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.

The emotional impact of urinary tract infections in women: a qualitative analysis.

BACKGROUND: While many studies address the clinical management of participants with uncomplicated urinary tract infection (uUTI), the emotional impact of uUTIs has been investigated less often. The aim of this qualitative study was to understand the emotional experience of women with uUTIs. METHODS: This was a qualitative, exploratory, in-depth interview-based study conducted among women in the United States (US) and Germany. Women aged ≥ 18 years with at least one uUTI treated with antibiotics in the past year were recruited through a patient community panel and physician referrals. Participants were recruited using purposive sampling to include an equal split of those with 1 or ≥ 2 antibiotics, and an equal split of those treated for a single or recurrent uUTIs (≥ 2 uUTIs in the past year). A structured telephone interview included questions about symptoms, diagnosis, treatment, and retreatment (if any). Each participant was queried about her emotions and the impact of the uUTI on life activities. Thematic analysis of responses was carried out to identify common themes. RESULTS: A total of 65 participants completed the interview, 40 (61.5%) from the US and 25 (38.5%) from Germany. Major themes that emerged from the analyses included (1) a wide range of negative emotions were experienced due to uUTI symptoms, interference with activities of daily life, and effects on relationships and sleep; (2) varied emotions and understanding related to uUTI treatment and management approaches; (3) treatment failure caused frustration, worry, and anger; and (4) the prospect of recurrent uUTIs provoked dread and helplessness. CONCLUSION: Our research uncovered emotions of helplessness and dread experienced by women in the context of uUTI clinical treatment failure and recurrent uUTIs. Knowing patients' perspectives on UTI management will help guide the development of patient education and improve shared decision-making.

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].

[Presentation of an innovative interdisciplinary and cross-sector therapeutic concept for pain patients as part of a regional selective contract]. / Vorstellung eines innovativen interdisziplinären, sektoren-übergreifenden und gestuften Behandlungskonzepts für Schmerzpatient*innen im Rahmen eines regionalen Selektivvertrages nach §140a SGB V.

BACKGROUND: A graded therapeutic concept for the treatment of chronic pain patients in Germany is only available to a limited extent. Following the onset of coronavirus disease (COVID-19), care for these patients has become even worse. AIM: To develop and establish a cross-sector therapeutic concept for chronic pain patients as part of a selective contract. METHODS: Embedded in existing therapeutic procedures, we define seven clinical pathways (CPs) into which patients are directed, after an interdisciplinary assessment according to refined criteria. ORGANIZATION: In CP I, patients remain in standard therapy. In CP II, patients have the opportunity to participate in an additional inter-profession education program. In CP III, patients get a specialized outpatient treatment. CP IV is a partial inpatient treatment, where multiple inpatient attendance days are replaced by tele-medical treatment, via a rehabilitation app. CP V and VI are inpatient treatments over 8 and 15 days each. If patients need further psychotherapeutic support after an inpatient treatment, they can be treated by clinical psychotherapists for another six months in CP VII. EVALUATION: The evaluation takes place 3, 6 and 12 months after initial assessment and includes the German Pain Questionnaire with different psychometric tests.

REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care.

BACKGROUND: Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine. METHODS/DESIGN: In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention. DISCUSSION: If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care.  Trial registration DRKS, DRKS00020389, Registered 30 January 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020389 .

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.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters.

BACKGROUND: Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits. AIMS: We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR. METHODS: We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED. RESULTS: A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%). DISCUSSION: Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary. CONCLUSION: Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

[Medical specialist undertreatment in nursing home residents-Prevalence and extrapolation]. / Fachärztliche Unterversorgung bei Heimbewohnern ­ Prävalenzstudie und Hochrechnung.

BACKGROUND: Nursing home residents tend to have lower medical specialist utilization than other groups of older people; however, as yet there is little evidence whether nursing home residents obtain adequate medical specialist care. This study investigated whether nursing home residents receive adequate oral health care, ophthalmological care, otorhinolaryngologist care and neurological care. The unmet needs of the nursing home population in Germany was extrapolated. MATERIAL AND METHODS: Audiometry, eye examinations and oral visual inspection were performed in 409 residents from 44 nursing homes. Medical care in the previous 12 months as well as existing diagnoses were retrieved from the nursing documentation. Teams of physicians evaluated for each resident based on all collected data if the resident obtained specialist care that was adequate to the needs. RESULTS: Between 15% and 45% of the residents with need for medical specialist care did not receive adequate specialist care. Of all residents 27% had unmet need of specialist care in at least one of the investigated medical specialties. It is projected that up to 205,000 nursing home residents in Germany do not receive adequate medical specialist care. CONCLUSION: Given a considerable proportion of nursing home residents with unmet need of specialist care, interventions should be developed that help reduce the level of unmet needs.

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.

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.

Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research.

BACKGROUND: Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents' health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners. The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision. METHODS: A systematic literature search was performed in Medline via PubMed, Ebsco Scopus and CINAHL in May 2018. Studies were eligible if they contained information a) about the decision to transfer NHR to hospital and b) the experiences or influence of family members. The review followed Joanna Briggs Institute's (JBI) approach for qualitative systematic reviews. Screening, selection and quality appraisal of studies were performed independently by two reviewers. Synthesis of qualitative data was conducted through meta-aggregation. RESULTS: After screening of n = 2863 articles, in total n = 10 qualitative studies were included in the review. Results indicate that family members of NHR experience decision-making before hospitalization differently. They mainly reported NH-related, hospital-related, and family/resident-related factors influencing the transfer decision. The involvement of family members in the decision-making process varies - from no involvement to insistence on a decision in favor of their personal preferences. However, hospital transfer decisions and other treatment decisions (e.g. advance care planning (ACP) discussions) were commonly discussed with physicians and nurses. Conflicts between family members and healthcare providers mostly arose around the interpretation of resident's best interest. In general, family members perceive discussions as challenging thus leading to emotional stress and discomfort. CONCLUSION: The influence of NHR family members concerning hospital transfer decisions varies. Family members are an important link for communication between resident and medical staff and for communication between NH and hospital. Interventions aiming to reduce hospitalization rates have to take these findings into account.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1.

OBJECTIVES: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, -EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention.

BACKGROUND: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Reducing antibiotic use for uncomplicated urinary tract infection in general practice by treatment with uva-ursi (REGATTA) - a double-blind, randomized, controlled comparative effectiveness trial.

BACKGROUND: Uncomplicated urinary tract infections (UTI) are common in general practice and usually treated with antibiotics. This contributes to increasing resistance rates of uropathogenic bacteria. A previous trial showed a reduction of antibiotic use in women with UTI by initial symptomatic treatment with ibuprofen. However, this treatment strategy is not suitable for all women equally. Arctostaphylos uva-ursi (UU, bearberry extract arbutin) is a potential alternative treatment. This study aims at investigating whether an initial treatment with UU in women with UTI can reduce antibiotic use without significantly increasing the symptom burden or rate of complications. METHODS: This is a double-blind, randomized, and controlled comparative effectiveness trial. Women between 18 and 75 years with suspected UTI and at least two of the symptoms dysuria, urgency, frequency or lower abdominal pain will be assessed for eligibility in general practice and enrolled into the trial. Participants will receive either a defined daily dose of 3 × 2 arbutin 105 mg for 5 days (intervention) or fosfomycin 3 g once (control). Antibiotic therapy will be provided in the intervention group only if needed, i.e. for women with worsening or persistent symptoms. Two co-primary outcomes are the number of all antibiotic courses regardless of the medical indication from day 0-28, and the symptom burden, defined as a weighted sum of the daily total symptom scores from day 0-7. The trial result is considered positive if superiority of initial treatment with UU is demonstrated with reference to the co-primary outcome number of antibiotic courses and non-inferiority of initial treatment with UU with reference to the co-primary outcome symptom burden. DISCUSSION: The trial's aim is to investigate whether initial treatment with UU is a safe and effective alternative treatment strategy in women with UTI. In that case, the results might change the existing treatment strategy in general practice by promoting delayed prescription of antibiotics and a reduction of antibiotic use in primary care. TRIAL REGISTRATION: EudraCT: 2016-000477-21 . Clinical trials.gov: NCT03151603 (registered: 10 May 2017).

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.

Pro re nata (as needed) medication in nursing homes: the longer you stay, the more you get?

PURPOSE: Injudicious pro re nata (PRN) or as needed prescribing can lead to polypharmacy, potentially harmful drug interactions and total drug doses exceeding the maximum recommended. Despite the known risks and the widespread administration, there is a paucity of current research examining the use of PRN drugs in nursing homes. Therefore, we examined characteristics of PRN drug use and potential predictors in nursing homes. METHODS: The multicentre cross-sectional study included a heterogeneous sample of 21 nursing homes in Northwestern Germany comprising 852 residents. Descriptive statistics and multivariable regression models were used to analyse and present the collected data. RESULTS: Nearly three quarters (74.9 %) of all residents were treated with at least one PRN medication. On average, each resident was prescribed 2.5 ± 2.3 PRN drugs. On average, residents with no PRN prescriptions stayed since 2.4 ± 2.9 years in the nursing home. Residents with five and more PRN prescriptions were on average since 4.8 ± 4.3 years in the nursing home. In a multivariable analysis, length of stay above the median of 2.1 years (OR 2.4; 95 % CI 1.8, 3.2) and polypharmacy with five or more long-term drugs (OR 2.1; 95 % CI 1.5, 2.9) were associated with a higher number of PRN prescriptions. Most commonly used PRN drug was acetaminophen, which was prescribed to 289 (33.9 %) residents. CONCLUSIONS: The high prevalence of PRN medication should be taken into account when considering polypharmacy and inappropriate drug prescribing or using screening tools like the STOPP/START (screening tool of older persons' potentially inappropriate prescriptions/screening tool to alert doctors to right) criteria in nursing homes. Physicians should regularly reconsider the need of each PRN drug on the medication schedule. Moreover, the high prevalence of PRN medication and the association with length of stay highlights the importance of an accurate documentation.

Pain medication in German nursing homes: a whole lot of metamizole.

PURPOSE: Prescribing of metamizole (dipyrone), an analgesic that has been withdrawn from the market or never approved in many countries owing to safety concerns, is high in elder persons in Germany. This study assessed the use of pain medications in German nursing homes with a special focus on prescribing patterns of metamizole. METHODS: Using data of the 'Inappropriate Medication in Patients with Renal Insufficiency in Nursing Homes' (IMREN) study conducted between October 2014 and April 2015 in nursing homes in Bremen and Lower Saxony, we studied prescribing of analgesics including both scheduled and as-needed medications. For residents with scheduled medication, dosage and duration of use were analysed. RESULTS: A total of 852 residents from 21 nursing homes were included. They were on average 83.5 years old, and 76.5% were women; 73.8% received at least one analgesic with 70.3% obtaining World Health Organization step I drugs. The most frequently prescribed substances were metamizole (for 40.6%) and paracetamol (acetaminophen; 35.6%), with paracetamol given mostly as-needed. The proportion of residents receiving metamizole increased with age (up to 47.4% in persons aged 90 years and over). Of 143 residents with scheduled metamizole (16.8%), the mean daily dosage was 1843 mg (interquartile range [IQR]: 1500-2250); 66.9% received metamizole for at least 90 days and 23.2% for at least 365 days (mean duration 276 days; IQR: 59-314). DISCUSSION: There is a discrepancy between prescribing of metamizole for older persons, on the one hand, and evidence on comparative effectiveness and safety as well as approval and recommendations, on the other hand. Copyright © 2016 John Wiley & Sons, Ltd.

[Medical services for nursing home residents : Results of the study on inappropriate medication in patients with renal insufficiency in nursing homes]. / Ärztliche Versorgung von Pflegeheimbewohnern : Ergebnisse der Studie "Inappropriate medication in patients with renal insufficiency in nursing homes".

BACKGROUND: In Germany approximately 800,000 people are living in nursing homes. Outpatient medical treatment is provided by general practitioners (GP) and a variety of medical specialists. While nearly all residents have regular contact with GPs, care by specialists differs between the various disciplines. AIM: In this study an assessment of medical treatment for nursing home residents by GPs and specialists was made and compared with the available diagnoses. MATERIAL AND METHODS: Between October 2014 and April 2015 a cross-sectional study was conducted in nursing homes in Bremen and the surrounding areas. Anonymized data based on residents' files were collated by nursing staff. Every contact with various specialists within the preceding 12 months was assessed and grouped into (a) no physician visit, (b) resident visited physician and (c) physician visited resident. Analyses were stratified for age, sex and level of care dependency as well as dementia and further comorbidities. RESULTS: A total of 852 residents in 21 nursing homes were included (mean age 83.5 years, 76.5 % female) in the study. Dementia was diagnosed in 57.7 %. Nearly all residents had had contact with their GP in the previous 12 months, mostly by home visits (96.9 %). The majority (54.5 %) had not seen a dentist in the preceding 12 months and 25.4 % had been visited by a dentist. Of the residents 47.4 % were visited by a neurologist or psychiatrist but only 4.5 % visited these specialists in their practice. Higher care dependency and younger age were associated with more frequent visits by neurologists and psychiatrists. Contact rates to ophthalmologists (29.3 %) and urologists (20.5 %) were less frequent. A diagnosis of diabetes mellitus had no influence on the contact rate with ophthalmologists. CONCLUSION: Medical care by specialists is characterized by huge variations. Besides a frequent contact rate with GPs there seems to be an undersupply regarding care by dentists and ophthalmologists.

Drug-disease interaction in elderly patients in family practice.

OBJECTIVE: To determine the frequency of potential drug-disease interaction in elderly patients in family practice. To assess which drugs and diagnoses are associated with a high risk related to drug-disease interaction and whether there are gender- or age-related differences. METHODS: In routinely recorded electronic patient records, patients at least 65 years old with at least one diagnosis named in Beers list and one prescription were identified. Potential drug-disease interaction (PDDI) was presumed if within the same 3 months a "Beers" diagnosis and a potentially inappropriate prescription with respect to this diagnosis were documented for a patient. Multiple logistic regression analysis identified factors associated with a high risk of PDDI. RESULTS: Of 24,619 patients (63.4% women) corresponding to our inclusion criteria, 10.4% were exposed to at least one PDDI. Almost no (0.0%) PDDI was associated with the most common Beers disorder hypertension (prevalence 49.2%). However, 23.4% of men suffering from bladder outflow obstruction (prevalence 17.6% in males) were exposed to at least one PDDI. PDDI was quite common in some rarer conditions, for example, indications for anticoagulation (prevalence 2.6%, 31.5% PDDI). PDDI was not influenced by gender, but associated with taking more than 4 drugs (OR 1.91 (1.83 - 2.00)), suffering from more than one Beers disorder (OR 1.24 (1.16 - 1.31)), and advanced age (OR 1.10 (1.05 - 1.15)). CONCLUSIONS: High risk patient groups could be identified. Some disorders as well as some drugs are particularly prone to risky constellations; these should be reflected in systems assisting prescribing with regard to patient safety.