Impact of regular televisits on unplanned hospital admissions of nursing home residents in rural Germany: a pre-post intervention study

Impact of regular televisits on unplanned hospital admissions of nursing home residents in rural Germany: a pre-post intervention study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of regular televisits on unplanned hospital admissions of nursing home residents in rural Germany: a pre-post intervention study Anne-Catherine Redeker, Tobias Martin, Sarah Veldeman, Carina Barbosa Pereira, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5448947/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Sep, 2025 Read the published version in BMC Geriatrics → Version 1 posted 8 You are reading this latest preprint version Abstract BACKGROUND Hospital admissions occur frequently in nursing homes and are often preventable. Inappropriate hospitalizations due to ambulatory care sensitive conditions bring major risks for the residents, put the emergency departments under pressure and generate high costs for the health sector. Telemedical solutions are of great potential to intensify medical follow-up of the residents and therefore reduce hospital admissions. In this study, we evaluated whether the implementation of regular medical televisits, in addition to on-site nursing home visits, can reduce unplanned hospital admissions. METHODS In 2021 a nursing home in rural Germany introduced a telemedical system, linking the facility to a general practitioner. Data concerning the unplanned hospitalizations of the residents was collected for 2021/22 and for 2018/19, serving as pre-intervention comparison. Thereafter, hospital admissions were compared between the two time periods, and between residents of 2021/22 who did or did not receive regular televisits by their general practitioner. RESULTS Baseline characteristics were comparable between residents of 2018 and 2021, as well as between residents of 2021 receiving or not telemedical care. Unplanned hospital admissions had significantly decreased (P < .0001) after implementation of regular televisits. Furthermore, a significantly lower (P = .04) number of hospital admissions was noted among residents benefiting from regular televisits by their general practitioner, compared to the control group solely followed by regular on-site nursing home visits. CONCLUSIONS The successful implementation of a telemedical system providing ambulatory care in nursing homes shows promising results to reduce unplanned hospital admissions and possibly avoid its negative consequences. TRIAL REGISTRATION Not applicable, as no healthrelated intervention, modifying biomedical outcome or healthrelated measures in patients, took place. Telemedicine televisit avoidable hospital admission nursing home nursing-home sensitive condition general practitioner geriatric care Figures Figure 1 Figure 2 Figure 3 Background Hospital admissions occur frequently among nursing home (NH) residents in Germany [ 1 , 2 ] and are of major concern to the German healthcare system. Other European countries and the United States also report an important number of these hospitalizations [ 3 , 4 ], with rates per person-year more than twice as high as for the age-matched community dwellers [ 5 ]. Furthermore, there has been an increase of admissions over time [ 6 ], and without timely solutions, this trend will most likely progress, as discussed in the following paragraphs. The German Federal Statistical Office presumes that in 2040 the amount of 67-year-olds and older is going to account for 25–27% of the population, while the percentage of the very old (> 80 years) will continue to rise until 2060 and lie between 9% and 13% [ 7 ]. Moreover, the prevalence of chronic diseases within the older adult population is considered high [ 8 ]. This is therefore accompanied by an important usage of time and personnel resources to assure adequate medical care. Meanwhile, the increase of ambulatory home care [ 9 ], among others due to the potential of ICT (information and communication technology) [ 10 ], can lead to a deferral of entering the NH. As a result, the NH population, in addition of increasing [ 9 , 11 ], is becoming older [ 12 ] and includes a high number of multimorbid patients [ 8 ]. At present, the medical care of NH residents is mainly provided by general practitioners (GPs) [ 13 ] and on-site caregivers, consisting of qualified nursing staff. In Germany, the widening gap between the demand and supply of ambulatory physicians [ 14 ] is going to cause an approximate unmet need of 20 000 GPs in two years from now [ 15 ]. Alongside this development, the shortage of nursing staff for inpatient care, intensified by the COVID-19 pandemic, could count up to 307 000 caregivers in 2035 [ 11 ]. In consequence, the healthcare of a higher number of NH residents, carrying a larger burden of diseases, will need to be provided with fewer personnel resources. This will create a relevant conflict, while trying to keep up with the present standard of medical care. Especially rural areas, where the accessibility to healthcare providers is already limited [ 16 ], are going to be affected early on. This makes finding solutions for these areas even more important, particularly in view of the claim for equal living conditions (including access to a certain infrastructure and elementary requirements such as health) strived by German politics [ 17 , 18 ]. In NHs the distinct lack of GPs is felt by a decrease in on-site nursing home visits [ 19 , 20 ]. As the latter occur less frequently, clinical signs of a decompensating chronic disease or health status deterioration sometimes might not be detected early enough, leading to an acute event of illness. In this case, the reduced availability of the attending GP often forces the nursing staff to contact the emergency services [ 21 ]. In fact, the number of ambulance interventions in NHs increased by 68.9% between 2004 and 2013 [ 22 ]. The involved paramedics or emergency physicians, who are not acquainted with the patient’s medical history, tend to take patients to the already crowded Emergency Departments (EDs) [ 23 , 24 ], potentially resulting in an inappropriate, avoidable hospital admission [ 21 , 25 ]. The hospital admissions, which could have been prevented by better ambulatory care, are so called ambulant sensitive and are employed by some healthcare systems as a quality indicator of ambulatory healthcare [ 26 ]. An important number of hospitalizations in NHs, approximately between 30% and 50%, have been found to be caused by ambulatory care sensitive conditions [ 1 , 27 , 28 ]. However, the NH residents form a geriatric patient group, which differs significantly from the rest of the population, for example (e.g.) by age, level of care, comorbidities, and disease spectrum [ 1 , 29 ]. Hence, experts developed an equivalent list of 58 nursing home-sensitive diagnoses for which hospitalizations are potentially avoidable [ 29 ]. Preventing these hospitalizations in NHs is of relevance for all three parties involved; patients, care-providers, and healthcare payers. For geriatric patients, a hospital stay can be associated with decline in physical function, e.g. due to confusion or disorientation [ 30 , 31 ] and it represents an incisive event in the patient’s autonomy. Especially NH residents have a high probability of developing a delirium [ 32 ], often associated with pre-existing dementia, when being torn out of their daily environment. Further hospital-associated health complications, such as nosocomial infections, worsen the outcome. In fact, the in-hospital mortality among NH residents is high, reaching up to 34% [ 3 , 5 , 32 ]. Avoiding hospitalization protects residents from major risks, while care-providers save on effort, time, and resources. Eventually, healthcare payers benefit from important cost-savings [ 33 , 34 ]. For 2017, the total amount of potentially avoidable costs, considering nursing home-sensitive hospital admissions in the national German context, was estimated about 760 million euros [ 29 ]. Telehealth care is increasingly used in NHs and has recently experienced a worldwide boom during the COVID-19 pandemic [ 35 – 37 ]. The engagement to use telehealth among older adults is influenced by specific barriers such as lack of self-efficacy, knowledge, support, functionality, and information about the benefits [ 38 ]. Nevertheless, telehealth has proven to be well accepted among older patients [ 39 – 42 ], an important prerequisite for successful implementation of telemedical systems. Digital familiarity and perceived usefulness can be mentioned as having a positive impact on acceptance and satisfaction with telemedicine [ 43 , 44 ]. In addition to the mentioned potential for NH residents, important elements for teleconsultation, such as the training of nurses and the required trust between physician and nurse [ 45 , 46 ], hold potential to improve the physician-nurse interaction and cooperation. As nurses play a major, more extensive role during remote consultation, the successful nurse-physician collaboration is essential to ensure quality for patient care [ 47 ]. Telemedical solutions have the potential to improve quality of care and reduce hospital admissions for NH residents [ 48 – 50 ]. The article of Hofmeyer et al. observed an important decrease of unplanned hospital transfers from 39–17% (2012–2015), while providing a 24/7 teleconsultation service to rural long-term care facilities [ 51 ]. Further studies with different models of care, assuring unscheduled telemedical assessment, also reported a decline of ED visits and/or reduction in hospital admissions for NH residents [ 52 – 56 ]. Besides acute telecare, routine scheduled teleconsultations conducted by different specialists (including geriatricians) were associated with less transfers and a lower hospitalization rate as well [ 34 , 57 , 58 ]. Telemedicine consultation reduced the hospitalization of NH residents in 14 out of 16 studies (published between 2001–2022) identified in a review by Valk-Draad & Bohnet-Joschko [ 59 ]. Thereof, few studies had a higher level of evidence. While the mentioned telemedical services were used for acute assessment by different specialists in case of health status deterioration to avoid hospital admission, our study concentrates on the impact of regular televisits by a GP, improving the continuity of medical care of NH residents. Due to the continuous, longstanding care of GPs in NHs, the GPs alongside with the on-site caregivers, are potentially best suited to detect and asses health status deterioration early on. Since GPs also take over a major part of chronic disease management, intensified follow-up by GPs through televisits could prevent a relevant amount of nursing home-sensitive hospital admissions, which mainly include chronic diseases such as diabetes mellitus type 2 or chronic kidney disease [ 29 ]. Furthermore, our study evaluates the impact of regular televisits by a GP on inpatient nursing home care, while current literature mainly describes findings from long-term care facilities, where the level of care remains unclear (e.g. nursing homes, assisted living facilities, skilled nursing facilities, continuing care retirement communities). This study examined whether the implementation of regular medical televisits, in addition to on-site nursing home visits, by a GP reduces unplanned hospital admissions for NH residents in inpatient older adult care. Methods Study Design In order to evaluate the effect of regular televisits in inpatient older adult care, we conducted a single-centre, retrospective, longitudinal, pre-post intervention study (Fig. 1 ). In 2021, a NH in rural Germany introduced a telemedical system, linking the facility to one of the cooperating GPs (referred to as GP1). During a period of 12 months, from the 01.08.2021 to the 31.07.2022, GP1 followed his patients by regular televisits, in addition to on-site nursing home visits. GP1 took care of an average of 27 residents (32% of the NH population), forming the telemedical care group. The remaining 57 residents (68%) represent the control group and were followed by other GPs, who did not participate in telemedical care. A historical study arm, covering the time period from the 01.08.2018 to the 31.07.2019 served as pre-intervention comparison. Unplanned hospital admissions from the NH residents were analysed and compared before (2018/19) and after (2021/22) intervention, thus introduction of the telemedical system. A sub-analysis consisted in comparing the hospitalizations between the telemedical care group and the control group. Baseline characteristics of the residents were collected for both reference dates: 01.08.2018 and 01.08.2021, in order to compare the populations at the beginning of the two time periods. All residents meeting both criteria’s: age ≥ 18 years and inpatient older adult care were included. Setting The study took place in a NH in the Eifel region within the district Euskirchen, in North Rhine-Westphalia, Germany (Stiftung Evangelisches Alten- und Pflegeheim Gemünd). The district Euskirchen has a population density of 158 inhabitants per km² [ 60 ]. The municipality of Schleiden, to which Gemünd belongs, has a GP coverage rate of 109.8%, meaning that there is neither an undersupply nor oversupply of GPs. However, in the district Euskirchen only 75.8% of patients are cared for by a GP located less than 10km away, which is the lowest percentage compared to other Rhineland districts [ 61 ]. The NH has 84 places for inpatient older adult care, spread over four different residential areas. GP1 oversees approximately one-third of the residents. Before introduction of the telemedical system, GP1 visited his patients every second week by on-site nursing home visit. This was maintained during 2021/22 and complemented by regular televisits every second week whenever GP1 did not visit his patients on-site. The patient’s need for consultation was assessed weekly by GP1, in cooperation with the on-site caregivers. If needed, a scheduled televisit took place to either follow-up on a known health issue or to assess a newly emerged health deterioration. Therefore, not every resident of the telemedical care group was televisited by GP1 every second week, the decision for consultation was made at GP1’s discretion and solely based on his professional medical judgment. Every second week during fixed televisit hours (scheduled by GP1 and the caregivers), a varying number of residents from the telemedical care group, who needed consultation, were televisited by GP1 in cooperation with the on-site caregivers. The televisit assessment depended on the patient's current health issue (ranging from simply discussing the health status and therapeutic measures to performing specific examinations using the devices for point-of-care (POC) diagnostic) and did not follow a predefined standard operating procedure. The televisits played a sheer complementary role and never functioned as replacement for on-site nursing home visits. The entire caregiver staff was educated and trained through continuous telemedical exercise courses. The other GPs, responsible for the remaining residents, continued following their patients by regular on-site nursing home visits only. In acute situations, GPs (GP1 and other GPs), if available, conducted unscheduled on-site nursing home visits or, if the situation was assessed as life-threatening, emergency services were contacted. While the resident distribution always stayed about one-third for GP1 and two-thirds for other GPs, group composition slightly changed over time, because residents dropped out (e.g., by death) and were added (e.g., moving-in) to the two different groups. Telemedical System All televisits were performed using the medical “TeleDoc” cart system developed by the Docs in Clouds TeleCare GmbH, Aachen, Germany (Fig. 2 ). The “TeleDoc” system had already been tested by a GP for inpatient older adult care within a prior pilot study of our research group, showing feasibility and acceptance of the system [ 39 ]. In addition to audio and video communication between patient and physician (definition of a video consultation), a televisit allows diagnostic procedures by on-site paramedical personnel, to whom therapeutic measures can be delegated. The currently available “TeleDoc” cart is equipped with displays, secure communication technology and the following medical devices for POC diagnostic: digital stethoscope, blood pressure meter, blood glucose meter, pulse oximeter, electrocardiogram (ECG), thermometer and adjustable room camera with optical zoom. Via the installed “TeleDoc” software, a televisit could be started, connecting GP1 to the patient and caregiver in the NH. The visit took place using audio- and video communication, allowing interaction between the patient, GP1 and trained caregiver. The latter used the integrated devices for on-site medical examination, if requested by GP1. The thereby gathered information from anamnesis and POC diagnostic subsequently served as basis for further decision-making to GP1. Eventually, GP1 delegated the implementation of therapeutic measures to the on-site caregiver if needed. During televisits, data safety was guaranteed through end-to-end encryption for data transmission, as well as for bidirectional audio- and video connection. The “TeleDoc” software also allowed asynchronous communication between GP1 and the caregivers. Documents could be exchanged and uploaded to the televisit record. Moreover, caregivers could prepare the televisits by documenting diagnostic data, which they found necessary to already collect before starting a televisit. These data could then also be viewed by GP1 independently of the televisit. This modality of asynchronous televisits using a web-based waiting room is described in further detail in the article of Martin et al. [ 62 ]. Several kick-off training sessions for the NH caregivers and the linked GP were held in small groups to introduce the telemedical system. The practical testing of the medical devices for POC diagnostic was a central component of the initial training concept. Thereafter, caregiver staff trainings took place, improving the handling with the “TeleDoc” software and the medical devices, while reflecting the importance of these devices for their work and the medical care of NH residents. Simulated scenarios were used to train and consolidate the acquired skills. The training courses took place in person, also some training units could be completed online. The article of Martin et al. shows a timeline of the telemedical implementation process including further information regarding the training [ 62 ]. Data Collection All data was collected retrospectively by accessing the nursing care documentation system of the facility. Following population data, presented in Tables 1 and 2 , were documented systematically for every resident included: general personal characteristics (including care level), length of stay in the NH and occurred hospitalizations, geriatric, cardiovascular, ischaemic, neuropsychiatric, respiratory, and gastrointestinal risk factors, as well as several non-classified diagnoses. Furthermore, information concerning every unplanned hospital admission, such as time and type of transfer, hospitalization cause (medically confirmed reason for hospital admission, determined by the responsible GP, the emergency paramedics, or the emergency physician), in-hospital diagnosis, length of stay and event of death, was retrieved. Statistical Methods The two-sample t-test was applied on continuous variables and the chi-squared or Fisher’s exact test (depending on the number of observations) on categorical variables. Solely two-tailed statistical tests were used to calculate the P-value, whose statistical significance level was defined by < .05. Continuous variables were checked for normal distribution before applying the two-sample t-test and are summarized by mean and standard deviation. To compare the total frequency of unplanned hospitalization between the two time periods and groups, we applied the Fisher’s exact test, which is an exact method, especially for small sample sizes. Hospitalization was considered as an event that occurred or not (categorical outcome). As we compared proportions of a categorical outcome for independent and not correlated groups, the Fisher's exact test was used. For all statistical analysis we employed the programming language Python (version 3.9.7), using the open-source cross-platform integrated development environment (IDE) Spyder (version 5.1.5) and the web-based interactive computational environment Jupyter Notebook (version 3.9.7). The population and group comparison tables were produced using the open-source Python package named tableone [ 63 ]. Missing data concerning baseline characteristics and hospitalization causes are displayed in the tables and are not included in the comparison. Results Study Population Baseline characteristics of the residents on the 01.08.2018 and 01.08.2021 are presented in Table 1. The two populations are comparable, comprising 85 residents in 2018 and 84 residents in 2021. For both, the mean age was approximately 86 years and residents were mainly female (75.3% in 2018 and 82.1% in 2021). The care level distribution was similar, with most residents classified in level 4 (34.1% and 32.1%), followed by level 3 and 5, both compromising about 30% of the residents, and ending with the lowest care level 2. No significant difference was noticed regarding the specific geriatric syndromes, such as aconuresis and (&) anal incontinence, dementia & cognitive impairment, fall risk, gait & mobility disorder, and immobility. The cardiovascular risk factors did not significantly differ between both populations, with arterial hypertension being the most frequent diagnosis (68.2% and 79.8%). Furthermore, relevant diagnoses for ischaemic, neuropsychiatric, respiratory, and gastrointestinal risk were grouped into specific markers, which were comparable as well. For example, 45.9% of the residents in 2018 and 45.2% in 2021 had at least one disease associated with increased ischaemic risk (e.g., coronary heart disease or peripheral arterial occlusive disease). For further non-classified diagnoses, renal insufficiency was twice as common among residents in 2021 (28.6%) than in 2018 (14.1%). This being the only significant difference (P = .035) between the two populations. Eventually, the mean length of stay in the facility was 2.8 years for both populations. In addition, no significant difference in baseline characteristics was found comparing the patient group of GP1 in 2018 with the telemedical care group [Additional file 1]. Looking at the population of the 01.08.2021, the telemedical care group counted 23 residents, whereas the control group included 61 residents (Table 2 ). Neither the age, gender nor care level distribution was significantly different between the two groups. Same for the specific geriatric syndromes, cardiovascular risk factors and four different markers. For gastrointestinal risk factors, the P-value was close to significance level (P = .054). Significant difference was noted for the three following characteristics: diagnosis of chronic pain (P = .001), as well as number (P = .022) and days (P = .037) of hospitalization since moving-in. In fact, residents of the telemedical care group had had more hospital admissions (mean 3.0 to mean 0.9) and a higher mean of hospital days (24.7 to 8.9) since moving-in, than residents of the control group. Both were mainly due to a few statistical outliers, values that lay more than 1.5 times the interquartile range above the upper quartile. Table 1. Baseline characteristics of the NH population on the 01.08.2018 and the 01.08.2021: data listed as mean with standard deviation (SD) and counts (n) with percentages (%). Missing Overall 01.08.2018 01.08.2021 P-Value n 169 85 84 Gender, n (%) Male 0 36 (21.3) 21 (24.7) 15 (17.9) 0.368 Female 133 (78.7) 64 (75.3) 69 (82.1) Age, mean (SD) 0 85.9 (7.6) 86.1 (6.9) 85.7 (8.3) 0.753 Care level, n (%) 2 0 16 (9.5) 10 (11.8) 6 (7.1) 0.720 3 50 (29.6) 24 (28.2) 26 (31.0) 4 56 (33.1) 29 (34.1) 27 (32.1) 5 47 (27.8) 22 (25.9) 25 (29.8) GP, n (%) GP1 0 46 (27.2) 23 (27.1) 23 (27.4) 1.000 Other GPs 123 (72.8) 62 (72.9) 61 (72.6) Length of stay in the NH, mean (SD) 0 2.8 (3.4) 2.8 (3.3) 2.8 (3.6) 0.871 Number of hospitalizations since moving-in the NH, mean (SD) 0 1.6 (2.4) 1.8 (2.3) 1.5 (2.6) 0.341 Days of hospitalization since moving-in the NH, mean (SD) 0 14.8 (24.0) 16.4 (24.4) 13.2 (23.7) 0.392 Geriatric syndromes: Aconuresis, n (%) 0 70 (41.4) 31 (36.5) 39 (46.4) 0.247 Anal incontinence, n (%) 0 54 (32.0) 28 (32.9) 26 (31.0) 0.911 Dementia/Cognitive impairment, n (%) 0 101 (59.8) 48 (56.5) 53 (63.1) 0.471 Fall risk, n (%) 1 140 (83.3) 75 (88.2) 65 (78.3) 0.129 Gait & mobility disorder, n (%) 0 32 (18.9) 15 (17.6) 17 (20.2) 0.815 Immobility, n (%) 0 12 (7.1) 6 (7.1) 6 (7.1) 1.000 Cardiovascular risk factors: Arterial hypertension, n (%) 0 125 (74.0) 58 (68.2) 67 (79.8) 0.126 Diabetes mellitus, n (%) 0 46 (27.2) 22 (25.9) 24 (28.6) 0.826 Adiposity (BMI≥30), n (%) 1 30 (17.9) 16 (18.8) 14 (16.9) 0.897 Hyperlipidaemia/Dyslipidaemia, n (%) 0 94 (55.6) 44 (51.8) 50 (59.5) 0.390 MARKER ischaemic risk: CHD/Status post cardiac infarction/Atherosclerosis/Vascular stenosis/(P)AOD , n (%) 0 77 (45.6) 39 (45.9) 38 (45.2) 1.000 MARKER neuropsychiatric risk: Dementia/Cognitive impairment/Schizophrenic disorder/Psychotic disorder, n (%) 0 103 (60.9) 50 (58.8) 53 (63.1) 0.681 MARKER respiratory risk: COPD/Bronchial asthma/Chronic bronchitis, n (%) 0 18 (10.7) 7 (8.2) 11 (13.1) 0.439 MARKER gastrointestinal risk: Gastritis/Oesophagitis/Gastroesophageal reflux, n (%) 0 40 (23.7) 21 (24.7) 19 (22.6) 0.890 Cardiac arrhythmia, n (%) 0 66 (39.1) 29 (34.1) 37 (44.0) 0.244 Cardiac pacemaker, n (%) 0 17 (10.1) 9 (10.6) 8 (9.5) 1.000 Cardiac insufficiency, n (%) 0 34 (20.1) 13 (15.3) 21 (25.0) 0.167 Renal insufficiency, n (%) 0 36 (21.3) 12 (14.1) 24 (28.6) 0.035 Hypotension, n (%) 0 2 (1.2) 1 (1.2) 1 (1.2) 1.000 Hypothyroidism, n (%) 0 16 (9.5) 8 (9.4) 8 (9.5) 1.000 Chronic pain, n (%) 0 22 (13.0) 11 (12.9) 11 (13.1) 1.000 Morbus Parkinson/Parkinson syndrome, n (%) 0 14 (8.3) 10 (11.8) 4 (4.8) 0.170 Status post apoplexy/TIA, n (%) 0 44 (26.0) 23 (27.1) 21 (25.0) 0.897 Abbreviations. BMI: body mass index; CHD: coronary heart disease; (P)AOD: (peripheral) arterial occlusive disease; COPD: chronic obstructive pulmonary disease; TIA: transient ischaemic attack. Table 2. Baseline characteristics of the telemedical care group and the control group on the 01.08.2021: data listed as mean with standard deviation (SD) and counts (n) with percentages (%). Missing Overall Telemedical care group Control group P-Value n 84 23 61 Gender, n (%) Male 0 15 (17.9) 6 (26.1) 9 (14.8) 0.337 Female 69 (82.1) 17 (73.9) 52 (85.2) Age, mean (SD) 0 85.7 (8.3) 86.0 (8.2) 85.6 (8.4) 0.876 Care level, n (%) 2 0 6 (7.1) 2 (8.7) 4 (6.6) 0.886 3 26 (31.0) 6 (26.1) 20 (32.8) 4 27 (32.1) 7 (30.4) 20 (32.8) 5 25 (29.8) 8 (34.8) 17 (27.9) Length of stay in the NH, mean (SD) 0 2.8 (3.6) 3.7 (4.0) 2.4 (3.3) 0.163 Number of hospitalizations since moving-in the NH, mean (SD) 0 1.5 (2.6) 3.0 (4.1) 0.9 (1.4) 0.022 Days of hospitalization since moving-in the NH, mean (SD) 0 13.2 (23.7) 24.7 (32.9) 8.9 (17.5) 0.037 Geriatric syndromes: Aconuresis, n (%) 0 39 (46.4) 12 (52.2) 27 (44.3) 0.687 Anal incontinence, n (%) 0 26 (31.0) 9 (39.1) 17 (27.9) 0.465 Dementia/Cognitive impairment, n (%) 0 53 (63.1) 15 (65.2) 38 (62.3) 1.000 Fall risk, n (%) 1 65 (78.3) 21 (91.3) 44 (73.3) 0.134 Gait & mobility disorder, n (%) 0 17 (20.2) 6 (26.1) 11 (18.0) 0.543 Immobility, n (%) 0 6 (7.1) 2 (8.7) 4 (6.6) 0.663 Cardiovascular risk factors: Arterial hypertension, n (%) 0 67 (79.8) 18 (78.3) 49 (80.3) 1.000 Diabetes mellitus, n (%) 0 24 (28.6) 9 (39.1) 15 (24.6) 0.296 Adiposity (BMI≥30), n (%) 1 14 (16.9) 4 (18.2) 10 (16.4) 1.000 Hyperlipidaemia/Dyslipidaemia, n (%) 0 50 (59.5) 13 (56.5) 37 (60.7) 0.924 MARKER ischaemic risk: CHD/Status post cardiac infarction/Atherosclerosis/Vascular stenosis/(P)AOD, n (%) 0 38 (45.2) 8 (34.8) 30 (49.2) 0.349 MARKER neuropsychiatric risk: Dementia/Cognitive impairment/Schizophrenic disorder/Psychotic disorder, n (%) 0 53 (63.1) 15 (65.2) 38 (62.3) 1.000 MARKER respiratory risk: COPD/Bronchial asthma/Chronic bronchitis, n (%) 0 11 (13.1) 3 (13.0) 8 (13.1) 1.000 MARKER gastrointestinal risk: Gastritis/Oesophagitis/Gastroesophageal reflux, n (%) 0 19 (22.6) 9 (39.1) 10 (16.4) 0.054 Cardiac arrhythmia, n (%) 0 37 (44.0) 10 (43.5) 27 (44.3) 1.000 Cardiac pacemaker, n (%) 0 8 (9.5) 2 (8.7) 6 (9.8) 1.000 Cardiac insufficiency, n (%) 0 21 (25.0) 5 (21.7) 16 (26.2) 0.888 Renal insufficiency, n (%) 0 24 (28.6) 6 (26.1) 18 (29.5) 0.969 Hypotension, n (%) 0 1 (1.2) 1 (4.3) 0.274 Hypothyroidism, n (%) 0 8 (9.5) 8 (13.1) 0.100 Chronic pain, n (%) 0 11 (13.1) 8 (34.8) 3 (4.9) 0.001 Morbus Parkinson/Parkinson syndrome, n (%) 0 4 (4.8) 1 (4.3) 3 (4.9) 1.000 Status post apoplexy/TIA, n (%) 0 21 (25.0) 4 (17.4) 17 (27.9) 0.480 Abbreviations. BMI: body mass index; CHD: coronary heart disease; (P)AOD: (peripheral) arterial occlusive disease; COPD: chronic obstructive pulmonary disease; TIA: transient ischaemic attack. Hospital Admissions During 2021/22, 55 unplanned hospital admissions occurred for an average NH occupancy of 84 inpatient care residents. For the historical time period 2018/19, 74 unplanned hospitalizations were reported for an average NH occupancy of 83 residents. Thus, post-intervention, hospital admissions decreased by a total of 19, corresponding to a relative reduction of 26.6%. Meaning that in 2021/22, while regular televisits took place, there were a quarter less hospitalizations then during the historical period 2018/19. This result is of statistical significance (P<.0001). From the 55 unplanned hospitalizations in 2021/22, 15 concerned patients receiving regular televisits by GP1. On average, the telemedical care group counted 27 residents. In 2018/19, 19 of the 74 hospital admissions occurred to patients followed by GP1, which then cared for an average of 22 residents. Hence, within the group of GP1, admissions were reduced by 35.7%, while for the patient group followed by other GPs, the reduction was of 22.2%. The statistical significance of reduction was higher for the group of GP1, who conducted regular televisits during 2021/22 (Figure 3). As mentioned above, 15 of the 55 hospital admissions in 2021/22 concerned residents of the telemedical care group, while the remaining 40 admissions occurred to residents followed by other GPs with regular on-site nursing home visits only. On average, the control group counted 57 residents. Thus, during 2021/22, the number of unplanned hospital admissions was significantly lower (P=.04) for residents receiving regular televisits. Looking at the historical time period 2018/19, there was no significant difference (P=.5) in unplanned hospital admissions between the patient group of GP1 and the patient group followed by other GPs (moreover baseline characteristics and hospitalization causes were comparable for this analysis [Additional files 2 and 3]). Following hospitalization causes were identified for unplanned hospital admissions in 2021/22: breathing difficulties/dyspnoea, gastrointestinal problems, seizure, fall, general health status deterioration (unclear genesis), urologic problems, pain of the lower extremities/thorax/abdomen, hemic anomaly, and syncope. For three hospitalizations, the documentation of cause was missing. For the historical time period 2018/19, hospitalization causes were partly identical to 2021/22, adding: cardiovascular disorder, nephrological problems, suspected apoplexy/ transient ischaemic attack , suspected pneumonia, psychopathological anomaly, suspected thrombosis, oedema, inflammation signs of the lower extremities, exsiccosis, dermatological anomaly, medication adjustment and suspected lung embolism. There was no significant difference in distribution of the mentioned causes between admissions of 2021/22 and 2018/19 [Additional file 4]. Comparing the hospitalization causes of 2021/22 between the telemedical care group and the control group [Additional file 5], only the distribution of general state of health deterioration differed significantly (P=.046). The latter was documented ten times for hospitalizations concerning the control group, and not once for unplanned admission within the telemedical care group. Televisits For the study period of 12 months, 39 weeks with televisits were recorded. Out of 52 weeks, 6 must be deducted due to vacation of GP1 and during another 7 weeks, televisits could not take place due to other reasons. Hence, a total of 119 televisits occurred over a period of 39 weeks. Discussion Principal findings This study was the first field trial demonstrating the impact of regular televisits by a GP on unplanned hospital admissions in a NH in rural Germany. The introduction of a telemedical system, linking the facility to one of the cooperating GPs, was associated with a significant reduction of 26.6% in unplanned hospitalization for all residents. Thus, even residents who did not receive regular televisits, serving as control group, showed a reduction of 22.2% in unplanned hospitalization. However, the effect was significantly higher among residents receiving telemedical care, with a hospital admission decrease of 35.7%. Furthermore, this reflected in a significantly lower hospitalization rate in the telemedical care group, compared to the control group, during the intervention period. Since there was no significant difference for the hospital admission rate between the corresponding groups in 2018/19, the effect does not seem to be assignable to the linked GP. The few significant differences in baseline characteristics can be considered of small relevance for the analysis. Regarding the difference of renal insufficiency distribution, there was no significant difference in hospitalization cause for nephrological problems (P=.511) between 2018/19 and 2021/22 [Additional file 5]. We could not examine whether the impact of televisits or the telemedical implementation on hospital admissions was dependent on the severity of the residents' illnesses. For the latter we would recommend further studies with a different statistical approach. Interpretation of findings The results suggest that the implementation of a telemedical system, by increasing routine follow-up of NH residents through televisits, reduces unplanned hospital admissions. Intensified follow-up by a GP through televisits improves the continuity of medical care and can therefore prevent hospital admission. The impact of televisits is shown by the significantly lower numbe r of unplanned hospital admissions (P=.04) for residents receiving regular televisits, compared to the control group. The telemedical implementation led to changes in nursing practice, described in the article of Martin et al., which found that caregivers acknowledged improvements in their clinical skills, technological competencies, self-image and recognition [62]. As the linked GP and on-site caregivers weekly assessed which patient needed televisit, new responsibility was attributed to the nursing staff, being the main observer on-site. In addition, the role of the caregiver during televisits led to a shift of function, while the latter was responsible of undertaking the on-site diagnostic and potentially carrying out therapeutic measures delegated by the GP. The article of Sävenstedt, Bucht, Norberg & Sandman also concluded that the use of teleconsultations in a NH had an influence on the nurse’s and physician’s role, respectively becoming the presenter of medical problems and remote consultant [45]. A prerequisite, however, is the education and training of the on-site caregivers, assured through initiating and consolidating training sessions, so that they were sufficiently prepared for their new responsibilities. A geriatric nurse-led model of care presented by Zúñiga et al. reduced unplanned transfers from NHs to hospitals [64], showing the potential of giving greater responsibility to trained nursing staff. Furthermore, the reallocation of tasks and responsibility can strengthen the interprofessional cooperation. Besides qualified and skilled personnel, Valk-Draad & Bohnet-Joschko defined good cooperation as an important factor to avoid hospitalizations of NH residents [65]. Good cooperation between physician and caregiver has shown to ensure rational use of resources in relation to the patient’s needs and to coincide with high quality of health services [66]. Regarding the cooperation resulting from telemedical care, rational use of resources might provide additional time for holistic patient care, especially in light of future population and healthcare developments. Moreover, high quality of ambulatory care in NHs can prevent hospital admissions due to nursing home-sensitive conditions. Based on the cited literature, it can be assumed that secondary effects resulting from telemedical implementation, such as the training of staff and the interprofessional cooperation, had a positive impact on reducing unplanned hospital admissions for all NH residents. However, our study design did not allow to explicitly examine these secondary effects and their impact on the hospitalization rate, calling for further research in this field. Limitations An important limitation of our study was that it remains unclear if for our study period (2021/22) the hospitalization rate of NH residents was still influenced by the COVID-19 pandemic, as it had been the case at the beginning of the pandemic, where hospital admissions among NH residents decreased [67, 68]. Several factors including changes in care strategies, the direct impact of preventive measures, as well as a heightened risk awareness among NH residents and physicians, can explain this decrease [68-70]. In 2021/22, the hospitalization rate could also have returned to its pre-pandemic state, due to an ease of the situation in NHs, as a result of vaccinations and the end of the second lockdown in May 2021 [71,72]. Furthermore, hospital admissions could also have increased, as a consequence of neglected medical care and appointments, which had led to worsening health problems, especially among chronically ill people [73,74]. Even if the mentioned pandemic-related factors, responsible for hospital admission decrease, still played a role during our study period 2021/22, the direct impact of televisits can be represented by the significantly lower number of unplanned hospital admissions (P=.04) for residents receiving regular televisits, compared to the control group. Besides the impact of the COVID-19 pandemic on the hospitalization rate of NH residents, the influence of changes in residents and GPs of the facility, as well as in health care standards and documentation, cannot be excluded. Nevertheless, baseline characteristics of the residents were comparable for 2018 and 2021. Changes in the group of other GPs, including staff changes and modification in standards of care cannot be ruled out. However, the NH was led by the same head of nursing services for the two time periods (2018/19 and 2021/22) and therefore maintained the same nursing care management and standards on site. As data was collected from the nursing care documentation system of the facility, it is not possible to exclude partially incorrect documentation. However, the care documentation of the facility is included in the quality management manual followed by the NH and regularly checked for correctness by the Medical Service of the Health Insurance Companies. Following limitations must be considered regarding the generalisability of our findings. First, limitation lies within the specific setting of the study. The latter took place in a single facility in rural Germany with a limited population size. Within the study population, the mean length of stay in the NH, describing the number of years in inpatient care up to the date of the analysis, remained identical (2.8 years) between 2018 and 2021. It is important to distinguish between the length of stay as it was calculated for our study population, and the usually employed NH length of stay, representing the number of years in inpatient care up to the date of death. For both, surveys rather revealed a decreasing trend in German NHs [75,76], suggesting that our population might benefit of a high quality of care or a better health status. Data is lacking to exclude influencing factors such as the age at which people entered the NH. Moreover, the district of Euskirchen recorded a particularly high number of emergency transfers from various NHs to hospitals and potentially avoidable hospitalizations for the years 2017-2020, compared to other districts situated in the Rhineland and Hamburg [61]. This can be explained by the structural conditions of rural areas, such as transport difficulties, restricted medical services, and financial limitations, all leading to poor access and low availability of healthcare. Accordingly, the potential of telemedical solutions for reducing hospital admissions might be even greater in rural areas than elsewhere. Secondly, and independently from our study, the outcome and success of a telemedical implementation is depending on various factors. Financial and organisational barriers, such as the initial investment [48], appropriate reimbursement systems, the necessary telematic infrastructure or legal requirements [77-79], can already hinder the acquisition and use of telemedical systems. Further, the attitude, acceptance [77] and perceived ability of users [80] can play a major role. Eventually, it is essential to develop concepts which assure sustainability of telemedical projects after pilot phase [81-83], to enable the widespread use of telemedicine. Most of these barriers were overcome for implementation of the telemedical system surveyed in our study, as its introduction was part of a funded and thought-out project, but this is not always the case. In particular, the short-term overcoming of financial barriers was decisive for the implementation. Furthermore, the necessary infrastructure was available and the acceptance of the system had already been proven [39]. In order to understand and handle all barriers involved in introducing such a system, the change management should be analysed in more detail. The scope of action during a televisit by a GP remains limited, and severe situations of health deterioration still required on-site nursing home visits of the GP or the support of emergency services. Therefore, it cannot be excluded that in specific cases, unscheduled on-site nursing home visits by the GPs or emergency services have helped to avoid hospitalization. The employed telemedical system could promote communication and availability through intersectoral and technical networking (e.g. by reducing interprofessional hurdles, the system enables caregivers to have low-threshold contact with physicians) [84]. This potential can be of particular use to NHs in medical emergency situations. Telemedical networking creates standard communication paths using system interfaces and leading to an effective exchange of information, e.g., in the context of video consultations [85]. Valk-Draad & Bohnet-Joschko estimated that 35% of all NH hospitalizations (approximately 220 000 hospitalizations for Germany) could be prevented by combining optimized multidisciplinary communication and cooperation with digital expansion of the infrastructure, creation of legal prerequisites and remuneration structures [65]. The potential of an intersectoral telemedical cooperation network for optimizing acute care of NH residents and avoiding inappropriate hospitalizations, is going to be evaluated within the stepped-wedged trial named Optimal@NRW [86]. Strengths The strength of the study includes the design, which allowed for a double comparison of the telemedical effect. Besides looking at hospital admissions pre- and post-intervention, namely 2018/19 and 2021/22, the telemedical care group was compared to a control group. On the 01.08.2021 almost all NH residents were vaccinated twice against COVID-19, and a third vaccination was already offered by then. Accordingly, there should have been little impact of COVID-19 infections on hospital admissions at that time. Moreover, the historical period 2018/19 used for comparison was chosen wisely, as the pandemic had not yet begun. Following benefits evolved from the telemedical implementation. All residents received care from trained and therefore attentive caregivers, potentially noticing health status deterioration earlier. Residents of the telemedical care group were assessed weekly and, if needed, screened and examined through televisit, allowing adequate therapy in time. As the decision for televisit was made at GP1’s discretion, the potentially best, individual choice could be made for the residents, based on GP1’s experienced medical judgment. However, for broader implementation of the telemedical system, the development of SOPs (Standard Operating Procedure) as aid for decision-making would be beneficial. Furthermore, the telemedical system offered the advantage of POC diagnostic, which is not given by simple video consultation. Eventually, the implementation was associated with a reduction of unplanned hospital admissions for the residents. The mentioned benefits have the potential to improve the medical situation of care for NH residents and as a result increase patient safety. Conclusions Intensified follow-up by a GP through televisits improves the continuity of medical care and prevents hospital admission. This was shown by a significantly lower number of unplanned hospital admissions for residents receiving regular televisits compared to the control group. It remains unclear if the telemedical implementation through secondary effects played a role in reducing hospitalizations of NH residents, who did not receive televisits. The influence of various factors, such as the COVID-19 pandemic, on the hospitalization rate was not evaluated in this study and can therefore not be excluded. The implementation of a telemedical system providing outpatient care in form of regular televisits to NH residents shows promising results for decreasing unplanned hospital admissions. This telemedical solution can make an important contribution to healthcare, in light of meeting the challenges ahead. Abbreviations ED: Emergency Department e.g.: For example GP: General practitioner ICT: Information and communications technology NH: Nursing home POC: Point-of-care &: And Declarations Ethics approval and consent to participate Due to the nature of this retrospective study and the preserved anonymity of patients, a waiver of informed consent was obtained from the Ethics Committee at the Faculty of Medicine of the RWTH Aachen University (EK 179-23), by which the study was approved. Consent for publication Not applicable. Availability of data and materials All data discussed and analysed in the article are included in this publication and in its additional files. The raw datasets used to generate tables and additional files are available from the corresponding author on reasonable request. Competing interests MC is managing director and co-founder of Docs in Clouds Telecare GmbH, Aachen, Germany, the company that develops and distributes the “TeleDoc” system. CBP is and JK was working for Docs in Clouds Telecare GmbH, Aachen, Germany, in part-time. All other authors declare having no conflicts of interest. Funding Funding for the “AIDA” project (Arbeitsentwicklung in der Altenpflege) was provided by the European Regional Development Fund (ERDF) 2014-2020 of the European Union, and by the State of North Rhine-Westphalia, Germany. Authors' contributions AF, TM, SV, and MC conceptualized and designed the study. CBP, JK and MC provided statistical advice on the study design. AF, TM, SV, and MC supervised the implementation of the study and were responsible for the project administration. AF, TM and SV obtained research funding. ACR collected, managed, and analysed the data. ACR interpretated the findings and drafted the manuscript. All authors contributed substantially to its revision. All authors approved the published version of the manuscript. ACR takes responsibility for the paper as a whole. 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PMID: 31293238. doi: 10.1684/pnv.2019.0808. Pope R, Muchan M, Malin R, Binks R, Wagner A. The results of 24 hr teleconsultation with people at home and in residential care settings. International Journal of Integrated Care. 2013 11/19;13(7). doi: 10.5334/ijic.1421. Grabowski DC, O'Malley AJ. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for medicare. Health Aff (Millwood). 2014 Feb;33(2):244-50. PMID: 24493767. doi: 10.1377/hlthaff.2013.0922. Joseph JW, Kennedy M, Nathanson LA, Wardlow L, Crowley C, Stuck A. Reducing Emergency Department Transfers from Skilled Nursing Facilities Through an Emergency Physician Telemedicine Service. The western journal of emergency medicine. 2020 Oct 8;21(6):205-9. PMID: 33207167. doi: 10.5811/westjem.2020.7.46295. Low JA, Hui Jin T, Tan Lean Chin L, Agarwal N, Kim Huat G, Yeow A, et al. Cost analysis of implementing a telegeriatrics ecosystem with nursing homes: panel data analysis. 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Fakten zur regionalen Gesundheits- und Versorgungssituation der Bürgerinnen und Bürger im Rheinland und in Hamburg. https://www.aok.de/pk/magazin/cms/fileadmin/pk/rheinland-hamburg/pdf/gesundheitsreport-2022.pdf. Accessed 1 July 2023. Martin T, Veldeman S, Großmann H, Fuchs-Frohnhofen P, Czaplik M, Follmann A. Long-Term Adoption of Televisits in Nursing Homes During the COVID-19 Crisis and Following Up Into the Postpandemic Setting: Mixed Methods Study. JMIR aging. 2024 Jun 6;7:e55471. PMID: 38842915. doi: 10.2196/55471. Pollard TJ, Johnson AEW, Raffa JD, Mark RG. tableone: An open source Python package for producing summary statistics for research papers. JAMIA open. 2018 Jul;1(1):26-31. PMID: 31984317. doi: 10.1093/jamiaopen/ooy012. Zuniga F, Guerbaai RA, de Geest S, Popejoy LL, Bartakova J, Denhaerynck K, et al. Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design. J Am Geriatr Soc. 2022 May;70(5):1546-57. PMID: 35122238. doi: 10.1111/jgs.17677. Valk-Draad MP, Bohnet-Joschko S, Studiengruppe PSK. [Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2023 Feb;66(2):199-211. PMID: 36625862. doi: 10.1007/s00103-022-03654-4. Otterstad HK, Bomann-Larsen P, Gran MD. The importance of cooperation in primary health care. Utilization of physicians' services and home nursing services during different degrees of cooperation. Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke. 1990 Nov 10;110(27):3515-6. PMID: 2256087. Tan LF, Soh RYH, Seetharaman SK. Impact of the COVID-19 pandemic on hospital admissions of nursing home residents. Australasian journal on ageing. 2022 Jun;41(2):330-4. PMID: 34913228. doi: 10.1111/ajag.13032. Grimm F, Hodgson K, Brine R, Deeny SR. Hospital admissions from care homes in England during the COVID-19 pandemic: a retrospective, cross-sectional analysis using linked administrative data. International journal of population data science. 2020;5(4):1663. PMID: 34286106. doi: 10.23889/ijpds.v5i4.1663. Grund S, Gosch M, Laurentius T, Bollheimer C, Becker C, Bauer J. COVID-19 EPIDEMIC IN THE NURSING HOME – THE GERMAN EXPERIENCE. The Journal of Nursing Home Research Science (JNHRS). 2020 07/28. doi: 10.14283/jnhrs.2020.16. Sander M, Dano R, Bieber A, Dammermann A, Fleischer S, Dinand C, et al. Challenges, strategies and consequences from the perspective of German nursing home managers during the first wave of the COVID-19 pandemic - a qualitative interview study. BMC geriatrics. 2023 Mar 23;23(1):164. PMID: 36959576. doi: 10.1186/s12877-023-03787-4. Heudorf U, Förner M, Kunz S, Trost B. SARS-CoV-2 in Care Homes: Much Milder in 2022 Than at the Beginning of the Pandemic. Deutsches Arzteblatt international. 2023 Mar 13;120(9):142-3. PMID: 37185090. doi: 10.3238/arztebl.m2022.0386. Dequeker S, Callies M, Catteau L, Int Panis L, Islamaj E, Klamer S, et al. COVID-19 Clusters in Belgian Nursing Homes: Impact of Facility Characteristics and Vaccination on Cluster Occurrence, Duration and Severity. Viruses. 2023 Jan 13;15(1). PMID: 36680272. doi: 10.3390/v15010232. Ismail H, Marshall VD, Patel M, Tariq M, Mohammad RA. The impact of the COVID-19 pandemic on medical conditions and medication adherence in people with chronic diseases. Journal of the American Pharmacists Association : JAPhA. 2022 May-Jun;62(3):834-9.e1. PMID: 34844885. doi: 10.1016/j.japh.2021.11.013. Kendzerska T, Zhu DT, Gershon AS, Edwards JD, Peixoto C, Robillard R, et al. The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review. Risk management and healthcare policy. 2021;14:575-84. PMID: 33623448. doi: 10.2147/rmhp.S293471. Verweildauer von Pflegebedürftigen in stationären Pflegeeinrichtungen und Entwicklung der Pflegeplanung in Nordrhein-Westfalen. https://www.bundestag.de/resource/blob/410854/f2a05d5a058808fac2c71f59e9e9f0d5/wd-9-043-11-pdf-data.pdf. Accessed 1 July 2023. Die Verweildauern sinken. Statistische Analysen zur zeitlichen Entwicklung der Verweildauer in stationären Pflegeeinrichtungen. https://alters-institut.de/wp-content/uploads/2020/08/Alters-Institut-Die-Verweildauern-sinken-2015.pdf. Accessed 1 July 2023. Brauns HJ, Loos W. Telemedicine in Germany. Status, Barriers, Perspectives. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2015 Oct;58(10):1068-73. PMID: 26324096. doi: 10.1007/s00103-015-2223-5. Larsen F, Gjerdrum E, Obstfelder A, Lundvoll L. Implementing telemedicine services in northern Norway: barriers and facilitators. Journal of telemedicine and telecare. 2003;9 Suppl 1:S17-8. PMID: 12952708. doi: 10.1258/135763303322196196. Brooks E, Turvey C, Augusterfer EF. Provider barriers to telemental health: obstacles overcome, obstacles remaining. Telemed J E Health. 2013 Jun;19(6):433-7. PMID: 23590176. doi: 10.1089/tmj.2013.0068. Qi Tan AJ, Chua WL, McKenna L, Chin Tan LL, Lim YJ, Liaw SY. Enablers and barriers to nurse-facilitated geriatric teleconsultations in nursing homes: a qualitative descriptive multi-site study. Age and ageing. 2022 Dec 5;51(12). PMID: 36580553. doi: 10.1093/ageing/afac268. Bradford NK, Caffery LJ, Smith AC. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural and remote health. 2016 Oct-Dec;16(4):3808. PMID: 27744708. Singh R, Mathiassen L, Stachura ME, Astapova EV. Sustainable rural telehealth innovation: a public health case study. Health Serv Res. 2010 Aug;45(4):985-1004. PMID: 20459449. doi: 10.1111/j.1475-6773.2010.01116.x. Broens TH, Huis in't Veld RM, Vollenbroek-Hutten MM, Hermens HJ, van Halteren AT, Nieuwenhuis LJ. Determinants of successful telemedicine implementations: a literature study. Journal of telemedicine and telecare. 2007;13(6):303-9. PMID: 17785027. doi: 10.1258/135763307781644951. Offermann J, Ziefle M, Sira N, Groß D, Wilhelmy S. Telemedicine in nursing homes: Insights on the social acceptance and ethical acceptability of telemedical consultations. Digital health. 2023 Jan-Dec;9:20552076231213444. PMID: 37954688. doi: 10.1177/20552076231213444. May S, Jonas K, Fehler GV, Zahn T, Heinze M, Muehlensiepen F. Challenges in current nursing home care in rural Germany and how they can be reduced by telehealth - an exploratory qualitative pre-post study. BMC health services research. 2021 Sep 6;21(1):925. PMID: 34488746. doi: 10.1186/s12913-021-06950-y. Brucken D, Unterkofler J, Pauge S, Bienzeisler J, Hubel C, Zechbauer S, et al. Optimal@NRW: optimized acute care of nursing home residents using an intersectoral telemedical cooperation network - study protocol for a stepped-wedge trial. Trials. 2022 Sep 27;23(1):814. PMID: 36167557. doi: 10.1186/s13063-022-06613-1. Additional Declarations Competing interest reported. MC is managing director and co-founder of Docs in Clouds Telecare GmbH, Aachen, Germany, the company that develops and distributes the “TeleDoc” system. CBP is and JK was working for Docs in Clouds Telecare GmbH, Aachen, Germany, in part-time. All other authors declare having no conflicts of interest. Supplementary Files Additionalfile1.pdf Additionalfile2.pdf Additionalfile3.pdf Additionalfile4.pdf Additionalfile5.pdf ReportingguidelineBMC.docx Cite Share Download PDF Status: Published Journal Publication published 08 Sep, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 06 May, 2025 Reviews received at journal 24 Apr, 2025 Reviews received at journal 16 Apr, 2025 Reviewers agreed at journal 14 Apr, 2025 Reviewers agreed at journal 07 Apr, 2025 Reviewers invited by journal 05 Apr, 2025 Submission checks completed at journal 02 Apr, 2025 First submitted to journal 30 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5448947","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":439637074,"identity":"2aa8f0f0-3c55-49c5-b4f5-7a772658f4a0","order_by":0,"name":"Anne-Catherine Redeker","email":"data:image/png;base64,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","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Anne-Catherine","middleName":"","lastName":"Redeker","suffix":""},{"id":439637075,"identity":"38a492a9-ce31-42af-9735-933a60a8ada7","order_by":1,"name":"Tobias Martin","email":"","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Martin","suffix":""},{"id":439637077,"identity":"cfee7f6b-1815-413c-b3fd-a82f8d3b6bca","order_by":2,"name":"Sarah Veldeman","email":"","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Veldeman","suffix":""},{"id":439637078,"identity":"070c48ee-3460-4e37-ac67-da58d032a92f","order_by":3,"name":"Carina Barbosa Pereira","email":"","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Carina","middleName":"Barbosa","lastName":"Pereira","suffix":""},{"id":439637079,"identity":"428a6124-1510-4da5-9c85-57e407468a63","order_by":4,"name":"Janosch Kunczik","email":"","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Janosch","middleName":"","lastName":"Kunczik","suffix":""},{"id":439637080,"identity":"31f716a1-ff3c-429c-9eb6-189c60d78395","order_by":5,"name":"Michael Czaplik","email":"","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Czaplik","suffix":""},{"id":439637084,"identity":"e330d5e6-270f-4bd2-9710-dfe9bca64975","order_by":6,"name":"Andreas Follmann","email":"","orcid":"","institution":"RWTH Aachen University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Follmann","suffix":""}],"badges":[],"createdAt":"2024-11-13 17:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5448947/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5448947/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-06244-6","type":"published","date":"2025-09-08T15:57:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80275954,"identity":"88785690-a53d-4f2c-8083-6afc7180eff3","added_by":"auto","created_at":"2025-04-10 04:56:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65456,"visible":true,"origin":"","legend":"\u003cp\u003eThe study design, showing the pre-intervention period 2018/19 and the post-intervention period 2021/22 with regular televisits complementing on-site nursing home visits. The hospital symbols represent unplanned hospital admissions of NH residents.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/9dbb29c9aab18bae0caccfb3.png"},{"id":80276301,"identity":"dbf10db4-6cb2-4001-81ec-75af72cbc85a","added_by":"auto","created_at":"2025-04-10 05:04:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":175102,"visible":true,"origin":"","legend":"\u003cp\u003eThe commercially available “TeleDoc” cart system equipped with medical devices for POC diagnostic, which is shown from both sides.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/314b4a57f7fd66c563b69bb9.png"},{"id":80276302,"identity":"21195836-965c-47ad-a556-79cea7a3fd38","added_by":"auto","created_at":"2025-04-10 05:04:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":116567,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of unplanned hospital admissions of NH residents, represented by the hospital symbols, for the pre-intervention period 2018/19 and the post-intervention period 2021/22. The total of unplanned hospital admissions is shown at the top and broken down below into the different groups. The average number of NH residents in total and per group is listed with n. The arrows indicate the reduction (in percent, %) of admissions in total and per group between 2018/19 and 2021/22.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/344d490ff37ffb4fe2f5aafa.png"},{"id":91359076,"identity":"5697fde4-24d8-48e8-a33d-83425cd33bd0","added_by":"auto","created_at":"2025-09-15 16:05:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2245067,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/f35bbc25-f8a2-4c82-8524-33b419be0698.pdf"},{"id":80275955,"identity":"7e6e46af-ae03-4ae7-a87c-4f9ba6197f30","added_by":"auto","created_at":"2025-04-10 04:56:38","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":104086,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/29cc282e2fd2202075f414a3.pdf"},{"id":80278616,"identity":"b61443ec-f844-44e9-96ce-d864aa2f5dca","added_by":"auto","created_at":"2025-04-10 05:29:40","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":178966,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/0f69572d47e4f6c03647e0fc.pdf"},{"id":80275960,"identity":"084b50b4-f75f-4ee2-8534-2ffe0143f8fe","added_by":"auto","created_at":"2025-04-10 04:56:38","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":88789,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/a2636eee0ef326351e00733c.pdf"},{"id":80278517,"identity":"8acb1f48-49f8-4f51-9706-00724a1210aa","added_by":"auto","created_at":"2025-04-10 05:28:41","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":95962,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/44a8222c6b255e2f1698603e.pdf"},{"id":80275964,"identity":"244ae8e1-ea25-46eb-bb59-1eb32086268b","added_by":"auto","created_at":"2025-04-10 04:56:39","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":151293,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile5.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/01bda2d3618056b6b66424ef.pdf"},{"id":80278522,"identity":"1d46344a-c1e0-42c8-8a9a-801fdc403ff9","added_by":"auto","created_at":"2025-04-10 05:28:45","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":22500,"visible":true,"origin":"","legend":"","description":"","filename":"ReportingguidelineBMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-5448947/v1/54cb4374c8a59766fdc2488e.docx"}],"financialInterests":"Competing interest reported. MC is managing director and co-founder of Docs in Clouds Telecare GmbH, Aachen, Germany, the company that develops and distributes the “TeleDoc” system. CBP is and JK was working for Docs in Clouds Telecare GmbH, Aachen, Germany, in part-time. All other authors declare having no conflicts of interest.","formattedTitle":"Impact of regular televisits on unplanned hospital admissions of nursing home residents in rural Germany: a pre-post intervention study","fulltext":[{"header":"Background","content":"\u003cp\u003eHospital admissions occur frequently among nursing home (NH) residents in Germany [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and are of major concern to the German healthcare system. Other European countries and the United States also report an important number of these hospitalizations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], with rates per person-year more than twice as high as for the age-matched community dwellers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, there has been an increase of admissions over time [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and without timely solutions, this trend will most likely progress, as discussed in the following paragraphs.\u003c/p\u003e \u003cp\u003eThe German Federal Statistical Office presumes that in 2040 the amount of 67-year-olds and older is going to account for 25\u0026ndash;27% of the population, while the percentage of the very old (\u0026gt;\u0026thinsp;80 years) will continue to rise until 2060 and lie between 9% and 13% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Moreover, the prevalence of chronic diseases within the older adult population is considered high [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is therefore accompanied by an important usage of time and personnel resources to assure adequate medical care. Meanwhile, the increase of ambulatory home care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], among others due to the potential of ICT (information and communication technology) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], can lead to a deferral of entering the NH. As a result, the NH population, in addition of increasing [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], is becoming older [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and includes a high number of multimorbid patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. At present, the medical care of NH residents is mainly provided by general practitioners (GPs) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and on-site caregivers, consisting of qualified nursing staff. In Germany, the widening gap between the demand and supply of ambulatory physicians [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] is going to cause an approximate unmet need of 20 000 GPs in two years from now [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Alongside this development, the shortage of nursing staff for inpatient care, intensified by the COVID-19 pandemic, could count up to 307 000 caregivers in 2035 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In consequence, the healthcare of a higher number of NH residents, carrying a larger burden of diseases, will need to be provided with fewer personnel resources. This will create a relevant conflict, while trying to keep up with the present standard of medical care. Especially rural areas, where the accessibility to healthcare providers is already limited [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], are going to be affected early on. This makes finding solutions for these areas even more important, particularly in view of the claim for equal living conditions (including access to a certain infrastructure and elementary requirements such as health) strived by German politics [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn NHs the distinct lack of GPs is felt by a decrease in on-site nursing home visits [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. As the latter occur less frequently, clinical signs of a decompensating chronic disease or health status deterioration sometimes might not be detected early enough, leading to an acute event of illness. In this case, the reduced availability of the attending GP often forces the nursing staff to contact the emergency services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In fact, the number of ambulance interventions in NHs increased by 68.9% between 2004 and 2013 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The involved paramedics or emergency physicians, who are not acquainted with the patient\u0026rsquo;s medical history, tend to take patients to the already crowded Emergency Departments (EDs) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], potentially resulting in an inappropriate, avoidable hospital admission [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The hospital admissions, which could have been prevented by better ambulatory care, are so called ambulant sensitive and are employed by some healthcare systems as a quality indicator of ambulatory healthcare [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. An important number of hospitalizations in NHs, approximately between 30% and 50%, have been found to be caused by ambulatory care sensitive conditions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, the NH residents form a geriatric patient group, which differs significantly from the rest of the population, for example (e.g.) by age, level of care, comorbidities, and disease spectrum [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Hence, experts developed an equivalent list of 58 nursing home-sensitive diagnoses for which hospitalizations are potentially avoidable [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Preventing these hospitalizations in NHs is of relevance for all three parties involved; patients, care-providers, and healthcare payers. For geriatric patients, a hospital stay can be associated with decline in physical function, e.g. due to confusion or disorientation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and it represents an incisive event in the patient\u0026rsquo;s autonomy. Especially NH residents have a high probability of developing a delirium [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], often associated with pre-existing dementia, when being torn out of their daily environment. Further hospital-associated health complications, such as nosocomial infections, worsen the outcome. In fact, the in-hospital mortality among NH residents is high, reaching up to 34% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Avoiding hospitalization protects residents from major risks, while care-providers save on effort, time, and resources. Eventually, healthcare payers benefit from important cost-savings [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. For 2017, the total amount of potentially avoidable costs, considering nursing home-sensitive hospital admissions in the national German context, was estimated about 760\u0026nbsp;million euros [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTelehealth care is increasingly used in NHs and has recently experienced a worldwide boom during the COVID-19 pandemic [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The engagement to use telehealth among older adults is influenced by specific barriers such as lack of self-efficacy, knowledge, support, functionality, and information about the benefits [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Nevertheless, telehealth has proven to be well accepted among older patients [\u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], an important prerequisite for successful implementation of telemedical systems. Digital familiarity and perceived usefulness can be mentioned as having a positive impact on acceptance and satisfaction with telemedicine [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In addition to the mentioned potential for NH residents, important elements for teleconsultation, such as the training of nurses and the required trust between physician and nurse [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], hold potential to improve the physician-nurse interaction and cooperation. As nurses play a major, more extensive role during remote consultation, the successful nurse-physician collaboration is essential to ensure quality for patient care [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Telemedical solutions have the potential to improve quality of care and reduce hospital admissions for NH residents [\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The article of Hofmeyer et al. observed an important decrease of unplanned hospital transfers from 39\u0026ndash;17% (2012\u0026ndash;2015), while providing a 24/7 teleconsultation service to rural long-term care facilities [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Further studies with different models of care, assuring unscheduled telemedical assessment, also reported a decline of ED visits and/or reduction in hospital admissions for NH residents [\u003cspan additionalcitationids=\"CR53 CR54 CR55\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Besides acute telecare, routine scheduled teleconsultations conducted by different specialists (including geriatricians) were associated with less transfers and a lower hospitalization rate as well [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Telemedicine consultation reduced the hospitalization of NH residents in 14 out of 16 studies (published between 2001\u0026ndash;2022) identified in a review by Valk-Draad \u0026amp; Bohnet-Joschko [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Thereof, few studies had a higher level of evidence.\u003c/p\u003e \u003cp\u003e While the mentioned telemedical services were used for acute assessment by different specialists in case of health status deterioration to avoid hospital admission, our study concentrates on the impact of regular televisits by a GP, improving the continuity of medical care of NH residents. Due to the continuous, longstanding care of GPs in NHs, the GPs alongside with the on-site caregivers, are potentially best suited to detect and asses health status deterioration early on. Since GPs also take over a major part of chronic disease management, intensified follow-up by GPs through televisits could prevent a relevant amount of nursing home-sensitive hospital admissions, which mainly include chronic diseases such as diabetes mellitus type 2 or chronic kidney disease [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, our study evaluates the impact of regular televisits by a GP on inpatient nursing home care, while current literature mainly describes findings from long-term care facilities, where the level of care remains unclear (e.g. nursing homes, assisted living facilities, skilled nursing facilities, continuing care retirement communities).\u003c/p\u003e \u003cp\u003eThis study examined whether the implementation of regular medical televisits, in addition to on-site nursing home visits, by a GP reduces unplanned hospital admissions for NH residents in inpatient older adult care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn order to evaluate the effect of regular televisits in inpatient older adult care, we conducted a single-centre, retrospective, longitudinal, pre-post intervention study (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). In 2021, a NH in rural Germany introduced a telemedical system, linking the facility to one of the cooperating GPs (referred to as GP1). During a period of 12 months, from the 01.08.2021 to the 31.07.2022, GP1 followed his patients by regular televisits, in addition to on-site nursing home visits. GP1 took care of an average of 27 residents (32% of the NH population), forming the telemedical care group. The remaining 57 residents (68%) represent the control group and were followed by other GPs, who did not participate in telemedical care. A historical study arm, covering the time period from the 01.08.2018 to the 31.07.2019 served as pre-intervention comparison. Unplanned hospital admissions from the NH residents were analysed and compared before (2018/19) and after (2021/22) intervention, thus introduction of the telemedical system. A sub-analysis consisted in comparing the hospitalizations between the telemedical care group and the control group. Baseline characteristics of the residents were collected for both reference dates: 01.08.2018 and 01.08.2021, in order to compare the populations at the beginning of the two time periods. All residents meeting both criteria\u0026rsquo;s: age\u0026thinsp;\u0026ge;\u0026thinsp;18 years and inpatient older adult care were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study took place in a NH in the Eifel region within the district Euskirchen, in North Rhine-Westphalia, Germany (Stiftung Evangelisches Alten- und Pflegeheim Gem\u0026uuml;nd). The district Euskirchen has a population density of 158 inhabitants per km\u0026sup2; [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]. The municipality of Schleiden, to which Gem\u0026uuml;nd belongs, has a GP coverage rate of 109.8%, meaning that there is neither an undersupply nor oversupply of GPs. However, in the district Euskirchen only 75.8% of patients are cared for by a GP located less than 10km away, which is the lowest percentage compared to other Rhineland districts [\u003cspan class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe NH has 84 places for inpatient older adult care, spread over four different residential areas. GP1 oversees approximately one-third of the residents. Before introduction of the telemedical system, GP1 visited his patients every second week by on-site nursing home visit. This was maintained during 2021/22 and complemented by regular televisits every second week whenever GP1 did not visit his patients on-site. The patient\u0026rsquo;s need for consultation was assessed weekly by GP1, in cooperation with the on-site caregivers. If needed, a scheduled televisit took place to either follow-up on a known health issue or to assess a newly emerged health deterioration. Therefore, not every resident of the telemedical care group was televisited by GP1 every second week, the decision for consultation was made at GP1\u0026rsquo;s discretion and solely based on his professional medical judgment. Every second week during fixed televisit hours (scheduled by GP1 and the caregivers), a varying number of residents from the telemedical care group, who needed consultation, were televisited by GP1 in cooperation with the on-site caregivers. The televisit assessment depended on the patient\u0026apos;s current health issue (ranging from simply discussing the health status and therapeutic measures to performing specific examinations using the devices for point-of-care (POC) diagnostic) and did not follow a predefined standard operating procedure. The televisits played a sheer complementary role and never functioned as replacement for on-site nursing home visits. The entire caregiver staff was educated and trained through continuous telemedical exercise courses. The other GPs, responsible for the remaining residents, continued following their patients by regular on-site nursing home visits only. In acute situations, GPs (GP1 and other GPs), if available, conducted unscheduled on-site nursing home visits or, if the situation was assessed as life-threatening, emergency services were contacted. While the resident distribution always stayed about one-third for GP1 and two-thirds for other GPs, group composition slightly changed over time, because residents dropped out (e.g., by death) and were added (e.g., moving-in) to the two different groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTelemedical System\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll televisits were performed using the medical \u0026ldquo;TeleDoc\u0026rdquo; cart system developed by the Docs in Clouds TeleCare GmbH, Aachen, Germany (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The \u0026ldquo;TeleDoc\u0026rdquo; system had already been tested by a GP for inpatient older adult care within a prior pilot study of our research group, showing feasibility and acceptance of the system [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]. In addition to audio and video communication between patient and physician (definition of a video consultation), a televisit allows diagnostic procedures by on-site paramedical personnel, to whom therapeutic measures can be delegated. The currently available \u0026ldquo;TeleDoc\u0026rdquo; cart is equipped with displays, secure communication technology and the following medical devices for POC diagnostic: digital stethoscope, blood pressure meter, blood glucose meter, pulse oximeter, electrocardiogram (ECG), thermometer and adjustable room camera with optical zoom.\u003c/p\u003e\n\u003cp\u003eVia the installed \u0026ldquo;TeleDoc\u0026rdquo; software, a televisit could be started, connecting GP1 to the patient and caregiver in the NH. The visit took place using audio- and video communication, allowing interaction between the patient, GP1 and trained caregiver. The latter used the integrated devices for on-site medical examination, if requested by GP1. The thereby gathered information from anamnesis and POC diagnostic subsequently served as basis for further decision-making to GP1. Eventually, GP1 delegated the implementation of therapeutic measures to the on-site caregiver if needed. During televisits, data safety was guaranteed through end-to-end encryption for data transmission, as well as for bidirectional audio- and video connection. The \u0026ldquo;TeleDoc\u0026rdquo; software also allowed asynchronous communication between GP1 and the caregivers. Documents could be exchanged and uploaded to the televisit record. Moreover, caregivers could prepare the televisits by documenting diagnostic data, which they found necessary to already collect before starting a televisit. These data could then also be viewed by GP1 independently of the televisit. This modality of asynchronous televisits using a web-based waiting room is described in further detail in the article of Martin et al. [\u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eSeveral kick-off training sessions for the NH caregivers and the linked GP were held in small groups to introduce the telemedical system. The practical testing of the medical devices for POC diagnostic was a central component of the initial training concept. Thereafter, caregiver staff trainings took place, improving the handling with the \u0026ldquo;TeleDoc\u0026rdquo; software and the medical devices, while reflecting the importance of these devices for their work and the medical care of NH residents. Simulated scenarios were used to train and consolidate the acquired skills. The training courses took place in person, also some training units could be completed online. The article of Martin et al. shows a timeline of the telemedical implementation process including further information regarding the training [\u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data was collected retrospectively by accessing the nursing care documentation system of the facility. Following population data, presented in Tables 1 and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, were documented systematically for every resident included: general personal characteristics (including care level), length of stay in the NH and occurred hospitalizations, geriatric, cardiovascular, ischaemic, neuropsychiatric, respiratory, and gastrointestinal risk factors, as well as several non-classified diagnoses. Furthermore, information concerning every unplanned hospital admission, such as time and type of transfer, hospitalization cause (medically confirmed reason for hospital admission, determined by the responsible GP, the emergency paramedics, or the emergency physician), in-hospital diagnosis, length of stay and event of death, was retrieved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two-sample t-test was applied on continuous variables and the chi-squared or Fisher\u0026rsquo;s exact test (depending on the number of observations) on categorical variables. Solely two-tailed statistical tests were used to calculate the P-value, whose statistical significance level was defined by \u0026lt;\u0026thinsp;.05. Continuous variables were checked for normal distribution before applying the two-sample t-test and are summarized by mean and standard deviation. To compare the total frequency of unplanned hospitalization between the two time periods and groups, we applied the Fisher\u0026rsquo;s exact test, which is an exact method, especially for small sample sizes. Hospitalization was considered as an event that occurred or not (categorical outcome). As we compared proportions of a categorical outcome for independent and not correlated groups, the Fisher\u0026apos;s exact test was used. For all statistical analysis we employed the programming language Python (version 3.9.7), using the open-source cross-platform integrated development environment (IDE) Spyder (version 5.1.5) and the web-based interactive computational environment Jupyter Notebook (version 3.9.7). The population and group comparison tables were produced using the open-source Python package named tableone [\u003cspan class=\"CitationRef\"\u003e63\u003c/span\u003e]. Missing data concerning baseline characteristics and hospitalization causes are displayed in the tables and are not included in the comparison.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eStudy Population\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBaseline characteristics of the residents on the 01.08.2018 and 01.08.2021 are presented in Table\u0026nbsp;1. The two populations are comparable, comprising 85 residents in 2018 and 84 residents in 2021. For both, the mean age was approximately 86 years and residents were mainly female (75.3% in 2018 and 82.1% in 2021). The care level distribution was similar, with most residents classified in level 4 (34.1% and 32.1%), followed by level 3 and 5, both compromising about 30% of the residents, and ending with the lowest care level 2. No significant difference was noticed regarding the specific geriatric syndromes, such as aconuresis and (\u0026amp;) anal incontinence, dementia \u0026amp; cognitive impairment, fall risk, gait \u0026amp; mobility disorder, and immobility. The cardiovascular risk factors did not significantly differ between both populations, with arterial hypertension being the most frequent diagnosis (68.2% and 79.8%). Furthermore, relevant diagnoses for ischaemic, neuropsychiatric, respiratory, and gastrointestinal risk were grouped into specific markers, which were comparable as well. For example, 45.9% of the residents in 2018 and 45.2% in 2021 had at least one disease associated with increased ischaemic risk (e.g., coronary heart disease or peripheral arterial occlusive disease). For further non-classified diagnoses, renal insufficiency was twice as common among residents in 2021 (28.6%) than in 2018 (14.1%). This being the only significant difference (P\u0026thinsp;=\u0026thinsp;.035) between the two populations. Eventually, the mean length of stay in the facility was 2.8 years for both populations.\u003c/p\u003e \u003cp\u003eIn addition, no significant difference in baseline characteristics was found comparing the patient group of GP1 in 2018 with the telemedical care group [Additional file 1].\u003c/p\u003e \u003cp\u003eLooking at the population of the 01.08.2021, the telemedical care group counted 23 residents, whereas the control group included 61 residents (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Neither the age, gender nor care level distribution was significantly different between the two groups. Same for the specific geriatric syndromes, cardiovascular risk factors and four different markers. For gastrointestinal risk factors, the P-value was close to significance level (P\u0026thinsp;=\u0026thinsp;.054). Significant difference was noted for the three following characteristics: diagnosis of chronic pain (P\u0026thinsp;=\u0026thinsp;.001), as well as number (P\u0026thinsp;=\u0026thinsp;.022) and days (P\u0026thinsp;=\u0026thinsp;.037) of hospitalization since moving-in. In fact, residents of the telemedical care group had had more hospital admissions (mean 3.0 to mean 0.9) and a higher mean of hospital days (24.7 to 8.9) since moving-in, than residents of the control group. Both were mainly due to a few statistical outliers, values that lay more than 1.5 times the interquartile range above the upper quartile.\u003c/p\u003e \u003cp\u003eTable 1. Baseline characteristics of the NH population on the 01.08.2018 and the 01.08.2021: data listed as mean with standard deviation (SD) and counts (n) with percentages (%).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"750\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e01.08.2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e01.08.2021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e36 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e21 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e15 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.368\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e133 (78.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e64 (75.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e69 (82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e85.9 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e86.1 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e85.7 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.753\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare level, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e10 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e50 (29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e24 (28.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e26 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e56 (33.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e29 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e27 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e47 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e22 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e25 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGP, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGP1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e46 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e23 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e23 (27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther GPs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e123 (72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e62 (72.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e61 (72.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of stay in the NH, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2.8 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2.8 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.871\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of hospitalizations since moving-in the NH, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.6 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.8 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.5 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays of hospitalization since moving-in the NH, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e14.8 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e16.4 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e13.2 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeriatric syndromes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAconuresis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e70 (41.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e31 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e39 (46.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.247\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnal incontinence, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e54 (32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e28 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e26 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.911\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDementia/Cognitive impairment, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e101 (59.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e48 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e53 (63.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.471\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFall risk, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e140 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e75 (88.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e65 (78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.129\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGait \u0026amp; mobility disorder, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e32 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e15 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e17 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImmobility, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e12 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular risk factors:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArterial hypertension, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e125 (74.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e58 (68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e67 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes mellitus, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e46 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e22 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e24 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.826\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdiposity (BMI\u0026ge;30), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e30 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e16 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e14 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHyperlipidaemia/Dyslipidaemia, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e94 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e44 (51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e50 (59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.390\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER ischaemic risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHD/Status post cardiac infarction/Atherosclerosis/Vascular stenosis/(P)AOD , n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e77 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e39 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e38 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER neuropsychiatric risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDementia/Cognitive impairment/Schizophrenic disorder/Psychotic disorder, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e103 (60.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e50 (58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e53 (63.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER respiratory risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOPD/Bronchial asthma/Chronic bronchitis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e18 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e7 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e11 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER gastrointestinal risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastritis/Oesophagitis/Gastroesophageal reflux, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e40 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e21 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e19 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac arrhythmia, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e66 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e29 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e37 (44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac pacemaker, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e17 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e9 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e8 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac insufficiency, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e34 (20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e13 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e21 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal insufficiency, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e36 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e12 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e24 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypotension, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypothyroidism, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e8 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e8 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic pain, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e22 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e11 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e11 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorbus Parkinson/Parkinson syndrome, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e14 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e10 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e4 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatus post apoplexy/TIA, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e44 (26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e23 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e21 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations. BMI: body mass index; CHD: coronary heart disease; (P)AOD: (peripheral) arterial occlusive disease; COPD: chronic obstructive pulmonary disease; TIA: transient ischaemic attack.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 2. Baseline characteristics of the telemedical care group and the control group on the 01.08.2021: data listed as mean with standard deviation (SD) and counts (n) with percentages (%).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"750\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTelemedical care group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e15 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e9 (14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e69 (82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e17 (73.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e52 (85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e85.7 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e86.0 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e85.6 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.876\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare level, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.886\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e26 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e20 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e27 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e7 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e20 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e25 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17 (27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of stay in the NH, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e3.7 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e2.4 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of hospitalizations since moving-in the NH, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.5 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e3.0 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e0.9 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays of hospitalization since moving-in the NH, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e13.2 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e24.7 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e8.9 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeriatric syndromes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAconuresis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e39 (46.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e12 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e27 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.687\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnal incontinence, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e26 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17 (27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.465\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDementia/Cognitive impairment, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e53 (63.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e38 (62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFall risk, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e65 (78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e21 (91.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e44 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGait \u0026amp; mobility disorder, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e17 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e11 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.543\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImmobility, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e6 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.663\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular risk factors:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArterial hypertension, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e67 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e18 (78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e49 (80.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes mellitus, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e15 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdiposity (BMI\u0026ge;30), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e14 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e4 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e10 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHyperlipidaemia/Dyslipidaemia, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e50 (59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e13 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e37 (60.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER ischaemic risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHD/Status post cardiac infarction/Atherosclerosis/Vascular stenosis/(P)AOD, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e38 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e30 (49.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER neuropsychiatric risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDementia/Cognitive impairment/Schizophrenic disorder/Psychotic disorder, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e53 (63.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e38 (62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER respiratory risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOPD/Bronchial asthma/Chronic bronchitis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e11 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e3 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e8 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMARKER gastrointestinal risk:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastritis/Oesophagitis/Gastroesophageal reflux, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e19 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e10 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac arrhythmia, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e37 (44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e27 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac pacemaker, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e6 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac insufficiency, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e5 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e16 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.888\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal insufficiency, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e18 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.969\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypotension, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypothyroidism, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e8 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic pain, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e11 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorbus Parkinson/Parkinson syndrome, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e4 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e3 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatus post apoplexy/TIA, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 148px;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17 (27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations. BMI: body mass index; CHD: coronary heart disease; (P)AOD: (peripheral) arterial occlusive disease; COPD: chronic obstructive pulmonary disease; TIA: transient ischaemic attack.\u003c/p\u003e\u003ch3\u003e\u003cstrong\u003eHospital Admissions\u003c/strong\u003e\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDuring 2021/22, 55 unplanned hospital admissions occurred for an average NH occupancy of 84 inpatient care residents. For the historical time period 2018/19, 74 unplanned hospitalizations were reported for an average NH occupancy of 83 residents. Thus, post-intervention, hospital admissions decreased by a total of 19, corresponding to a relative reduction of 26.6%. Meaning that in 2021/22, while regular televisits took place, there were a quarter less hospitalizations then during the historical period 2018/19. This result is of statistical significance (P\u0026lt;.0001). From the 55 unplanned hospitalizations in 2021/22, 15 concerned patients receiving regular televisits by GP1. On average, the telemedical care group counted 27 residents. In 2018/19, 19 of the 74 hospital admissions occurred to patients followed by GP1, which then cared for an average of 22 residents. Hence, within the group of GP1, admissions were reduced by 35.7%, while for the patient group followed by other GPs, the reduction was of 22.2%. The statistical significance of reduction was higher for the group of GP1, who conducted regular televisits during 2021/22 (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs mentioned above, 15 of the 55 hospital admissions in 2021/22 concerned residents of the telemedical care group, while the remaining 40 admissions occurred to residents followed by other GPs with regular on-site nursing home visits only. On average, the control group counted 57 residents. Thus, during 2021/22, the number of unplanned hospital admissions was significantly lower (P=.04) for residents receiving regular televisits.\u003c/p\u003e\n\u003cp\u003eLooking at the historical time period 2018/19, there was no significant difference (P=.5) in unplanned hospital admissions between the patient group of GP1 and the patient group followed by other GPs (moreover baseline characteristics and hospitalization causes were comparable for this analysis [Additional files 2 and 3]).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Following hospitalization causes were identified for unplanned hospital admissions in 2021/22: breathing difficulties/dyspnoea, gastrointestinal problems, seizure, fall, general health status deterioration (unclear genesis), urologic problems, pain of the lower extremities/thorax/abdomen, hemic anomaly, and syncope. For three hospitalizations, the documentation of cause was missing. For the historical time period 2018/19, hospitalization causes were partly identical to 2021/22, adding: cardiovascular disorder, nephrological problems, suspected apoplexy/\u003cem\u003etransient ischaemic attack\u003c/em\u003e, suspected pneumonia, psychopathological anomaly, suspected thrombosis, oedema, inflammation signs of the lower extremities, exsiccosis, dermatological anomaly, medication adjustment and suspected lung embolism. There was no significant difference in distribution of the mentioned causes between admissions of 2021/22 and 2018/19 [Additional file 4].\u003c/p\u003e\n\u003cp\u003eComparing the hospitalization causes of 2021/22 between the telemedical care group and the control group [Additional file 5], only the distribution of general state of health deterioration differed significantly (P=.046). The latter was documented ten times for hospitalizations concerning the control group, and not once for unplanned admission within the telemedical care group.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTelevisits\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eFor the study period of 12 months, 39 weeks with televisits were recorded. Out of 52 weeks, 6 must be deducted due to vacation of GP1 and during another 7 weeks, televisits could not take place due to other reasons. Hence, a total of 119 televisits occurred over a period of 39 weeks.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch3\u003e\u003cstrong\u003ePrincipal findings\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study was the first field trial demonstrating the impact of regular televisits by a GP on unplanned hospital admissions in a NH in rural Germany. The introduction of a telemedical system, linking the facility to one of the cooperating GPs, was associated with a significant reduction of 26.6% in unplanned hospitalization for all residents. Thus, even residents who did not receive regular televisits, serving as control group, showed a reduction of 22.2% in unplanned hospitalization. However, the effect was significantly higher among residents receiving telemedical care, with a hospital admission decrease of 35.7%. Furthermore, this reflected in a significantly lower hospitalization rate in the telemedical care group, compared to the control group, during the intervention period. Since there was no significant difference for the hospital admission rate between the corresponding groups in 2018/19, the effect does not seem to be assignable to the linked GP. The few significant differences in baseline characteristics can be considered of small relevance for the analysis. Regarding the difference of renal insufficiency distribution, there was no significant difference in hospitalization cause for nephrological problems (P=.511) between 2018/19 and 2021/22 [Additional file 5]. We could not examine whether the impact of televisits or the telemedical implementation on hospital admissions was dependent on the severity of the residents\u0026apos; illnesses. For the latter we would recommend further studies with a different statistical approach.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eInterpretation of findings\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe results suggest that the implementation of a telemedical system, by increasing routine follow-up of NH residents through televisits, reduces unplanned hospital admissions. Intensified follow-up by a GP through televisits improves the continuity of medical care and can therefore prevent hospital admission. The impact of televisits is shown by the significantly lower numbe r of unplanned hospital admissions (P=.04) for residents receiving regular televisits, compared to the control group. The telemedical implementation led to changes in nursing practice, described in the article of Martin et al., which found that caregivers acknowledged improvements in their clinical skills, technological competencies, self-image and recognition [62]. As the linked GP and on-site caregivers weekly assessed which patient needed televisit, new responsibility was attributed to the nursing staff, being the main observer on-site. In addition, the role of the caregiver during televisits led to a shift of function, while the latter was responsible of undertaking the on-site diagnostic and potentially carrying out therapeutic measures delegated by the GP. The article of S\u0026auml;venstedt, Bucht, Norberg \u0026amp; Sandman also concluded that the use of teleconsultations in a NH had an influence on the nurse\u0026rsquo;s and physician\u0026rsquo;s role, respectively becoming the presenter of medical problems and remote consultant [45]. A prerequisite, however, is the education and training of the on-site caregivers, assured through initiating and consolidating training sessions, so that they were sufficiently prepared for their new responsibilities. A geriatric nurse-led model of care presented by Z\u0026uacute;\u0026ntilde;iga et al. reduced unplanned transfers from NHs to hospitals [64], showing the potential of giving greater responsibility to trained nursing staff. Furthermore, the reallocation of tasks and responsibility can strengthen the interprofessional cooperation. Besides qualified and skilled personnel, Valk-Draad \u0026amp; Bohnet-Joschko defined good cooperation as an important factor to avoid hospitalizations of NH residents [65]. Good cooperation between physician and caregiver has shown to ensure rational use of resources in relation to the patient\u0026rsquo;s needs and to coincide with high quality of health services [66]. Regarding the cooperation resulting from telemedical care, rational use of resources might provide additional time for holistic patient care, especially in light of future population and healthcare developments. Moreover, high quality of ambulatory care in NHs can prevent hospital admissions due to nursing home-sensitive conditions. Based on the cited literature, it can be assumed that secondary effects resulting from telemedical implementation, such as the training of staff and the interprofessional cooperation, had a positive impact on reducing unplanned hospital admissions for all NH residents. However, our study design did not allow to explicitly examine these secondary effects and their impact on the hospitalization rate, calling for further research in this field.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAn important limitation of our study was that it remains unclear if for our study period (2021/22) the hospitalization rate of NH residents was still influenced by the COVID-19 pandemic, as it had been the case at the beginning of the pandemic, where hospital admissions among NH residents decreased [67, 68]. Several factors including changes in care strategies, the direct impact of preventive measures, as well as a heightened risk awareness among NH residents and physicians, can explain this decrease [68-70]. In 2021/22, the hospitalization rate could also have returned to its pre-pandemic state, due to an ease of the situation in NHs, as a result of vaccinations and the end of the second lockdown in May 2021 [71,72]. Furthermore, hospital admissions could also have increased, as a consequence of neglected medical care and appointments, which had led to worsening health problems, especially among chronically ill people [73,74]. Even if the mentioned pandemic-related factors, responsible for hospital admission decrease, still played a role during our study period 2021/22, the direct impact of televisits can be represented by the significantly lower number of unplanned hospital admissions (P=.04) for residents receiving regular televisits, compared to the control group.\u003c/p\u003e\n\u003cp\u003eBesides the impact of the COVID-19 pandemic on the hospitalization rate of NH residents, the influence of changes in residents and GPs of the facility, as well as in health care standards and documentation, cannot be excluded. Nevertheless, baseline characteristics of the residents were comparable for 2018 and 2021. Changes in the group of other GPs, including staff changes and modification in standards of care cannot be ruled out. However, the NH was led by the same head of nursing services for the two time periods (2018/19 and 2021/22) and therefore maintained the same nursing care management and standards on site. As data was collected from the nursing care documentation system of the facility, it is not possible to exclude partially incorrect documentation. However, the care documentation of the facility is included in the quality management manual followed by the NH and regularly checked for correctness by the Medical Service of the Health Insurance Companies.\u003c/p\u003e\n\u003cp\u003eFollowing limitations must be considered regarding the generalisability of our findings. First, limitation lies within the specific setting of the study. The latter took place in a single facility in rural Germany with a limited population size. Within the study population, the mean length of stay in the NH, describing the number of years in inpatient care up to the date of the analysis, remained identical (2.8 years) between 2018 and 2021. It is important to distinguish between the length of stay as it was calculated for our study population, and the usually employed NH length of stay, representing the number of years in inpatient care up to the date of death. For both, surveys rather revealed a decreasing trend in German NHs [75,76], suggesting that our population might benefit of a high quality of care or a better health status. Data is lacking to exclude influencing factors such as the age at which people entered the NH. Moreover, the district of Euskirchen recorded a particularly high number of emergency transfers from various NHs to hospitals and potentially avoidable hospitalizations for the years 2017-2020, compared to other districts situated in the Rhineland and Hamburg [61]. This can be explained by the structural conditions of rural areas, such as transport difficulties, restricted medical services, and financial limitations, all leading to poor access and low availability of healthcare. Accordingly, the potential of telemedical solutions for reducing hospital admissions might be even greater in rural areas than elsewhere. Secondly, and independently from our study, the outcome and success of a telemedical implementation is depending on various factors. Financial and organisational barriers, such as the initial investment [48], appropriate reimbursement systems, the necessary telematic infrastructure or legal requirements [77-79], can already hinder the acquisition and use of telemedical systems. Further, the attitude, acceptance [77] and perceived ability of users [80] can play a major role. Eventually, it is essential to develop concepts which assure sustainability of telemedical projects after pilot phase [81-83], to enable the widespread use of telemedicine. Most of these barriers were overcome for implementation of the telemedical system surveyed in our study, as its introduction was part of a funded and thought-out project, but this is not always the case. In particular, the short-term overcoming of financial barriers was decisive for the implementation. Furthermore, the necessary infrastructure was available and the acceptance of the system had already been proven [39]. In order to understand and handle all barriers involved in introducing such a system, the change management should be analysed in more detail.\u003c/p\u003e\n\u003cp\u003eThe scope of action during a televisit by a GP remains limited, and severe situations of health deterioration still required on-site nursing home visits of the GP or the support of emergency services. \u0026nbsp;Therefore, it cannot be excluded that in specific cases, unscheduled on-site nursing home visits by the GPs or emergency services have helped to avoid hospitalization. The employed telemedical system could promote communication and availability through intersectoral and technical networking (e.g. by reducing interprofessional hurdles, the system enables caregivers to have low-threshold contact with physicians) [84]. This potential can be of particular use to NHs in medical emergency situations. Telemedical networking creates standard communication paths using system interfaces and leading to an effective exchange of information, e.g., in the context of video consultations [85]. Valk-Draad \u0026amp; Bohnet-Joschko estimated that 35% of all NH hospitalizations (approximately 220 000 hospitalizations for Germany) could be prevented by combining optimized multidisciplinary communication and cooperation with digital expansion of the infrastructure, creation of legal prerequisites and remuneration structures [65]. The potential of an intersectoral telemedical cooperation network for optimizing acute care of NH residents and avoiding inappropriate hospitalizations, is going to be evaluated within the stepped-wedged trial named Optimal@NRW [86].\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStrengths\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe strength of the study includes the design, which allowed for a double comparison of the telemedical effect. Besides looking at hospital admissions pre- and post-intervention, namely 2018/19 and 2021/22, the telemedical care group was compared to a control group. On the 01.08.2021 almost all NH residents were vaccinated twice against COVID-19, and a third vaccination was already offered by then. Accordingly, there should have been little impact of COVID-19 infections on hospital admissions at that time. Moreover, the historical period 2018/19 used for comparison was chosen wisely, as the pandemic had not yet begun. Following benefits evolved from the telemedical implementation. All residents received care from trained and therefore attentive caregivers, potentially noticing health status deterioration earlier. Residents of the telemedical care group were assessed weekly and, if needed, screened and examined through televisit, allowing adequate therapy in time. As the decision for televisit was made at GP1\u0026rsquo;s discretion, the potentially best, individual choice could be made for the residents, based on GP1\u0026rsquo;s experienced medical judgment. However, for broader implementation of the telemedical system, the development of SOPs (Standard Operating Procedure) as aid for decision-making would be beneficial. Furthermore, the telemedical system offered the advantage of POC diagnostic, which is not given by simple video consultation. Eventually, the implementation was associated with a reduction of unplanned hospital admissions for the residents. The mentioned benefits have the potential to improve the medical situation of care for NH residents and as a result increase patient safety.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIntensified follow-up by a GP through televisits improves the continuity of medical care and prevents hospital admission. This was shown by a significantly lower number of unplanned hospital admissions for residents receiving regular televisits compared to the control group. It remains unclear if the telemedical implementation through secondary effects played a role in reducing hospitalizations of NH residents, who did not receive televisits. The influence of various factors, such as the COVID-19 pandemic, on the hospitalization rate was not evaluated in this study and can therefore not be excluded.\u003c/p\u003e\n\u003cp\u003eThe implementation of a telemedical system providing outpatient care in form of regular televisits to NH residents shows promising results for decreasing unplanned hospital admissions. This telemedical solution can make an important contribution to healthcare, in light of meeting the challenges ahead. \u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eED: Emergency Department\u003c/p\u003e\n\u003cp\u003ee.g.: For example\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGP: General practitioner\u003c/p\u003e\n\u003cp\u003eICT: Information and communications technology\u003c/p\u003e\n\u003cp\u003eNH: Nursing home\u003c/p\u003e\n\u003cp\u003ePOC: Point-of-care\u003c/p\u003e\n\u003cp\u003e\u0026amp;: And\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eDue to the nature of this retrospective study and the preserved anonymity of patients, a waiver of informed consent was obtained from the Ethics Committee at the Faculty of Medicine of the RWTH Aachen University (EK 179-23), by which the study was approved.\u003c/p\u003e\n\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003ch3\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eAll data discussed and analysed in the article are included in this publication and in its additional files. The raw datasets used to generate tables and additional files are available from the corresponding author on reasonable request. \u003c/p\u003e\n\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eMC is managing director and co-founder of Docs in Clouds Telecare GmbH, Aachen, Germany, the company that develops and distributes the \u0026ldquo;TeleDoc\u0026rdquo; system. CBP is and JK was working for Docs in Clouds Telecare GmbH, Aachen, Germany, in part-time. All other authors declare having no conflicts of interest.\u003c/p\u003e\n\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eFunding for the \u0026ldquo;AIDA\u0026rdquo; project (Arbeitsentwicklung in der Altenpflege) was provided by the European Regional Development Fund (ERDF) 2014-2020 of the European Union, and by the State of North Rhine-Westphalia, Germany.\u003c/p\u003e\n\n\u003ch3\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eAF, TM, SV, and MC conceptualized and designed the study. CBP, JK and MC provided statistical advice on the study design. AF, TM, SV, and MC supervised the implementation of the study and were responsible for the project administration. AF, TM and SV obtained research funding. ACR collected, managed, and analysed the data. ACR interpretated the findings and drafted the manuscript. All authors contributed substantially to its revision. All authors approved the published version of the manuscript. ACR takes responsibility for the paper as a whole.\u003c/p\u003e\n\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\n\u003cp\u003eThe authors acknowledge and thank the NH \u0026ldquo;Stiftung Evangelisches Alten- und Pflegeheim Gem\u0026uuml;nd\u0026rdquo; (Schleiden, Germany) and its head of nursing services Arno Brauckmann, as well as Dr.med. Ekaterini Karidas-Moitzheim and the AOK Rhineland/Hamburg for their cooperation and support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeutgeb R, Berger SJ, Szecsenyi J, Laux G. Potentially avoidable hospitalisations of German nursing home patients? A cross-sectional study on utilisation patterns and potential consequences for healthcare. BMJ open. 2019 Jan 21;9(1):e025269. PMID: 30670526. doi: 10.1136/bmjopen-2018-025269.\u003c/li\u003e\n\u003cli\u003ePulst A, Fassmer AM, Schmiemann G. 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The impact of the COVID-19 pandemic on medical conditions and medication adherence in people with chronic diseases. Journal of the American Pharmacists Association : JAPhA. 2022 May-Jun;62(3):834-9.e1. PMID: 34844885. doi: 10.1016/j.japh.2021.11.013.\u003c/li\u003e\n\u003cli\u003eKendzerska T, Zhu DT, Gershon AS, Edwards JD, Peixoto C, Robillard R, et al. The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review. Risk management and healthcare policy. 2021;14:575-84. PMID: 33623448. doi: 10.2147/rmhp.S293471.\u003c/li\u003e\n\u003cli\u003eVerweildauer von Pflegebed\u0026uuml;rftigen in station\u0026auml;ren Pflegeeinrichtungen und Entwicklung der Pflegeplanung in Nordrhein-Westfalen. https://www.bundestag.de/resource/blob/410854/f2a05d5a058808fac2c71f59e9e9f0d5/wd-9-043-11-pdf-data.pdf. Accessed 1 July 2023. \u003c/li\u003e\n\u003cli\u003eDie Verweildauern sinken. Statistische Analysen zur zeitlichen Entwicklung der Verweildauer in station\u0026auml;ren Pflegeeinrichtungen. https://alters-institut.de/wp-content/uploads/2020/08/Alters-Institut-Die-Verweildauern-sinken-2015.pdf. Accessed 1 July 2023. \u003c/li\u003e\n\u003cli\u003eBrauns HJ, Loos W. Telemedicine in Germany. Status, Barriers, Perspectives. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2015 Oct;58(10):1068-73. PMID: 26324096. doi: 10.1007/s00103-015-2223-5.\u003c/li\u003e\n\u003cli\u003eLarsen F, Gjerdrum E, Obstfelder A, Lundvoll L. Implementing telemedicine services in northern Norway: barriers and facilitators. Journal of telemedicine and telecare. 2003;9 Suppl 1:S17-8. PMID: 12952708. doi: 10.1258/135763303322196196.\u003c/li\u003e\n\u003cli\u003eBrooks E, Turvey C, Augusterfer EF. Provider barriers to telemental health: obstacles overcome, obstacles remaining. Telemed J E Health. 2013 Jun;19(6):433-7. PMID: 23590176. doi: 10.1089/tmj.2013.0068.\u003c/li\u003e\n\u003cli\u003eQi Tan AJ, Chua WL, McKenna L, Chin Tan LL, Lim YJ, Liaw SY. Enablers and barriers to nurse-facilitated geriatric teleconsultations in nursing homes: a qualitative descriptive multi-site study. Age and ageing. 2022 Dec 5;51(12). PMID: 36580553. doi: 10.1093/ageing/afac268.\u003c/li\u003e\n\u003cli\u003eBradford NK, Caffery LJ, Smith AC. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural and remote health. 2016 Oct-Dec;16(4):3808. PMID: 27744708.\u003c/li\u003e\n\u003cli\u003eSingh R, Mathiassen L, Stachura ME, Astapova EV. Sustainable rural telehealth innovation: a public health case study. Health Serv Res. 2010 Aug;45(4):985-1004. PMID: 20459449. doi: 10.1111/j.1475-6773.2010.01116.x.\u003c/li\u003e\n\u003cli\u003eBroens TH, Huis in\u0026apos;t Veld RM, Vollenbroek-Hutten MM, Hermens HJ, van Halteren AT, Nieuwenhuis LJ. Determinants of successful telemedicine implementations: a literature study. Journal of telemedicine and telecare. 2007;13(6):303-9. PMID: 17785027. doi: 10.1258/135763307781644951.\u003c/li\u003e\n\u003cli\u003eOffermann J, Ziefle M, Sira N, Gro\u0026szlig; D, Wilhelmy S. Telemedicine in nursing homes: Insights on the social acceptance and ethical acceptability of telemedical consultations. Digital health. 2023 Jan-Dec;9:20552076231213444. PMID: 37954688. doi: 10.1177/20552076231213444.\u003c/li\u003e\n\u003cli\u003eMay S, Jonas K, Fehler GV, Zahn T, Heinze M, Muehlensiepen F. Challenges in current nursing home care in rural Germany and how they can be reduced by telehealth - an exploratory qualitative pre-post study. BMC health services research. 2021 Sep 6;21(1):925. PMID: 34488746. doi: 10.1186/s12913-021-06950-y.\u003c/li\u003e\n\u003cli\u003eBrucken D, Unterkofler J, Pauge S, Bienzeisler J, Hubel C, Zechbauer S, et al. Optimal@NRW: optimized acute care of nursing home residents using an intersectoral telemedical cooperation network - study protocol for a stepped-wedge trial. Trials. 2022 Sep 27;23(1):814. PMID: 36167557. doi: 10.1186/s13063-022-06613-1.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Telemedicine, televisit, avoidable hospital admission, nursing home, nursing-home sensitive condition, general practitioner, geriatric care","lastPublishedDoi":"10.21203/rs.3.rs-5448947/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5448947/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBACKGROUND\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHospital admissions occur frequently in nursing homes and are often preventable. Inappropriate hospitalizations due to ambulatory care sensitive conditions bring major risks for the residents, put the emergency departments under pressure and generate high costs for the health sector. Telemedical solutions are of great potential to intensify medical follow-up of the residents and therefore reduce hospital admissions. In this study, we evaluated whether the implementation of regular medical televisits, in addition to on-site nursing home visits, can reduce unplanned hospital admissions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMETHODS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn 2021 a nursing home in rural Germany introduced a telemedical system, linking the facility to a general practitioner. Data concerning the unplanned hospitalizations of the residents was collected for 2021/22 and for 2018/19, serving as pre-intervention comparison. Thereafter, hospital admissions were compared between the two time periods, and between residents of 2021/22 who did or did not receive regular televisits by their general practitioner.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRESULTS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBaseline characteristics were comparable between residents of 2018 and 2021, as well as between residents of 2021 receiving or not telemedical care. Unplanned hospital admissions had significantly decreased (P\u0026thinsp;\u0026lt;\u0026thinsp;.0001) after implementation of regular televisits. Furthermore, a significantly lower (P\u0026thinsp;=\u0026thinsp;.04) number of hospital admissions was noted among residents benefiting from regular televisits by their general practitioner, compared to the control group solely followed by regular on-site nursing home visits.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSIONS\u003c/b\u003e\u003c/p\u003e \u003cp\u003e The successful implementation of a telemedical system providing ambulatory care in nursing homes shows promising results to reduce unplanned hospital admissions and possibly avoid its negative consequences.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTRIAL REGISTRATION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNot applicable, as no healthrelated intervention, modifying biomedical outcome or healthrelated measures in patients, took place.\u003c/p\u003e","manuscriptTitle":"Impact of regular televisits on unplanned hospital admissions of nursing home residents in rural Germany: a pre-post intervention study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 04:56:34","doi":"10.21203/rs.3.rs-5448947/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-06T10:41:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-24T19:54:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-16T19:19:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296832116683550155694061037040977908365","date":"2025-04-14T10:55:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288880712768973381787701258247652344990","date":"2025-04-07T15:33:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-05T07:53:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-02T04:47:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-03-30T19:30:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a447be8c-540a-417e-930b-442ebd2e9599","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T16:02:45+00:00","versionOfRecord":{"articleIdentity":"rs-5448947","link":"https://doi.org/10.1186/s12877-025-06244-6","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-09-08 15:57:10","publishedOnDateReadable":"September 8th, 2025"},"versionCreatedAt":"2025-04-10 04:56:34","video":"","vorDoi":"10.1186/s12877-025-06244-6","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06244-6","workflowStages":[]},"version":"v1","identity":"rs-5448947","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5448947","identity":"rs-5448947","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}