gms | German Medical Science

GMS Health Technology Assessment

Deutsche Agentur für Health Technology Assessment (DAHTA)

ISSN 1861-8863

Medical specialist attendance in nursing homes

Short Report

  • corresponding author Katrin Balzer - Nursing research group, Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
  • author Stefanie Butz - Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
  • Jenny Bentzel - Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
  • Dalila Boulkhemair - Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
  • author Dagmar Lühmann - Institute for General Practice, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

GMS Health Technol Assess 2013;9:Doc02

doi: 10.3205/hta000108, urn:nbn:de:0183-hta0001086

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/hta/2013-9/hta000108.shtml

Published: April 23, 2013

© 2013 Balzer et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.

The complete HTA Report in German language can be found online at: http://portal.dimdi.de/de/hta/hta_berichte/hta298_bericht_de.pdf


Abstract

The care in nursing homes was examined based on scientific studies. The analysis focuses on dementia and type II diabetes. There is evidence for deficits in the supply of medical specialist attendance to nursing home residents with these diseases in Germany. Compared with corresponding guidelines the medical care for nursing home residents may be too low or inadequate.

Keywords: aged, delivery of health care, integrated, Germany, nursing homes, primary health care


Summary

Policy question

In 2009, about 718,000 care dependent persons were residing in nursing homes in Germany. This population is characterised by a high prevalence of chronic diseases, health impairments and multimorbidity which gives rise to a large need of medical and nursing care. Against this background empirical analyses and discussions within the expert community suggest that the supply of medical specialist attendance to nursing home residents may be too low or inadequate [1], [2].

Scientific background

A number of German investigations demonstrate that nursing home residents, despite higher morbidity, receive less medical specialist attendance than community dwelling individuals of the same age. Furthermore, high prescription rates of psycholeptics and anti-depressives suggest inadequate medical care, while low prescription rates of anti-dementia drugs suggest undersupply [1], [2], [3]. While the quality of the underlying evidence is low, the data may still be interpreted as potential indicators of inadequate specialist care. But the problem of inadequate specialist care has so far been described on the basis of structural and procedural data only. Available studies provide no information on health consequences which could prove actual undersupply or inadequate care.

Communicational, infrastructural, economical and legal aspects are debated as potential causes for suboptimal (specialist) medical care in nursing homes. Over the last few years, legislation has been trying to counter these problems by loosening contracting options (Selektivverträge nach § 73b SGB V, § 140a-b SGB V, § 119b SGB V; Verpflichtung der Sicherstellung nach § 12 Abs. 2 SGB XI, 3 92b SGB XI). These regulative changes triggered a number of pilot projects aiming to optimize medical care for nursing home residents. So far, there is no systematic and comparative overview available describing these projects and their results. Still, such a scientifically sound comparison is needed to determine the effects of structural and procedural modifications and allow conclusions on advantages and disadvantages of various organisational options.

Research questions

This article presents the summary of a Health Technology Assessment commissioned by DAHTA which aimed to identify areas of potential undersupply or inadequate supply of specialist medical care to nursing home residents in Germany and to point out their potentially adverse health consequences. It was guided by the following research questions:

  • Which are the diseases, health disturbances and impairments that determine the morbidity of nursing home residents?
  • What is the status quo of medical care (including prescriptions) for nursing home residents with the above mentioned diseases and health impairments?
  • Which standards of medical care (including prescriptions) are required – according to recommendations of evidence based consensus guidelines – for nursing home residents suffering from diseases and health impairments mentioned above?
  • Which economical, ethical and legal aspects have to be taken into consideration when analysing the supply of specialist medical care to nursing home residents?

In order to identify areas of undersupply or inadequate care, health care utilization data were compared to recommendations from evidence-based consensus guidelines.

Furthermore, pilot and research projects were described that target the improvement of specialist medical care to nursing home residents. As special form, the Dutch model of the Elderly Care Physician, was described, which combined a specialized medical training with the sole responsibility to provide care for nursing home residents.

Methods

The report was based on a systematic review of the literature. Literature searches comprised electronic database searches (more than 30 databases), hand searches in pertinent journals, internet searches for grey literature, and searches in guideline databases. Results of the first search from July 2010 were updated in November 2011, while the search for reports on pilot projects was continuously updated.

Cross-sectional studies, prospective studies and secondary data evaluations containing data collected after the year 2000 were chosen to answer the first two research questions (morbidity and health care utilization). The methodological quality of these studies was assessed by standard criteria for observational studies.

For comparison of health care utilization with recommendations from evidence-based guidelines, dementia and type II diabetes were used as examples. These conditions were chosen because of their high prevalence in the target population, their marked health consequences and the availability of utilization data as well as evidence-based consensus guidelines. Guideline recommendations addressing specialist medical care were extracted from the German Disease Management Guidelines (Nationale VersorgungsLeitlinien) or guidelines that satisfied the criteria for S3 guidelines of the Association of the Scientific Medical Societies (AWMF). The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to assess methodological quality of included guidelines.

In order to analyse ethical and legal aspects of inadequate medical specialist care, content-related investigations were analysed, independently of study design. Legal documents, commentaries and position papers were considered as well.

For the description of pilot projects, publications were not filtered by methodological criteria. The methodological quality of studies reporting evaluation data was assessed by an instrument derived from checklists of the British National Institute for Clinical Excellence (NICE). In order to gain additional information concerning the pilot projects, standardised telephone interviews with contact persons involved in these projects were conducted. Out of twelve scheduled interviews, only three could be realised.

Data from epidemiological as well as health care utilization studies, guidelines and publications referring to pilot projects were entered in tables (presented in the appendix of the report), with the main results narratively summarised in the main text. Data on actual utilization of medical (specialist) care were compared to respective guideline recommendations by means of structured discussion. Ethical and legal aspects were summarised in text form only.

Results

The comprehensive search strategy yielded 4,322 references, out of which 185 satisfied the inclusion criteria. These were analysed in order to answer the research questions.

Morbidity of nursing home residents

Data to describe health status and utilization of medical care by nursing home residents were derived from publications referring to almost 40 study cohorts. Of those, 32 represented primary research projects and eight were based on secondary data analyses. The validity of 20 studies appeared to be severely compromised, 16 studies displayed single deficits and only four studies were assessed as methodologically sound. Methodological problems mainly referred to limited representativity of study populations and the risk of confounding. Furthermore, risk of bias induced by cluster effects was hardly dealt with at all.

General population of nursing home residents

Data on disease prevalence in non-selected nursing home populations from Germany were reported in 17 studies. They indicated a high prevalence of cardiovascular diseases (above 70%), mental disorders (above 60%), affections of the urogenital system (above 50%) and nervous system (about 40%) as well as musculoskeletal diseases (about 50%). The average nursing home resident was simultaneously affected by four to five different health problems. The spectrum of mental diseases was dominated by dementia (prevalence 50 to 70%), followed by affective disorders that pertain to 33% of residents. A number of studies reported the prevalence of health problems and impairments that represent symptoms and/or consequences of multimorbidity: continence problems (70 to 80%), problems with nutrition (20 to 30% at risk for malnutrition), or non-cognitive mental disturbances (25 to about 50%.) Three studies reporting data on oral health of nursing home residents consistently revealed a poor state of teeth, dentures and parodontium.

Eight studies reported incidence of complications or hospitalisation rates. Within three months about 20% of residents contracted an infectious disease, and two studies reported a mean number of 0.07 fall-related fractures per year or 0.04 hip fractures per person-year, respectively. Hospital admission rates, reported in six studies, varied around 30%, with highest rates within the last twelve months of life. Almost a third of nursing home residents died in hospital.

Nursing home residents with dementia

Six studies reported data on the prevalence of comorbidities and other health impairments in nursing home residents suffering from dementia. From a methodological point of view, two of these studies could be characterised as high quality, while the other four hat to be considered problematic. Typical problems arose from selection of the study sample, quality of information regarding clinical variables and/or the risk of confounding.

Among somatic disorders, the highest prevalence was reported for cardiovascular diseases and hypertension (each about 44%). Compared to nursing home residents without dementia, the prevalence of somatic conditions was lower in residents with dementia (except for cerebrovascular problems and glaucoma). Among psychiatric disorders, the highest prevalence rates were reported for depression and other affective disorders (12 to <30%). Data on the prevalence of different types of dementia were available from two studies: Alzheimer type of dementia was the most prevalent form (50% to 75%), followed by vascular dementia (15%). Further health impairments referred to vision (20%) and hearing (>30%), recurrent pains (18%) and continence problems (nearly 90%). Except for pain, all conditions were more often detected in residents with dementia compared to residents without dementia. Prevalence of depression, agitation and apathy was reported to be 30 to 50% or even higher. The rate of 30% hospital admissions per year equalled that of residents without dementia.

Nursing home residents with diabetes mellitus

According to data from three studies, prevalence of diabetes mellitus in German nursing home residents was 25% (of these 80% type II). Comorbidities were common: arterial hypertension (41 to 68%), coronary heart disease (27 to 38%), stroke (24 to 29%), dementia (34 to 57%), and continence problems (29 to 71%). Results from one study suggested that, on average, diabetic residents present with ten diagnoses and four geriatric syndromes (e.g. immobility, incontinence, cognitive decline). Diabetic sequelae such as amputations were found in 12% of diabetics, blindness in 5% and dependency on dialysis in about 2%. Variable prevalence rates were reported for other health problems related to diabetes mellitus: <5 to 10% for foot problems and <5 to 20% for neuro- or nephropathy.

Medical attendance in nursing home residents
General population of nursing home residents

Data on the utilization of generalist and specialist medical care by nursing home residents were taken from five studies, among them one with multiple methodological problems. None of the results were adjusted for confounding. The studies point out that, on average, almost all residents were attended by a primary care physician or internal medicine specialist once every three months. Specialist co-attendance most often involved neurologists and psychiatrists (in 50% or more of residents). The rates of consultations by ophthalmologists (about 22%), otolaryngologists (15%), urologists, gynaecologists or dermatologists (<10%) were markedly lower. Surprisingly low was the involvement of physicians (primary or secondary care) in the management of incontinence (only 36% of cases).

Data on drug prescriptions were taken from twelve studies, among them three comprehensive analyses of sickness fund data. Except for two studies, the methodological quality of the studies did not entail substantial risks of bias. On average, four or more drugs were prescribed per resident, with about the half of residents receiving at least one psychotropic drug. Neuroleptics (low potency), anti-depressives, anxiolytics and hypnotics/sedatives were the most frequently prescribed psychotropic drugs. The frequency of psychotropic drug prescriptions varied markedly among institutions, with the variability only in part being explained by institutional characteristics. One analysis of administrative data yielded information on prescription rates of remedies and rehabilitation measures. It was shown that prescription rates in general were very low (five to 25 units of physiotherapy per person-year and five units of occupational therapy or speech therapy per person-year). On average one hospitalisation for rehabilitation was prescribed per 100 residents per year.

Four studies demonstrated that 20 to 50% of residents were receiving dental care, consisting of mostly less than one treatment per year. Three studies reported health care data on tube fed residents. One third of them was prescribed an insufficient amount of calories (= 1,000 kcal/day), which were not even fully supplied in 20% of these cases.

Nursing home residents with dementia

Data on health care utilization by nursing home residents with dementia were reported by five studies. Their results had to be interpreted with caution because adjustments for confounding were not made.

The main results concerning utilization of medical specialist care could be summarised as follows: While nearly all residents had received adequate primary care, only 30 to 40% were co-attended by neurologists or psychiatrists. Other medical specialists, including dentists, were visited less often. Findings from several studies indicated an insufficient diagnostic workup of cognitive impairments. This involved false-positive (up to 15%) and false-negative (up to 30%) diagnoses as well as a lack of differentiation between the various forms of dementia.

Results from the available studies indicated that nursing home residents suffering from dementia on average took five drugs for somatic disorders and one psychotropic drug (median). Antipsychotics and neuroleptics (>50% of residents), anti-dementia drugs and anticonvulsants (each about 17%) were the most frequently prescribed psychotropic drugs. Descriptive analyses of prescription rates did not indicate any correlation with prevalence of specific neurological or psychiatric symptoms. A strikingly high frequency of prescriptions of sedatives was noted in residents with few non-cognitive symptoms and with a high prevalence of apathy (>30%).

Non-pharmacological interventions were prescribed less frequently than pharmaceuticals. About 20% of residents were receiving physiotherapy and about 10% occupational therapy. In general, the frequency of physiotherapy and logopaedics prescriptions seemed to be lower in residents with dementia than in residents without dementia, even after adjusting for confounders related to population characteristics.

Nursing home residents with diabetes mellitus

Four studies with multiple methodological problems presented health care utilization data for nursing home residents with diabetes mellitus. Primary care was mostly supplied by medical generalists with co-attendance by diabetes specialists in about 25% of the population. On average, insulin-dependent diabetics were attended by primary care physicians twice a month, non-insulin-dependent diabetics once every three months. It is stated in one study that every third nursing home resident with diabetes mellitus had been examined by an ophthalmologist once a year, about 10% were registered within a disease management programme.

According to two studies, insulin therapy was the most frequently used treatment, followed by oral anti-diabetic medication and purely dietetic intervention. In patients on insulin therapy, blood glucose levels were measured once every day, mostly without definition of specific target values.

Analysis of guidelines

Recommendations concerning care for people with dementia were taken from the guideline of the German College for General Practitioners and Family Physicians (DEGAM) and from the conjoint guideline (S3) of the German Association for Psychiatry and Psychotherapy (DGPPN) and the German Alzheimer Society and Support Group (Deutsche Alzheimergesellschaft e. V. und Selbsthilfe Demenz). They referred to specialist consultation during the (initial) diagnostic work-up and for pharmacological treatment.

Recommendations referring to the care of patients with diabetes mellitus were extracted from the German Disease Management Guidelines Modules for foot complications, retinal complications, neuropathy, and kidney disease. Most recommendations related to screening examinations and consecutive referrals to medical specialists in case of determined diagnostic findings. Regular consultations of an ophthalmologist were recommended for the early detection of retinal complications.

Congruence of current health care utilization with guideline recommendations was analysed in the discussion part of this report.

Economic, ethical and legal aspects of medical specialist attendance of nursing home residents
Economic aspects

References found did not encompass any publications that explicitly addressed economic aspects of specialist medical care for nursing home residents.

Legal aspects

Four publications addressed topics that relate to recent reforms of the German health care system (GKV-WSG, PflWG). The introduction of more flexibility to contracting by modification of § 119b SGB V was welcomed by the authors, especially the fact that integrated care models are not limited to specific sickness funds any more. Furthermore, it was noted positively that qualification requirements are fixed by law now. At the same time the physician community cautioned that patients’ right to freely choose a doctor, the physician’s right to freely practice their profession might be at stake (Directors of nursing homes must not be given discretionary power.). Also, a medicalisation of nursing home residency was feared.

Relevant changes of the GKV-WSG included the opportunity to supply nursing home residents with specialised palliative care as well as the opportunity to integrate nursing homes as contracting partners into integrated care models. While search results of this HTA-report did not contain any references pertaining to the former aspect, the latter opportunity is currently being tested in a number of pilot projects (see below).

In a number of papers authors argued that insufficient fees for doctors attending nursing home residents constitute a still unsolved problem.

Two publications described legal causes for inadequate care using the prescription of psychotropic drugs as an example. The authors claimed that most of the problems arose from the sectoral structure of health care with its communication problems. In this respect, some authors favoured the introduction of nursing home physicians who should mainly have coordinating, educating and quality control tasks. This model of on-site physicians could be implemented on the grounds of § 140 SGB V and § 92b SGB XI.

Ethical aspects

One of the two publications relating to ethical aspects was discarded, because it deals with aspects of no relevance for this report.

Ethical aspects of medical care for nursing home residents were discussed in an empirical investigation again using psychotropic drug prescription as an example. The authors stated problems with regard to autonomous decision making of residents when their behaviour interferes with co-habitants’ and staffs’ rights and when any kind of force was applied. The fact, that sometimes it is nearly impossible to obtain the necessary informed consent from the patient was considered problematic from a legal point of view as well. Often it may be difficult to get an impression of the values and beliefs individual nursing home residents adhere to. Concerning the ethical requirement of beneficience, the authors emphasised the imperative of technical and vocational skills but also of the need for cooperation between the different professions in order to achieve positive treatment effects. As a prominent example, difficulties in managing challenging behaviour in nursing home residents were pointed out. The discussion of the ethical rule of non-maleficience again referred to the requirement of professional competence. The ethical principle of justice had first been discussed from an economical point of view, but eventually was referred to societal values which form the normative framework and the availability of resources for the elderly care.

Pilot projects

128 publications, among them three scientific papers, were analysed in order to describe pilot projects aiming to improve the availability of medical specialist care for nursing home residents. After screening the documents, two types of pilot projects were distinguished: projects initiated by the scientific community and projects initiated by health care institutions and corporations.

Scientific pilot projects

Eleven out of 128 included publications reported on pilot projects initiated by scientific institutions. Three of these papers qualified as scientific publications.

The Teamwerk-Projekt (later called Duales Konzept, consisting of a prophylaxis and a therapy module) addressed dental care for nursing home residents. The prophylaxis module comprised individually tailored prophylaxis interventions along with education of the nursing staff. In the therapy module, those residents in need of determined treatment were treated by foster dentists either in specific competence centres or in the nursing home. The authors reported positive clinical results for the first phase. For the second phase a reduction of 22% of the cost for dental care compared to the reference period was reported.

The other two scientifically initiated pilot projects belonged to topic 3 (assuring evidence based care) of the Leuchtturmprojekt Demenz financed by the Federal Ministry of Health during 2008/2009. The project InDemA (Interdisziplinäre Implementierung von Qualitätsinstrumenten zur Versorgung von Menschen mit Demenz in Altenheimen) targeted the improvement of dealing with challenging behaviours displayed by nursing homes residents. The intervention comprised implementation of basic recommendations for nursing staff and the guideline Demenz of the DEGAM with primary care physicians. Effectiveness of the intervention, e. g. referring to the endpoints prescription rates of psychotropic drugs (especially neuroleptics) and prevalence of provocative behaviour, was evaluated in a prospective investigation using a pre-post design. For both endpoints after nine months statistically significant and clinically relevant improvements were reported. From a methodological point of view the pre-post design, high drop-out rates and the unclear influence of contextual factors hampered interpretability of results.

The second project investigated the effects of implementing a guideline (Guideline of the American Geriatrics Society and American Association for Geriatric Psychiatry) to guide the care of nursing home residents with dementia (VIDEANT project). In a cluster-randomised trial in 16 Berlin nursing homes the endpoints apathy, agitation, depression and daily doses of psychotropic medication were investigated. So far there were only a few positive key results available from a poster presentation.

Pilot projects initiated by health care institutions and corporations

Information on 16 pilot projects targeting the improvement of medical specialist care for nursing home residents was available. The project descriptions were based on press releases, contracts, presentation slides, journal and newspaper articles. There was no comprehensive and coherent description available for any of these projects. Nine out of 16 projects explicitly defined improvement of medical specialist care as primary project goal.

Two pilot projects targeted care for nursing home residents with specific diagnoses: Solinger Konzept for patients requiring artificial ventilation (an integrated care model according to § 140 SGB V) and the Hessian Care contract according to § 73c SGB V by AOK, KV (Association of Statutory Health Insurance Physicians) and Bundesverband der Deutschen Nervenärzte (BVDN) for Hessian nursing home residents with psychiatric diagnoses. Three pilot projects by the Kuratorium Wohnen im Alter (KWA) (Luise-Kieselbach-Haus; Parkstift Rosenau, KWA Bad Dürrheim) addressed, beside assuring general and specialist medical care, improvement of the inter-professional communication. The nursing home physician project by the Arbeiterwohlfahrt (AWO) München also specifically addressed improvement of specialist care by coordination through a nursing home physician employed by the institution (authorised by the Bavarian Association of Statutory Health Insurance Physicians and at the same time participating in an integrated care programme after § 140 SGB V run by the Bavarian AOK).

The project Pflegenetze Bayern also specifically addressed specialist care by requiring participating physicians’ networks to integrate medical specialists, in particular psychiatrists and neurologists. Cooperation was regulated via contracts for integrated care programmes in connection with primary care contracts according to § 73b SGB V.

The cooperation contract between the Hessian Association of Statutory Health Insurance Physicians and the Bundesverband privater Anbieter sozialer Dienste (bpa) represented an implementation of the framework KV-Initiative Pflegeheim which by now has been signed by all 17 associations of statutory health insurance physicians. Another form of organising specialist care for nursing homes was demonstrated by the Bayerischen Geriatrischen Praxisverbünde, which may also be subsumed under the KV-Initiative Pflegeheim.

The remaining seven pilot projects aimed to improve medical care for nursing home residents in general. The project Pflege mit dem Plus had been running in Berlin since 1998. As an integrated care model in combination with a primary care contact, it was based on § 140a, § 73c SGB V and § 92b SGB XI. Primary care was supplied either by specifically employed nursing home physicians or by cooperating primary care physicians. This project (and the three projects described below) comprised regular ward rounds, comprehensive documentation, on-call duties, quality circles and multi-professional team meetings. The project Careplus is conducted in Berlin as well. It combined contracts for integrated care and contracts for special outpatient care (§ 140a and § 73c SGB V). Partners were nursing homes, health care funds, and physicians. The above mentioned concepts were also brought into practice by the project Integrierte Versorgung Pflegeheim (IVP) of the AOK Baden-Württemberg. Cooperating partners include the AOK Baden-Württemberg, the Confederation of Primary Care Physicians, a primary care contract community, the MEDIVERBUND AG, and a number of nursing homes. More integrated care models were run by the AOK Hessen, AOK Westfalen-Lippe and the AOK North-East in cooperation with the Association of Statutory Health Insurance Physicians of Mecklenburg-West Pomerania. Their aims corresponded to those of the Careplus project from Berlin. Another form of cooperation was piloted by the Modellregion Emsland. Here, an existing network of primary care physicians was going to employ a nursing home-based physician who was to take care of nursing home residents and hereby relieve some pressure from the network offices.

For some of the pilot projects positive effects on procedural and economic indicators reflecting quality of care of nursing home residents were reported. However, there was no comprehensible evaluation plan available for any of these projects, thus the validity of the results cannot be judged.

The Dutch model Elderly Care Physician

The Netherlands are the only country in the world that introduced a medical specialty training specifically designed for physicians caring for nursing home residents. It was established in 1990 and complements the specialty of clinical geriatrics which targets the care for patients with acute geriatric conditions in hospital. The specialty training Elderly Care Medicine is tailored to the needs of nursing home residents suffering from somatic and mental multi-morbidity. It targets improvement and preservation of physical and cognitive functioning, the embedding of medical care into a multidisciplinary team and the explicit consideration of multi-morbidity. The 36-month training programme is completed in nursing homes and in outpatient care and has a strong psychogeriatric focus. Theoretical training is completed once a week at an academic training centre (university). Although Elderly Care Physicians are mostly employed by nursing homes, they are increasingly consulted by primary care physicians to attend geriatric patients living in their own home environment. Since 2010, about 100 Elderly Care Physicians have graduated each year.

Discussion and conclusions

Areas of undersupply and inadequate care

Based on a literature review which includes more than 40 studies presenting individual patient data, a high prevalence of age-related, often co-existing somatic and mental diseases and health problems in nursing home residents was demonstrated.

Against the background of this morbidity and in comparison to evidence-based recommendations the systematically compiled data on utilization of medical care suggested the following areas of undersupply or inadequate care for residents with dementia or diabetes mellitus type:

  • Imprecise and nonspecific diagnostic work-up of dementia diagnoses,
  • Undersupply of anti-dementia drugs in residents suffering from Alzheimer type dementia,
  • Inadequate prescribing of psychotropic drugs in general and neuroleptics in particular for the treatment of neuropsychiatric symptoms in residents with dementia,
  • Undersupply of remedies for the non-pharmacological treatment of residents with dementia,
  • Undersupply of specialist care for residents with diabetes mellitus concerning regular ophthalmologic examinations.

Studies including nursing home residents in general also indicated some amount of clinically inadequate, non-targeted and protracted prescriptions of psychotropic drugs. Furthermore, utilization data suggested deficits in dental care for nursing home residents in general, in ophthalmologic care for residents with dementia and deficits in medical care for patients with continence problems or alimentation via feeding tube.

Taken together, the results of the literature review suggest that the identified problems with (specialist) medical care for nursing home residents have multiple causes. Contributing factors are inadequate diagnoses and documentation of diseases and health problems, an insufficient documentation of prescriptions and their fulfillment as well as insufficient communication between different professions. These problems apply to all involved medical professions, including primary care, but also to the nursing profession. Furthermore, an insufficient implementation of evidence-based recommendations for medical care regarding certain diseases is demonstrated.

Unfortunately, available data do not allow identification of factors that contribute to the above mentioned weaknesses in the care process or hinder the implementation of evidence-based recommendations. Furthermore, it cannot be clarified whether insufficient integration of medical specialists is causal for suboptimal care processes and whether areas of undersupply actually impair the residents’ health status.

Economic implications

The references identified allow no empirically based conclusions on economic consequences of optimal versus suboptimal medical specialist care for nursing home residents. According to the criteria of this HTA-report, there is no solid data base to back statements (also encountered in mass media) of potential cost savings in the range of millions of euro.

Ethical and legal implications

Legal and ethical considerations concerning the availability of medical specialist care for nursing home residents refer to three problematic areas: i) the structural framework (including financial resources), ii) inter- and intra-professional communication and cooperation, and iii) the obligation to provide professional competence.

Pilot projects

The information obtained concerning pilot projects for the improvement of medical specialist care in German nursing homes is not as informative as expected in the planning phase of this HTA-report. There are a number of activities addressing the problem by utilizing different approaches that are backed by the legal frameworks of SGB V and SGB XI. From these initiatives promising as well as indifferent results are reported. However, based on available data it is not possible

  • To present a reliable and comprehensive overview of ongoing, completed and planned projects,
  • To give a sufficiently detailed description of projects, and
  • To derive evidence-based statements concerning the effectiveness of interventions to improve medical specialist care for nursing home residents.

It remains unclear, whether project descriptions along with evaluation protocols and results are non-existent or simply have not been published.

Excursus Elderly Care Physician

The Dutch concept of Elderly Care Physician must be appreciated within the specific context of the Dutch health care system. In the Netherlands, Elderly Care Physicians are employed by nursing homes where they supply primary medical care for the residents. In the German context, this arrangement is a subsidiary model which is only sporadically implemented in German nursing homes. Compared to the German curricula for the further education in geriatrics (specialists of internal medicine and geriatrics, or additional education in geriatrics), the Dutch training programme is very practice-oriented and at the same time anchored in academia (like all medical specialist trainings in the Netherlands). Beside clinical skills, it targets the development of communication and integration competence and puts a strong focus on psychogeriatric conditions. While it is not possible to transfer the entire concept to the German health care and medical training system, it should be discussed whether and how some of the main elements could be integrated into the German curricula, because they specifically address a number of the deficits identified by this report.

Recommendations

The available data base does not allow the deduction of unambiguous evidence-based recommendations for permanent modifications of the system of medical (specialist) care for nursing home residents in Germany. Instead it is recommended to develop strategies for optimizing nursing and medical care taking into account the weaknesses identified by this report. All strategies need to be evaluated in pilot projects which are thoroughly planned, conducted and documented. Only this type of project allows generalisable conclusions on the causal relationship between processes of care and nursing home residents’ state of health and quality of life.

In order to improve the degree of insight achieved by pilot projects it is suggested that

  • Reporting projects’ planning, conduct and results should be made mandatory for publicly funded projects,
  • Published project descriptions should be coherent, comprehensive and sufficiently detailed,
  • Every project must be evaluated,
  • A comprehensive cross-sponsor and cross-project documentation platform should be initiated (e. g. web-based database).
Research needs

This report points out a lack of methodologically sound empirical evidence that could form a base for recommendations how to re-organise and shape medical specialist care for nursing home residents in Germany. To fill this gap, well planned and conducted studies that follow international standards (e. g. http://www.consort-statement.org/ (accessed 01.10.2012), http://squire-statement.org/ (accessed 01.10.2012)) are required to accompany pilot projects aiming to optimize medical (specialist) care for nursing home residents.

The development and planning of structural and procedural changes of medical specialist care furthermore requires meaningful health care utilization studies that apply adequate measures to minimise selection and information biases and adjust for confounding factors. Especially the influence of factors relating to institutional characteristics or details of medical care on process and outcome indicators need to be investigated more thoroughly. Recommendations for the publication of epidemiologic studies should be followed.

The development and planning of strategies to optimize structures and processes of medical (specialist) care also requires systematic analyses of promoting and hindering factors for implementation of existing evidence-based recommendations for the treatment of age-related diseases and for the uptake of legal opportunities offered by SGB V and SGB XI.


Notes

Competing interests

The authors declare that they have no competing interests.

INAHTA Checklist

Checklist for HTA related documents (Attachment 1 [Attach. 1]).


References

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