[Current Developments of the Interdisciplinary Subject Rehabilitation, Physical Medicine, Naturopathic Treatment in the German Medical Faculties: Results of the DGRW Faculty Survey in 2015]. / Aktuelle Entwicklungen der rehabilitationsbezogenen Lehre in den humanmedizinischen Studiengängen in Deutschland: Ergebnisse der DGRW-Fakultätenbefragung 2015.

To ascertain the current development of the rehabilitation-related medical teaching in the interdisciplinary subject Rehabilitation, Physical Medicine, Naturopathic Treatment (Q12) regarding its execution, content, exams and evaluation of teaching at the Medical Faculties the German Society of Rehabilitation Science conducted another faculty survey in 2015. Representatives of all degree courses of human medicine in German Universities (n=41) received a pseudonymised standardised questionnaire in summer 2015. The response rate was 76% (n=31). Half of the faculties (48%) stated that they had a teaching and research unit for at least 1 of the 3 subjects of the interdisciplinary Q12. The Q12-teaching of faculties including these units partially differed from the other faculties. Model medical education programmes provide on average 2 semesters more for Q12-teaching in comparison to the traditional programmes. More than 3 quarters of the traditional programmes and all other courses include other medical professionals besides physicians as lecturers. Multiple choice questions still constitute the most common examination type (94%). Nearly all Medical Faculties evaluate the rehabilitation-related teaching but only half of all them have implemented a financial gratification based on the evaluation results. Even 10 years after the implementation of Q12, major variations were demonstrated regarding the execution, content and methods of medical education in rehabilitation. In the future the influence of the National Competence Based Catalogues of Learning Objectives for Undergraduate Medical Education on the Q12-development and the Q12-teaching in medical university education in Germany with foreign qualification will be of particular interest.

[Psychometric Testing of a Generic Assessment Tool for the Identification of Biopsychosocial Impairments in Persons with an Approval for Medical Rehabilitation]. / Psychometrische Testung eines generischen Assessments zur Erfassung bio-psycho-sozialer Beeinträchtigungen bei Versicherten mit Bewilligung einer medizinischen Rehabilitation.

BACKGROUND: In Germany, different rehabilitation measures were developed for patients with problems due to their specific chronic disease. The aim of the study was to test a generic assessment tool for a valid identification of disability patterns. This tool can effectively display the demand of specific rehabilitation measures in the medical rehabilitation. METHODS: The generic assessment tool was tested in a representative sample of individuals who have been granted a medical rehabilitation by the German Federal Pension Insurance. With this sample, we performed a cross-sectional study. RESULTS: Full data were available for 2 530 persons. Our analyses showed good psychometric properties of the integrated instruments concerning missing rate, ceiling and floor effects, reliability and factorial validity. We could identify a 3-dimensional structure of the assessment tool according to the biopsychosocial model. CONCLUSION: The presented assessment tool is suitable for the identification of biopsychosocial impairments and resources. This can help to allocate patients with chronic diseases in appropriate rehabilitation facilities and therapeutic modules.

[Development of a Set of Rehabilitation Related Multiple-choice-questions in Medical Education]. / Entwicklung eines Prüfungsfragenpools für die rehabilitationsbezogene Lehre im Studiengang Humanmedizin.

In the rehabilitation related teaching as in other subjects of the medical training multiple choice (MC) examinations are the most frequent type of examinations. Compared to other subjects only a few MC questions are available for the interdisciplinary subject Rehabilitation. Therefore an internet-based online platform "Pool of rehabilitation related MC questions" was developed to assist teachers regarding the provision, design and organization of high-quality rehabilitation related MC questions. A total of 502 existing MC questions were collected from 12 German Medical Faculties. After removal of 59 questions not suitable for formal and content reasons a total of 443 questions were presented to 6 reviewers for triple reviews (a total of 1 329 expert reviews received). Of the 502 questions 335 (67%) were included in the final pool including short cases with 46 case studies. The questions refer to the following learning objectives: principles of rehabilitation (40%), rehabilitative interventions (20%), diagnosis and assessment (18%), initiation and control of the rehabilitation process (12%) and methods/quality of rehabilitative interventions (10%). The use of the online platform modules resp. the questions are for free for lecturers. This includes the compilation and output of complete examinations, the statistical evaluation, and other audit-related materials. This examination pool counteracts the current lack of quality-assured rehabilitation-related MC questions and contributes to set common standards for the Medical Faculties to rehabilitation related examinations.

[Concerning the impact of psychological comorbidity for chronic back pain: frequency, reduced earning capacity pension and rehabilitation aftercare in the course of the rehabilitation cohorts 2002­2009]. / Zur Relevanz psychischer Komorbiditäten bei chronischem Rückenschmerz: Häufigkeitsbild, Erwerbsminderungsrenten und Reha-Nachsorge im Zeitverlauf der Reha-Kohorten 2002­2009.

BACKGROUND AND OBJECTIVE: Psychological comorbidities play a key role in the chronification process of back pain. The aim of this longitudinal study is to analyze the diagnostics of psychological comorbidities, their influence on back pain patients and the recommendations of aftercare over the course of time. METHODS: A descriptive analysis of diagnosed psychological comorbidities for the rehabilitation cohorts from 2002 to 2009 was conducted as well as a modelling of Poisson regressions to calculate relative risks and incidence rates. RESULTS: The frequency of at least one psychological comorbidity ranges from 17.6 to 17.9% in the years 2002­2004 and from 18.9 to 20.9% in the years 2005­2009. The risk of reduced earning capacity pension for persons with a comorbid psychological disorder is increasing significantly in almost all rehabilitation cohorts regardless of gender and adjusted for other risk factors compared to persons without comorbid psychological disorders. The number of recommended aftercare procedures is increasing over all cohorts:starting in 2005 with less than 5% of patients to every fourth patient with an aftercare recommendation in 2009. CONCLUSION: The frequencies of psychological comorbidities as reported in the discharge letters for the cohorts of patients in rehabilitation are below the reported frequencies of epidemiological studies. Psychological comorbidities have a considerable impact on pension for reduced earnings capacity. This finding could be useful for recommending aftercare programs.

[Validation of the Patient Classification System Rehabilitee-Management-Categories (RMK) in Patients with Chronic Back Pain in Regular Medical Treatment]. / Validierung der Gültigkeit des Patientenklassifikationsansatzes der Rehabilitanden-Management-Kategorien (RMK) für chronische Rückenerkrankungen im Heilverfahren.

BACKGROUND AND OBJECTIVE: The Rehabilitee-Management-Categories (RMK) have been developed by the Charite - University Medicine Berlin for 10 years. A content- and time-stable classification approach should support health care providers to offer therapy standards that are better adjusted to the needs of patients. At the same time, stability means for healthcare payers that the admission management to clinics with specialised services could be optimized. METHODS: The stability of the RMK classification was tested with the help of latent class analysis (LCA) in independent samples. The data sets are taken from 3 different studies carried out from 2006 to 2011. Only patients with chronic back pain (M40-M54) who were in regular medical treatment provided by the German Pension Fund were included. RESULTS: A statistically stable 4-class solution was found in all samples. Kappa-coefficients from 0.605 to 0.72 showed a good consistence of the RMK-algorithm from the first LCA with the respective latent class analyses. CONCLUSION: The RMK-approach offers possible uses for both healthcare providers and healthcare payers by assessing the need of treatments according to the ICF approach. Among other things, this approach can be used to fulfil the quality guideline in a differing way.

[Comorbidity from the patient perspective - does it work? Validity of a questionnaire on self-estimation of comorbidity (SCQ-D)]. / Komorbidität im Patientenurteil - geht das? Validität eines Instruments zur Selbsteinschätzung der Komorbidität (SCQ-D).

To minimize the medical effort for the measurement of comorbidity, which is a relevant factor for various outcome measures, the Self-Administered Comorbidity Questionnaire (SCQ) for patient self-evaluation has been developed. After successfully testing the psychometric characteristics and content of the original English version a validation of the German translation (SCQ-D) has so far been lacking. A total of 218 patients with gonarthrosis and coxarthrosis (average age 71.5 years) were included in the survey. A questionnaire for doctors as well as patients was used to collect data at five different measurement times (postoperative, beginning and end of rehabilitation as well as 4 months and 1 year postoperatively). To evaluate the matching of comorbidities according to the SCQ-D and the Charlson Comorbidity Index (CCI), aggregate indices for "problems" and "treatment" as well as correlation and kappa coefficients were calculated. The assessment of predictive validity in terms of treatment outcome was operationalized using the WOMAC and the postoperative 1 year hospitalization by applying multilevel models. The patient self-assessment using the SCQ-D correlated well with the physician assessment using CCI in terms of aggregate indices of 13 given disease groups with r = 0.49 (problems) and r = 0.48 (treatment). However, the results showed significant differences for certain diseases in the conclusions. The comorbidity measured by the SCQ-D proved to be a valid predictor of the hospitalization and the treatment outcome. Concerning the need for resource efficient data collection especially in large sample studies, the SCQ-D is a useful patient self-administered instrument to assess the type and extent of comorbidities.

[Rehabilitee-management-categories (RMK)--results of the development phase and of the first clinical implementation in alcohol rehabilitation centres]. / Rehabilitanden-Management-Kategorien (RMK)--Entwicklungsprozess und ausgewählte Ergebnisse am Beispiel der Suchtrehabilitation.

BACKGROUND: Due to the introduction of lump sum reimbursement systems for acute-care settings (DRGs), patient classification systems have been developed in Germany during the last 15 years to adapt a case-based lump sum system to the field of medical rehabilitation. The concept of Rehabilitee-Management-Categories (RMK), developed by the Charité - Universitätsmedizin Berlin, classifies rehabilitees primarily by their relevant impairments of activity and participation, as these factors mainly determine treatment needs and resources required in rehabilitation. It can, inter alia, be used to optimize the demand-related allocation of treatment services in the rehabilitation centres as well as lead to more transparency in the allocation process. RMK results are reported on the example of inpatient rehabilitation of alcohol dependence. METHODS: Utilizing internationally established assessments, an RMK-assessment was developed that allows the assessment of rehab treatment needs of patients undergoing alcohol dependence rehabilitation. The RMK-assessment was completed by n=731 rehabilitees. Latent class analysis was applied to find groups of cases. To facilitate the RMK-patient classification a software-based algorithm was developed and implemented in 12 rehabilitation centres (implementation study). To validate the results of the first study phase, the data collected during implementation (n=1,533) was again analyzed using latent class analysis. Combined standardized and qualitative user surveys were conducted at the end of the implementation study. RESULTS: On the basis of 15 needs-related patient characteristics, 4 comparable case groups (AL-1 to AL-4) each were identified in 2 independent samples, groups that differed significantly in their degree of dependence-related, psychological and social impairment. The user survey confirmed the basic clinical plausibility of the 4 different case groups as well as the feasibility of the instruments applied in a rehabilitation setting. CONCLUSIONS: The RMK-concept offers a new approach for a demand-related patient classification in medical rehabilitation. The RMK-instruments allow a standardized initial assessment of impairment and treatment needs in alcohol rehabilitation and can hence be used for objective comparisons between rehabilitation centres. The results of the RMK-assessment provide relevant information about demand-related treatment requirements, which is a matter of great interest in the context of limited resources. Appropriate treatment requirements for the 4 RMK-case groups will be defined and verified in the next step of the RMK-concept. A financial evaluation of the RMK is possible in principal, will however require more extensive development, not least in order to model and evaluate the health-economic implications involved.

[Risk Index Disability Pension (RI-DP). A register-based case-control study with 8,500 men and 8,405 women]. / Risikoindex Erwerbsminderungsrente (RI-EMR). Eine prozessdatenbasierte Fall-Kontroll-Studie mit 8500 Männern und 8405 Frauen.

The aim of our study was to identify variables of prognostic relevance for disability pensions (DP) in the register data of the German Pension Fund (GPF) and to use the identified variables to construct a risk index. The study was designed as a case-control study of insurants of the GPF Bund using disability pensioners from 2004-2008 as cases and active insurants as controls. Independent variables were selected from the accumulated register data from 2001-2003. Data of 8,500 men and 8,405 women were analyzed. The strongest predictor of future DP were days of sickness benefits. Men with short-term benefits had 6.1 times higher odds of receiving a DP, while men receiving long-term benefits had even 66.3 times higher odds of receiving a DP. For women, the odds were increased 3.8 and 38.4 times, respectively. The risk index score was calculated by transforming the linear combination of parameter estimators and personal characteristics to values ranging from 0-100. ROC analyses and survival analyses confirmed the prognostic relevance of the index score. Independent samples were used to validate our models. Our results show that the GPF has information which could enable an active strategy to enhance the provision of medical rehabilitation.

[Rehabilitation as a subject of health services research]. / Rehabilitation als Gegenstand der Versorgungsforschung.

Since the mid-1990s, the lack of proper development in health services research in the healthcare system of the Federal Republic of Germany has been repeatedly criticised by healthcare policy-makers and experts alike, whilst also being the subject of a number of reform initiatives. Rehabilitation sciences, which were established in Germany as an autonomous scientific discipline in the early 1990s, could benefit in terms of conception, methodology and organisation from these activities and the new interest bestowed on healthcare sector research. At the same time, the converse also holds true since from the very beginning health services research has played a particular role in the development of rehabilitation sciences-unlike the role it has played in the overall healthcare system. The complex nature of the areas of research covered by rehabilitation, together with the theoretical plurality and methodological diversity associated with it, may be ascribed to the fact that (up to the present) this sector has lacked a broader framework connecting together health research concerns and issues. This article presents a comprehensive overview of current concerns and issues as evidenced in publications of the past 15 years that make an explicit contribution to health services research. It highlights the rehabilitation system research undertaken in the past decade as a central plank of health services research. Furthermore, it also investigates the backdrop to health services research in rehabilitation in terms of its development, its research concerns, its methodology, its organisation and its infrastructural embeddedness.

[Demographic and curative factors of need for rehabilitation--possibilities and limits of simple time series models]. / Demographische und kurative Bedingungsfaktoren des Reha-Bedarfs--Möglichkeiten und Grenzen von einfachen Zeitreihenmodellen.

Regarding rehabilitation demands, macro-analytical time-series models outline a method for the estimation of effective rehabilitation needs and for explaining the magnitude of the requirements. Their range is limited, in so far as they are unable to clarify the rehabilitation requirement regarding individual micro-level behavioural aspects. For the moment the rehabilitation requirements are hidden units in the models. Differing macro-dimensions have been gradually included in the analysis. The demographic parameters of the potential patients in need of rehabilitation are the fundamental starting point. Rehabilitation requirements are increasingly modelled by the magnitude of the curative requirements. These are characterised in the rehabilitation as "preliminary or follow up". Two examples of simple time-series models in rehabilitation--for the development of rehabilitation demand--illustrate empirically, which possibilities and boundaries are set in view of demographic and curative requirements by the interpretative range of the macro-concepts. What is methodically interesting with it, is how the analytical borders of such time-series models can experience a recognisable theoretical broadening, through a projection in real logistical facts--here in the interaction between prognosis and retrospection.

[Concept and measurement of need for rehabilitation--framework for a multidimensional investigational approach]. / Zum Begriff und zur Messbarkeit der Rehabilitationsbedürftigkeit--Ein Rahmenkonzept für einen mehrdimensionalen Untersuchungsansatz.

As before the concept and content regarding the need for rehabilitation have still not been sufficiently clarified. In particular, an operationalization of the underlying parameters, as the basis for their measurement is absent. Some exemplary research concepts have been introduced and their methodological implications have been put out. Resulting from this, up till now, in the most developed model, determining the need for rehabilitation has been developed as a latent multi-dimensional variable. A framework, as a starting point for a multi-dimensional investigation regarding the need for rehabilitation has been introduced. According to this, the need for rehabilitation is a multidimensional, qualitative construct, that can not be directly observed and measured. The empirical investigation, which is based on this, limits the description of the need for rehabilitation to the various patterns of determinants, (description by a set of requirement factors and arranged factors) which result in different effects. Therefore different samples regarding the qualitative aspect do not mean the lesser or greater need for rehabilitation based on a continuum of measurement, but different qualitative forms which are visible in different effects.

[Rehabilitation management categories. A new approach to case mix in medical rehabilitation]. / Rehabilitanden-Management-Kategorien (RMKs). Ein neuer Ansatz zur Fallgruppenbildung in der medizinischen Rehabilitation.

Creating typical treatment case groups in medical rehabilitation, in short: Rehabilitee Management Categories (RMKs, Rehabilitanden-Management-Kategorien), is a key issue for quality assurance within the frame of modern concepts of Total Quality Management (TQM), not least utilizing current organization and management concepts (Managed Care). So far, the problem of creating highly homogeneous case groups has remained unsolved on the basis of the present methodological framework. Critical prerequisites for any further scientific work on this problem are being established in the field of medical rehabilitation with the help of the Classification of Therapeutic Services (CTS) as well as development of instruments documenting therapy plans for typical rehabilitation case groups, process-relevant quality features and definitions of therapy goals as a basis for quality screening under the Pension Insurance quality assurance programme in medical rehabilitation. These developments have clearly contributed to expanding the theoretical foundations as well as the prerequisites for empirical grounding of Rehabilitee Management Categories in medical rehabilitation under the Pension Insurance scheme. A project for determination of rehabilitation case groups which is based on these developments, is due to start at the Humboldt University and Technical University, Berlin in the near future within a rehab promotion initiative of the German Pension Insurance system in cooperation with the Federal Ministry of Research and Technology. Conceptually, the determination of Rehabilitee Management Categories by far exceeds all previous approaches as (1) it will be generated by an iterative process of empirical service descriptions and theoretical consensus building among experts, (2) not only static parameters but also process-related details will be recorded, and (3) quality requirements will be defined for the rehabilitation process and outcome. As a result, rehabilitation-relevant case groups are to be created, which will include a definition of process- and outcome-oriented quality standards. Unlike previous case group concepts, the new approach encompasses quality management issues as an integral part of its development. Since this concept for determination of Rehabilitee Management Categories incorporates the definition of quality standards, i.e., guidelines, prerequisites will be created for integrating these standards into quality management concepts, as well as service management across the interfaces of the German service delivery system (Managed Care).

[Berlin-Brandenburg-Saxony Rehabilitation Research Group]. / Reha-Forschungsverbund Berlin-Brandenburg-Sachsen (BBS).

The principal subject of the Rehabilitation Research Network of Berlin, Brandenburg and Saxony (BBS) is "the theoretical and practical bases of the organisation and economics of rehabilitation". What is involved is a nation-wide analysis of the rehabilitation system, i.e. obtaining empirical information on the question as to what organisational forms are currently used to carry out rehabilitation and what results are achieved. This empirical stocktaking also includes economic aspects as far as possible. This study is to serve as a basis for developing, testing and implementing steps to rationalise steering mechanisms in the rehabilitation system. The first aspect to be studied is "national steering problems in institutionalised forms of rehabilitation". The focus is on projects on information management and performance and quality management in rehabilitation sciences as well as on the actual work of a number of bodies paying for rehabilitation (Bundesversicherungsanstalt für Angestellte, Landesversicherungsanstalten) as well as rehabilitation facilities (clinics etc.). The two other focuses of the study will examine "rehabilitative adjustment to remedies and technical aids/prostheses" and problems facing "family members in the context of rehabilitation". In studying these two areas, we are particularly interested in examining the interaction between institutionalised aspect of rehabilitation and informal factors both inside and outside the system. The BBS approach is supported by close co-operation with the regional pension insurance institutes (BfA, LVAs) with regard to both the data model and steps being taken. The principal instrument of co-operation is the "Gesellschaft für Rehabilitationswissenschaften e.V." (Society for Rehabilitation Sciences). In Berlin the BBS co-operates with Free University, the Technical University and the Robert Koch Institute and in Saxony with the universities in Dresden and Leipzig. Responsibility for scientific questions in the BBS lies with the Institute for Rehabilitation Sciences of Berlin's Humboldt University.

[Assessment of long-term needs and expenditures development for rehabilitation services of the BfA with reference to the growth and occupational rehabilitation regulation (WFG)]. / Abschätzung der langfristigen Bedarfs- und Ausgabenentwicklung für die Rehabilitationsleistungen der BfA unter Berücksichtigung des Wachstums- und Beschäftigungsförderungsgesetzes (WFG).

Based on a Prognos Model projection (1998 to 2040), the number of medical and occupational rehabilitation service treatments required will increase by about 70,000 between 1998 and 2015, reaching 500,000. Thereafter, the situation improves and the number drops to between 370,000 and 430,000. The WFG law provides a 2.7 billion DM budget for the entire time period which results in a growing deficit, reaching 1.7 billion DM by 2015, and enabling the provision of only 50% of the treatments required in the western states, if it is assumed that a reduction of treatment in the eastern states is precluded. This service deficit makes an increase in early retirements probable, thereby, generating costs on balance which exceed any potential savings in the areas of rehabilitation. It is, therefore, necessary to adapt the WFG law to the demands of real needs so that the BfA may continue to fulfill its legal obligation, "rehabilitation before retirement" to the accustomed and necessary extent.

[Cost-benefit evaluation of medical rehabilitation by social security pensions and effects of the growth and occupational rehabilitation regulation (WFG)]. / Kosten-Nutzen-Bewertung der medizinischen Rehabilitation der Rentenversicherung (RV) und die Auswirkungen des Wachstums- und Beschäftigungsförderungsgesetzes (WFG).

The retirement insurers, within the scope of their responsibility for health care, have already adopted the standard that calls for quality control, cost-efficiency, and outcome-focusing. For a start, the BfA (Federal Insurance Agency for Salaried Employees) has compiled a pilot evaluation presented here, based solely on its own costs and returns on costs. This evaluation demonstrates that rehabilitation "pays off". With regard to the WFG, this means that cost-saving in rehabilitation generates significant cost increases through loss of premium payments and necessary early-retirement outlays. The analysis presented shows that future investment in rehabilitation is required to ensure positive returns for the RV.

[Perimortal management--humanistic assignment and responsibility. Attempt at status determination]. / Perimortale Betreuung--humanistische Aufgabe und Verpflichtung. Versuch einer Standortbestimmung.

The scientific research and practical use of all questions concerning life demands interdisciplinary cooperation. This is the result of neglection of death and dying and new social and medical developments as there are institutionalisation of dying and scientific-technical progress. The foundation of the working group "perimortal medicine" in 1983 in the Association for clinical medicine gives the possibility to discuss theoretical and practical questions concerning the end of life, death and dying. It seems to be important, that also bereavement and sympathy belongs to the topics. The results will help to develop the quality of care for the dying and the survivors.