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 hospital admissions. Besides, GPs tended to the view that the nursing staff decides too soon in favour of a hospital transfer. Regarding areas for possible improvement, both groups rated very similarly 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% [42] and up to 40% [40]. 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 [35]. Remarkably, those findings also are in line with ours although that study was conducted in the US [35].
The NH staff estimated the proportions of both ED presentations and hospital admissions considerably lower than the GPs. This was also found in an US study by Ouslander et al. [38] when the involved nursing staff rated 23% of acute hospital transfers as potentially preventable. Vasilevskis et al. [54] compared the perspectives from hospital-based physicians and skilled nursing facility based staff on the avoidability of hospital readmissions of Medicare patients discharged to skilled nursing facilities. The authors found similarly that the nursing staff were less likely to rate these hospital visits as avoidable than the physicians. Further studies are needed to assess reasons for differences in ratings between various healthcare professionals.
Harrison et al. [39] used a series of vignettes based on common clinical scenarios and found that Scottish physicians and nurses most often agreed that the admission for the case with advanced dementia was inappropriate. This finding is comparable with ours. 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, a German study using claims data showed that hospitalisation rates of NH residents with dementia are almost as high as of those without dementia [55].
Interestingly, the proportions of agreement that NH residents often do not benefit from hospital admissions were in both surveyed groups higher than their assessed proportions of inappropriate hospital transfers. These findings seem to be conflicting at first sight. This especially occurs for the NH staff, since the nurses see the resident after 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 in our survey. This underlines that NH staff is often challenged by the complexity of hospital transfer decisions [37]. A multiplicity of factors influence the nurses to transfer a resident in a case of acute deterioration including family pressure [56], inability to provide a treatment on-site, and legal considerations [46,57]. 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 [23]. This is also supported by our finding that the majority of GPs thought that the NH staff initiates transfers to hospital too often.
Thus, it is not surprising that from the GPs’ and the NH staff’s perspectives the importance of measures to reduce hospital transfers differs. Physicians put the emphasis on NH-related factors and rated most importantly the improvement of the staffing capacity in NHs. Physicians’ concerns about understaffing have also been identified in other studies in England [48] and France [53]. In the same way, the staffing level plays a key role in the facility staff decision-making [34,46]. Further, an adequate training of the nurses is essential for a high quality of care [35] - about 90% of the GPs and 60% of the NH staff saw a need for action in this context. Diagnostic and treatment resources (e.g., oxygen, medications) available in the NH can be helpful [27,33,36,46]. Inadequate skills in the assessment of first signs of deterioration can result in further decline [43]. However, additional time needed for such residents limits the staff’s availability to care for others increasing tendency for hospital transfers [58,59]. Consequently, increasing the staffing ratio and continuous qualification activities are two key improvement measures [34–37,46,53,58].
Early appropriate medical care and can be facilitated by improved GP’s availability during office hours and out-of-hours [33,35,36,40,46] and may also improve the patient-physician relationship. 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. GP’s coordination function is estimated to be even more important for NH residents since GPs tend to have a greater expertise in the care of this frail population. Specialists’ contacts or treatment decisions without GP’s involvement contrast with this role. On the other side, the NH staff might think that GPs have less expertise in providing adequate care in all possible scenarios - although in Germany, GPs provide the bulk of medical care in this population [4,44]. Such disagreements can be caused by communication difficulties between nurses and physicians and uncertain responsibilities which are known to contribute to acute hospital transfers of NH residents [46]. Sharing information about a resident’s condition between nurses [33,34,53] and between nursing staff and GP [33,34,37,41,46,48] has the potential to prevent inappropriate hospital transfers. This is supported by our surveys in which both groups rated the interprofessional communication highly important. For instance, Dutch NHs employ next to the nursing staff specialized elderly care physicians (formerly NH physicians) [60,61] who provide a continuity of care which can reduce potentially inappropriate hospital transfers [62]. Concerning the communication among the staff we could see a larger discrepancy. Whereas the GPs rated this measure important, which was also shown in two studies in France [53] and the UK [34], the majority of the responding NHs perceived no problem here.
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 [27,33,35,42]. 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 [63] and problems in their use such as the often insufficient specificity are known [40,63,64]. Advance care planning (ACP) aims to discuss and record patient preferences concerning goals of care in the case of physical or mental deterioration [65] and a German study showed that its implementation leads to a better adoption of ADs in NHs [66]. A randomized controlled trial on the implementation of an AD program in Canadian NHs [67] indicates less hospital admissions in residents with ADs [67]. Thus, increasing the prevalence and the validity of ADs by further implementation of ACP could facilitate medical decision-making and prevent hospital transfers. This process 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 [24,25] but this study aimed to illustrate the perception of GPs and NH staff in Germany. Another limitation applies to the generalizability of the findings. On the one hand, 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. However, a comparison of all NHs’ answers with the ones from Bremen and Lower Saxony showed only slight differences. 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 [52] our GPs’ response ranges within other questionings among GPs in Germany [51,68]. In the NH survey we even had a higher proportion of returned questionnaires compared to other recently published studies conducted with German NHs [69,70]. However, for both surveys a selection bias cannot be ruled out. Although we showed in this study the views of two important groups there are of course other perspectives which should be obtained in future studies (from paramedics, hospital physicians, transferred residents and their family members).