Comparison of the findings with the existing literature
Based on two cross-sectional studies we found that GPs estimate the proportion of inappropriate hospital transfers higher than NH staff. On the contrary, more nursing staff agreed that residents do often not benefit from hospitalisations. Besides, GPs tended to the view that the nursing staff decides too soon in favour of a hospital transfer. The only congruency between both groups in areas for possible improvement was the presence of explicit ADs. The importance of the NH-related measures was rated higher by the GPs while the nursing staff focussed on physicians’ care and availability.
The GP survey suggests that 35% of hospital admissions and almost 40% of ED visits among NH residents are inappropriate. The latter finding is in line with two other studies where physicians judged the inappropriateness of transferring NH residents to EDs with proportions of 33% [38] and up to 40% [36]. A structured implicit review of medical records investigating both types of hospital transfers identified 36% of ED visits and 40% of hospital admissions as not appropriate [32]. Remarkably, those findings also are in line with ours although that study was conducted in the United States [32].
The NH staff estimated the proportions of both ED presentations and hospital admissions considerably lower than the GPs. This was also found by Ouslander et al. [34] when the involved nursing staff rated 23% of acute hospital transfers as potentially preventable. Vasilevskis et al. [49] compared the perspectives from hospital-based physicians and skilled nursing facility based staff on the avoidability of hospital readmissions. The authors found similarly that the nursing staff were less likely to rate these hospital visits as avoidable than the physicians.
Harrison et al. [35] used a series of vignettes based on common clinical scenarios for which the respondents should make concrete decisions regarding the appropriateness. The vignette with the highest agreement that the respective admission was inappropriate described a resident with advanced dementia. This finding is comparable with one of the four statements we listed in our questionnaires. Over three quarters of GPs and almost two thirds of NH staff agreed that hospital transfer decisions should be taken more cautiously for those residents. However, another German study showed that hospitalisation rates of NH residents with dementia are almost as high as of those without dementia [50].
Interestingly, the proportions of agreement that NH residents often do not benefit from hospitalisations were in both surveyed groups higher than their assessed proportions of inappropriate hospital transfers. The proportion of agreement was even higher among the NH staff than the GPs. Due to frailty of the institutionalised population [5–7] and the risk of a further functional decline associated with ED visits and acute admissions [16,17] their benefits are often questioned. Therefore, our findings seem to be conflicting. This ambivalence especially occurs for the NH staff, since the nurses see the resident after their discharge prior to the GPs in most cases and perceive the health status decline immediately. On the other hand, NH staff often considers no alternative than initiating a hospital transfer. This underlines that NH staff is often challenged by the complexity of hospital transfer decisions [43]. A multiplicity of factors influence the nurses to transfer a resident in a case of acute deterioration including family pressure, inability to provide a treatment on-site, and legal considerations [41,51]. Taken these together, conflicts and uncertainties may arise making nurses more likely to decide in favour of a hospital transfer compared to physicians. An Austrian study explored that most of unplanned transfers are initiated by nurses without physician involvement [20]. This is also supported by our finding that the majority of GPs thought that the NH staff often initiates transfers to hospital too early.
Thus, it is not surprising that from the GPs’ and the NH staff’s perspectives the importance of measures to reduce the number of hospital transfers differs. Physicians put the emphasis on NH-related factors. As a result, the measure with the highest level of agreement was the improvement of the staffing capacity in the facilities. Concerns about understaffing have also been identified in other studies on physicians’ [42,48] and facility staff’s perceptions [31,41]. Next to the staff-to-resident ratio an adequate training of the nurses is an essential factor for a high quality of care which may reduce inappropriate hospital transfers [32]. About 90% of the GPs and 60% of the NH staff saw a need for qualification activities for the nursing staff. The interaction of increasing the staffing ratio and continuous qualification activities encourages the nurses to react adequately in cases of acute deteriorations [31–33,41,43,48,52]. Diagnostic and treatment resources available in the NH can help achieving this aim [24,30,31,33,41]. Early appropriate medical care and transfer decisions are also facilitated by improving the GP’s availability, both during office hours and out-of-hours [30,32,33,36,41]. For the NH staff in our survey this was the most important measure directly followed by the demand for better medical specialist’s care and availability. Predominantly, the GPs agreed to the first point; however, they disagreed to improve specialist’s care. Specialists’ contacts or treatment decisions without further involvement of the respective GPs are in contrast to the GP’s coordination function which is estimated to be even more important for NH residents. On the other side, the NH staff might think that GPs have less expertise in providing adequate care in all possible scenarios although GPs provide the bulk of medical care in this population [4,53]. Such disagreements can be caused by communication difficulties between nurses and physicians and uncertain responsibilities in the facilities which are known to contribute to acute hospital transfers of NH residents [41]. For that reason sharing information about a resident’s condition effectively between the nurses [30,31,48] and between nursing staff and GP [30,31,41,42] has the potential to prevent inappropriate hospitalisations. This is supported by our surveys in which both groups rated the interprofessional communication highly important. The GPs rated this measure even more often as important. Similarly, we saw a discrepancy concerning the rating of the communication among the staff. Whereas the GPs rated this measure important as shown in other studies with physicians [48] and multiple stakeholders [31] the majority of the responding NHs perceived no problem here. However, even trained nurses feel more confident being backed by GPs. Therefore, a better communication and collaboration, particularly between GPs and NH staff, should be pursued [30,37,42,43]. For instance, Dutch NHs employ next to the nursing staff specially trained elderly care physicians (formerly NH physicians) [54,55] who provide a continuity of care which has shown to be effective in reducing potentially avoidable hospitalisations [56].
For both GPs and nurses, the availability of an AD can be a support to make hospital transfer decisions in better accordance with the resident´s wishes [24,30,32,38]. In our two surveys, it was the only measure for improvement rated in its importance very similar by both groups (approx. 75% agreement, resp.). Nevertheless, only a minority of residents is estimated to have a personal AD [57] and problems in their use such as the often insufficient specificity are known [36,57,58]. Increasing the prevalence and the validity of ADs by further implementation of advance care planning (ACP) could prevent hospitalisations. In this process, care preferences are discussed and recorded [59] and should ideally start before the NH placement.
Limitations and strengths
Some of the findings of this study, especially the stated proportions of inappropriate hospital transfers have to be interpreted with caution as they are attributed to personal impressions of the responding GPs and NH staff. There exists a broad range of ways to define appropriateness of transfers [21,22] but this study aimed to illustrate the perception of GPs and NH staff in Germany. Indeed, we could include facilities from all over Germany in our NH sample; however, we had only access to GP data from two federal states’ Associations of the Statutory Health Insurance Physicians. Therefore, another limitation applies to the generalizability of the findings. At the same time, we were able to achieve the target response in the GP survey (33.5%). In the NH survey we even attained a higher response than expected (45.5%). By using several strategies shown to increase the response of postal surveys [47] our GPs’ response ranges within other questionings among GPs in Germany [46,60]. In the NH survey we even had a higher proportion of returned questionnaires compared to other recently published studies conducted with German NHs [61,62].