The present study investigates perceived deficits in GP care and associated factors during the first wave of the COVID-19 pandemic in German nursing homes. We found that the majority of nursing home managers reported no deficits in GP care (routine visits, 84.3%; acute visits, 92.9%). Still, deficits in GP care (routine visits) were associated with visiting restrictions for GPs and the size of the nursing homes. Small nursing homes (1–50 residents) were more likely to report deficits in GP care (routine visits) compared to medium (51–100 residents) or large nursing homes (>100 residents). Further, deficits in GP care (acute visits) were associated with dementia as the focus of care and the burden of insufficient testing for SARS-CoV-2 among residents. Visiting restrictions for GPs were associated with dementia as the focus of care and COVID-19 incidence at the state level. Finally, COVID-19 cases in nursing homes were associated with the size of the facility, COVID-19-incidence at the state level, and the burden of insufficient testing for SARS-CoV-2 among residents.
Though prior evidence indicated major challenges for GP care due to the pandemic [21, 26, 27, 28, 29], the majority of nursing home managers in our sample did not report deficits in GP care during the first wave of the pandemic in Germany. Nevertheless, primary care in nursing homes had been a noticeable problem even before the pandemic began [15, 16], and even a slight worsening may have had a greater impact on residents as perceived by nursing home managers. Further, deficits in GP care may have been unevenly distributed over time, i.e., lacking during certain weeks of the pandemic and then compensated in the subsequent weeks.
In line with similar results from previous studies [26; 30], our findings imply that insufficient testing for SARS-CoV-2 infections among residents seems to be associated with COVID-19 cases and more deficits in GP care for acute medical cases in nursing homes. Prior research demonstrated that SARS-CoV-2 positive nursing home residents with asymptomatic cases can still contribute to the transmission of the coronavirus in long-term care facilities [10, 26, 31]. This research indicates that regular testing of residents and staff, regardless of the occurrence of symptoms, helps determine the true impact of COVID-19 [10] and is both desirable and recommended [26]. However, insufficient testing capacities appeared to be a major problem for infection prevention during the first wave of the COVID-19 pandemic in Germany, ultimately leading to a high burden for nursing home staff [23, 26].
In contrast to previous findings from Rothgang et al. [26], our results suggest that COVID-19 cases are more likely to be found in medium and large nursing homes (>50 residents) in Germany. However, our results support research from the USA [32], Canada [33], and Spain [34, 35]. For example, in a study of 9,395 nursing homes in the USA, Abrams et al. [32] showed that larger facility size, urban location, and state were significantly related to an increased probability of having COVID-19 cases in nursing homes [32]. In a cross-sectional analysis of nursing homes in Spain between March 1 and June 30, 2020, Soldevila et al. [35] found that larger nursing homes had a greater likelihood of a COVID-19 outbreak compared to their smaller counterparts (88.1% versus 37.0%, P < .001) [35]. Soldevila and colleagues [35] argued that large nursing homes were more vulnerable to a SARS-CoV-2 transmission due to the higher number of visiting relatives and working staff [35]. Furthermore, we found that a large facility size was linked to fewer deficits in GP care for routine visits. Though our results indicate that smaller nursing homes were less likely to have COVID-19 outbreaks, nursing home managers perceived more deficits in GP care (for routine visits but not acute visits) in these settings compared to medium and large nursing homes. One explanation could be that larger nursing homes might have a greater ability to provide a sufficient amount of nursing staff able to look after their residents and intervene at an early stage so that GPs don’t need to be consulted and no deficits in GP care occur. Otherwise, this unanticipated result may be attributed to the fact that GPs are probably able to see more patients at once during their routine visits to larger nursing homes. This simplicity of spatial opportunity and time-saving for GPs may emerge as a probable explanation for the lack of deficits in GP care for routine visits in larger care settings.
In our sample, almost one-third of nursing homes implemented visiting restrictions for GPs. This is comparable with previous findings by Rothgang and colleagues [26], who described among their surveyed German nursing homes that approximately one quarter did not allow access for external service providers (including GPs), and two-thirds only allowed access with limitations [26]. Likewise, our results show that visiting restrictions for GPs were associated with perceived deficits in GP care for routine visits. In an exploratory Dutch study [36], most physicians providing care for residents in nursing homes described visiting restrictions as an ethical dilemma wherein they balanced safety as mediated through infection prevention measures and liveability for the residents, i.e. compensating for the absence of face-to-face contact [36].
Further, our data implies that nursing homes with dementia as a focus of care were particularly burdened by the impacts of the pandemic, which is in line with previous research conducted by Gordon et al. [37], who highlighted the COVID-19 related challenges of isolation and visiting restrictions for the nursing home staff in managing residents of whom have up to three quarters a cognitive impairment [37]. Additionally, in our survey, nursing homes with dementia as the focus of care were more likely to have visiting restrictions for GPs and deficits in GP care for acute visits.
Furthermore, the association found between local COVID-19 incidence and COVID-19 cases in nursing homes in our data is also reflected in recent research out of the USA [32], Canada [33], and Spain [35]. Soldevila et al. [35] argue that a high incidence in the general population raises the possibility of virus transmission into nursing homes by nursing home staff and visiting relatives [35]. Further, deficits in GP care (acute visits) were especially reported in nursing homes that experienced insufficient testing for SARS-CoV-2 infections among residents as a strong or very strong burden. This was also the case in nursing homes with dementia as the primary focus of care. Similarly, Grimm et al. [38] showed that nursing home residents’ hospital admissions – including emergency admissions for acute coronary syndromes and stroke – declined during the first wave of the COVID-19 pandemic, potentially resulting in substantial unmet health issues [38].
Strengths and Limitations
Our study has both strengths and limitations. Strengths include the population-based design of the sampling. To our knowledge, our sample is the largest and most comprehensive sample of German nursing homes used to investigate the first wave of the COVID-19 pandemic; moreover, the composition of the sample corresponds to the distribution of nursing homes across Germany.
Despite the strength of the study sample size, this study design has some distinct limitations. First, because of the nature of a retrospective survey, a potential recall bias needs to be taken into account. Since the second wave of the pandemic had a more detrimental impact on German nursing homes than the first, it is possible that the first wave of the pandemic was remembered as easier to manage, or even the opposite. Nursing homes may have adapted between the first and second waves regarding the lack of personal protection equipment, testing devices, and the overwhelming experience of the pandemic. It is thus possible that deficits in GP care may be perceived less strongly by the surveyed nursing home managers given the challenging context. Second, a selection bias toward nursing homes that are less affected by the pandemic should be considered.
Moreover, the present study only investigates perceived deficits in GP care by managers in nursing homes; this does not cover inadequacies in the utilisation of other aspects of the healthcare system, such as medical specialists [16, 17, 18, 19, 20], which was beyond the focus of the present study. Furthermore, we measured neither the quantity nor the quality of GP care during the pandemic, and the results may be prone to biases. Nevertheless, data does not indicate that probable differences are due to unreliable answers from nursing home managers. Future studies should include validated questionnaires to evaluate GP care during the pandemic more precisely.
Finally, even though we took the cumulative incidence of COVID-19 cases from the state level into account, we were not able to differentiate between urban and rural areas, which could provide valuable context in the light of previous research [32] that found a significant relationship between the urban location of nursing homes and an increased rate of new COVID-19 infections.