dentists (73.7%), and urologists (71.3%). Regarding the actual utilization of medical specialists and health professionals, most nursing homes have regular contact to physiotherapists (97.1%), psychiatrists or neurologists (90.4%), speech therapists (85.0%), and dentists (84.8%). Remarkable discrepancies between need and utilization were found for urologists and ophthalmologists.

CONCLUSION

There is large variance in the number of GPs per nursing home, and needs for medical specialists, especially urologists and ophthalmologists, seem unmet. Interprofessional collaboration between GPs, medical specialists and allied health professionals should be improved, and GPs should play a more coordinating role.

[Assessment of care in patients with dementia in house calls by general practitioners]

Hintergrund

Demenzpatienten (DP) sind eine besondere Herausforderung für das Gesundheitssystem. Auf sie entfallen 5 % der Gesamtausgaben im Gesundheitswesen. Die krankheitsbedingten Defizite und der damit verbundene Versorgungsbedarf führen dazu, dass viele Patienten nicht mehr in der eigenen Häuslichkeit leben können und auf die Versorgung in Pflegeheimen (PH) angewiesen sind.

Fragestellung

Wie wird die gesamtheitliche Betreuung von DP im Hausbesuch (HB) eingeschätzt?

Hat die regionale Lage Einfluss auf die Wohnsituation bei DP?

Material und Methoden

Im Rahmen von SESAM‑5 wurden von 303 sächsischen Hausarztpraxen in einem Zeitraum von einem Jahr 4286 HB mittels Fragebogen dokumentiert und sowohl inhaltliche als auch strukturelle Merkmale erfasst.

Ergebnisse

Die Prävalenz von Demenz bei HB-Patienten betrug 27,5 %. Von diesen bewohnten 72,6 % ein PH oder betreutes Wohnen. Das medizinische Personal schätzte die gesamtheitliche Betreuung von DP im PH signifikant besser ein als in der eigenen Häuslichkeit. Diese Diskrepanz fiel im Vergleich von ländlichen und städtischen Gebieten noch deutlicher aus, obwohl in städtischen Gebieten signifikant mehr Patienten in PH wohnten (27 % vs. 51 %).

Diskussion

Die Betreuung dementer HB-Patienten wird vom versorgenden Personal überwiegend als gut eingeschätzt, wobei diese bei DP im PH vergleichsweise besser bewertet wird als in der eigenen Häuslichkeit. Dies kann durch einen hohen Versorgungsbedarf der DP erklärt werden. Der Kontrast zwischen ruralen und städtischen Gebieten ist durch infrastrukturelle, aber auch durch organisatorische Unterschiede in ländlichen Bereichen erklärbar, wo signifikant häufiger eine Mitbetreuung durch Angehörige erfolgt. Da bei DP kognitive Defizite im Vordergrund stehen, könnten alternative Wohnformen zukünftig mehr in den Fokus rücken.

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

Background

Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement.

Methods

Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests.

Results

We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492).

Conclusions

A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

Differences in medical specialist utilization among older people in need of long-term care - results from German health claims data

BACKGROUND

Elderly in need of long-term care tend to have worse health and have higher need of medical care than elderly without need for long-term care. Yet, characteristics associated with long-term care need can impede health care access: Higher levels of long-term care need come with physical and cognitive decline such as frailty and memory loss. Yet, it has not been investigated whether level of long-term care need is related to medical care utilization.

METHODS

We investigated the association between the level of long-term care and medical specialist utilization among nursing home residents and home care recipients. We applied zero-inflated Poisson regression with robust standard errors based on a sample of statutory health insurance members. The sample consisted of 100.000 elderly over age 60. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner utilization.

RESULTS

We found a strong gradient effect of the level of long-term care for 9 out of 12 medical specialties: A higher level of long-term care need was associated with a lower probability of having a medical specialist visit. Yet, we did not find clear effects of the level of long-term care need on the intensity of medical specialist care. These findings were similar for both the nursing home and home care setting.

CONCLUSION

The findings indicate that inequalities in medical specialist utilization exist between elderly with differing levels of long-term care need because differences in morbidity were controlled for. Elderly with higher need of long-term care might face more access barriers to specialist medical care.

Needs-based provision of medical care to nursing home residents: protocol for a mixed-methods study

INTRODUCTION

Nursing home residents typically have greater needs for medical care than community-dwelling elderly. However, restricted cognitive abilities and limited mobility may impede their access to general practitioners and medical specialists. The provision of medical care in nursing homes may therefore be inappropriate in some areas of medical care. The purpose of this mixed-methods study is to systematically assess, evaluate and explain met and unmet medical care needs in German nursing homes and to develop solutions where medical care is found to be inappropriate.

METHODS AND ANALYSIS

First, statutory health insurance claims data are analysed to identify differences in the utilisation of medical care between nursing home residents and community-dwelling elderly with and without need for long-term care. Second, the health status and medical care of 500 nursing home residents are assessed and evaluated to quantify met and unmet medical care needs. Third, qualitative expert interviews and case conferences and, fourth, quantitative analyses of linked data are used to provide structural, case-specific and generalisable explanations of inappropriate medical care among nursing home residents. Fifth, a modified Delphi study is employed to develop pilot projects aiming to improve medical care in nursing homes.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the University of Bremen on 23 November 2017. Research findings are disseminated through presentations at national and international conferences and publications in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00012383.

Rheumatologic care of nursing home residents with rheumatoid arthritis: a comparison of the year before and after nursing home admission

The purpose of this study was to investigate health care for patients with rheumatoid arthritis (RA) before and after admission to nursing homes. Data of a German health insurance fund from persons with diagnostic codes of RA, aged ≥65 years, admitted to a nursing home between 2010 and 2014 and continuously insured 1 year before and after admission were used. The proportion of patients with ≥1 rheumatologist visit and ≥1 prescription of biologic or conventional synthetic disease-modifying antirheumatic drugs (bDMARDs or csDMARDs), glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs) in the year before and after admission were calculated. Predictors of rheumatologic care after admission were analyzed by multivariable logistic regression. Of 75,697 nursing home residents, 2485 (3.3%) had RA (90.5% female, mean age 83.8). Treatment by rheumatologists and prescription of antirheumatic drugs decreased significantly in the year after admission (rheumatologic visits: 17.6 to 9.1%, bDMARDs: 2.1 to 1.5%, csDMARDs: 22.5 to 16.5%, glucocorticoids: 46.5 to 43.1%, NSAIDs: 47.4 to 38.5%). 60.2% of patients in rheumatologic care received csDMARDs compared with 14.5% without rheumatologic care. Rheumatologic care before admission to a nursing home strongly predicted rheumatologic care thereafter (OR 33.8, 95%-CI 23.2-49.2). Younger age and lower care level (reflecting need of help) were also associated with a higher chance of rheumatologic care. Rheumatologic care is already infrequent in old patients with RA and further decreases after admission to a nursing home. Patients without rheumatologic care are at high risk of insufficient treatment for their RA. Admission to a nursing home further increases this risk.

[Medication safety in nursing home residents with renal insufficiency - Results of a qualitative study]

BACKGROUND

Nursing home residents often suffer from multimorbidity and polypharmacy. Impaired renal function and the lack of dose adjustments further increase the risk of adverse drug reactions (ADR). The aims of this qualitative study were to analyze the reasons for inadequate drug treatment and to identify possible intervention options to improve safety of drug treatment in nursing home residents with renal insufficiency.

METHODS

Using a mixed-method approach a cross-sectional study and focus group discussions were performed in the project. Focus groups with general practitioners, nursing staff, nephrologists and pharmacists were held. Audiotapes were transcribed verbatim, qualitative content analysis of the transcripts according to Mayring was conducted using MAXQDA.

RESULTS AND CONCLUSIONS

Focus groups discussed different aspects and possible interventions related to inadequate drug treatment in nursing home residents with renal insufficiency. The main topics identified were "health service situation", "reasons for ADR" and "interventions". Regarding the current health service situation "infrastructure", "role of polypharmacy", "assessment of renal function" and the "different role models" were identified as relevant aspects for improving the safety of drug treatment in nursing homes. According to the participants, there is a lack of evidence-based standards regarding laboratory monitoring and estimation of kidney function.

Influence of age and sex on hospitalization of nursing home residents: A cross-sectional study from Germany

Background

Nursing homes residents (NHR) are frequently transferred to hospitals. There is some evidence that male NHR are more often hospitalized than females, but the influence of age is less clear and predictors might differ between sexes. Analyses according to age groups between males and females have only been investigated once and none of the existing studies have conducted multivariate analyses stratified by sex. Aim of this study was to fill this gap.

Methods

We used data of the “Inappropriate Medication in patients with REnal insufficiency in Nursing homes” (IMREN) study, which was conducted between October 2014 and April 2015 in nursing homes in northwestern Germany (Bremen and Lower Saxony). Anonymised data was obtained by nursing staff of the participating nursing homes. All residents living in the participating care units were included. We assessed whether they were hospitalized at least once during the preceding 12 months. Cluster-adjusted multivariate logistic regression was applied to identify variables associated with hospitalizations. All analyses were stratified by sex.

Results

Of 852 residents from 21 nursing homes (mean age 83.5 years; 76.5% females), 43.1% (95% confidence intervals [95% CI]: 35.6–50.5) were hospitalized at least once during the preceding 12 months. This proportion was higher in residents institutionalized within the last 6 months compared to those with a longer length of stay (65.7% vs. 39.5%). Although not statistically significant, males were more often hospitalized than females (52.4% vs. 40.3%) and differences between sexes are particularly remarkable for age, health status and length of stay. In females, the chance of being hospitalized decreased steadily with age (OR: 2.40 [95% CI: 1.24–4.64] and 1.60 [95% CI: 1.05–2.43] for age groups <75 and 75–84 years compared to 85+ years). On the other hand, males aged 75–84 years had a statistically significant lower chance compared to 85+ years olds (OR: 0.41; 95% CI: 0.19–0.90).

Conclusions

Differences in factors associated with hospitalizations might exist between sexes. We strongly suggest that further studies on hospitalizations of NHR should stratify their analyses by sex.