Target organ damage and control of cardiovascular risk factors in hypertensive patients. Evidence from the multicenter ESTher registry.

AIMS: This study investigated the incidence of hypertensive target organ damage (TOD), control of cardiovascular risk factors, and the short-term prognosis in hypertensive patients under contemporary guideline-oriented therapy. PATIENTS AND METHODS: A total of 1,377 consecutive patients (mean age 58.2 ± 9.9 years, 82.2 % male) with arterial hypertension were included in the ESTher (Endorganschäden, Therapie und Verlauf - target organ damage, therapy, and course) registry at 15 rehabilitation clinics within the framework of the National Genome Research Network. Cardiovascular risk factors, medication, comorbidities, and glomerular filtration rate (GFR) were assessed. Left ventricular hypertrophy (LVH), left ventricular mass (LVM), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF) were determined by two-dimensional echocardiography. The mean follow-up was 513 ± 159 days. Changes in continuous parameters were tested by the t test, changes in discrete characteristics are presented by means of transition tables and tested with the McNemar test. RESULTS: The mean LVEF was 59.3 ± 9.9 %, both mean LVM (238.6 ± 101.5 g) and LVMI (54.0 ± 23.6 g/m(2.7)) were increased while relative wall thickness (RWT, 0.46 ± 0.18) indicated the presence of concentric LVH. Of the patients, 10.2 % displayed renal dysfunction (estimated GFR < 60 ml/min/1.73 m(2)). The 1.5-year overall mortality was 1.2 %. Compared with discharge, at follow-up the proportion of patients with blood pressure (BP) values < 140/90 mmHg decreased from 68.7 % to 55.0 % (p < 0.001) and with low-density lipoprotein (LDL) values < 100 mg/dl from 62.6 % to 38.1 % (p < 0.001). At follow-up significantly more patients displayed a GFR value of < 60 ml/min/1.73 m(2) (10.2 % vs. 16.0 %, p < 0.001). CONCLUSION: A significant proportion of hypertensive rehabilitation participants displayed TOD including LVH and renal dysfunction. Even after stringent BP reduction, a considerable increase in nephropathy could be found after 18 months.

[Vocational inpatient and post-treatment proposals in cardiac rehabilitation patients (BERUNA): results of a randomized controlled trial]. / Berufsbezogene Rehabilitation und Nachsorge in der kardiologischen Rehabilitation (BERUNA): Ergebnisse einer randomisierten Kontrollgruppenstudie

BACKGROUND: The "Verband Deutscher Rentenversicherungsträger (VDR)" required the intense focus on vocational rehabilitation of medical problems since the early 1990s. By integrating elements of the working environment in the structures and processes of medical rehabilitation, vocational problems can be identified early in order to take appropriate countermeasures. Posttreatment proposals off er a way to provide a reliable long-term success. OBJECTIVE: The intention of this study is the implementation and the investigation of effectiveness of an intensified vocational program that integrates besides the in-patient rehabilitation post-treatment proposals as well. METHODS: Cardiac rehabilitation patient occurring special vocational problems participe. The recruited patients were randomized to either the vocational program or the common cardiac rehabilitation.Primary outcome was the vocational reintegration 12 months after the end of rehabilitation.The database was collected through a query of the pension insurance accounts and questionnaires. RESULTS: 306 people were included to the study at the beginning of rehabilitation. Rates of response:95 % of the survey to the end of rehabilitation,77 % of the survey 6 months and 73 % of the survey 12 months after the end of rehabilitation.The sample was characterized by great interferences of their professional involvement and a high demand for vocational treatments. At the beginning of the rehabilitation 50 % of study participants intended to make an application for reduction-pension. Nevertheless, one year after the end of rehabilitation a surprisingly high rate of vocational reintegration by over 70 % in both groups (IG: 72 %, KG: 75 %, p < 0.929) was indicated.The majority of the unemployed patients at the beginning of rehabilitation remained in the unemployment (IG: 69 %, KG: 65 %, p < 0.757). The participation rate at the post-treatment proposals was 42%. CONCLUSION: The results show that vocational programs in rehabilitation need to be revised, including with regard to the question, whether and in what way post-treatment proposals must be changed.

[Protect employability: effects of prevention programs offered by the German pension scheme]. / Beschäftigungsfähigkeit teilhabeorientiert sichern (Betsi): Ergebnisse der Einjahreskatamnese von Prävention-s-maßnahmen der Deutschen Rentenversicherung.

A pilot study was carried out in 4 medical rehabilitation centers to examine the practicability and effectiveness of preventive life-style interventions for employees with risk factors. The programs were developed in cooperation with the German pension scheme and employers. Selection criteria were risk factors as lack of physical activity, overweight, dorsal pain or job strain. The results demonstrate that preventive programs, which are conducted in addition to the normal working hours on the job, can be implemented successfully in rehabilitation units. The participation in the multimodal prevention program goes along with a stable reduction of risky health behavior: increased physical activity, stress coping, dietary change und weight reduction. The healthier life-style is reflected in an enhanced state of health and has also positive impact on the occupational field scale: The percentage of employees who believed to be able to work until their old-age pension, could be increased significantly (p<0.001) from 47% to 74%. Work-related risk behaviors like excessive demands on oneself were reduced and protective strategies were -developed.

[REDIA--impacts of DRG introduction in the acute sector on medical rehabilitation]. / REDIA - Auswirkungen der DRG-Einführung auf die Rehabilitation.

The REDIA study is the only long-term (2003-2009), prospective, multicentre study analyzing the impact of the DRG system on quality and costs in rehabilitation facilities. In 2004, Diagnosis Related Groups (DRG) were implemented on a mandatory basis in the German healthcare system as a reimbursement scheme for hospitals based on administered prices for procedures. Experiences from other countries revealed that introduction of DRG does not only have a significant impact on hospitals but also on rehabilitation facilities. The study approach ensures a comprehensive analysis as it considers major clinical, therapeutic, psychological and economic aspects. The REDIA study is the only nationwide empirical study that includes all stages of the implementation process: before DRG implementation, during the convergence phase and following implementation. An indication-specific comparison of the phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in admission of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversions of treatment efforts from the acute sector to the rehabilitative sector have been proven in terms of increased nursing efforts and potential changes in the therapeutic and medical treatments to be provided.

[DGRW update: rehabilitation in cardiovascular diseases. what's new in cardiac rehabilitation?]. / DGRW-Update: Rehabilitation bei Herz-Kreislauferkrankungen. Was gibt es Neues in der kardiologischen Rehabilitation?

BACKGROUND: A quality goal of medical rehabilitation is ongoing and continuous development of service standards orientated by the patient and new research findings. Because of the stark increase of research findings in the field of rehabilitation, it becomes difficult for the responsible rehabilitation providers to keep up to date on new findings and to realize the transfer of knowledge. Hence, the aim was to establish a literature research which surveys current national and international results in cardiac rehabilitation. METHODS: The literature search was undertaken using the electronic databases OVID and includes publications from 2009 and the first 2 months of 2010. The selection of studies was performed in a team of experts based on the criteria of relevance, usefulness and methodological quality of research for rehabilitation. RESULTS: 26 primary sources were selected, mainly focusing the fields "Cardiac rehabilitation: indications", "Risk factors and prevention", "Job-related reintegration", "Rehabilitation of specific medical disease patterns" and "New rehabilitation models". CONCLUSION: The studies examined show very clearly that cardiac patients can benefit from participation in cardiac rehabilitation treatment and that prevention represents a central task of medical care in the long-term treatment of coronary diseases. There is a need for further research, especially concerning the topics "New rehabilitation models" and "Job-related reintegration". The DGRW Update intends to depict current developments and to promote evidence-based medicine in rehabilitation.

[Flexibility of cardiologic rehabilitation exemplified by the Königsfeld (Ennepetal) model]. / Flexibilisierung in der kardiologischen Rehabilitation am Beispiel des Königsfelder (Ennepetaler) Modells.

Cardiac rehabilitation makes it possible to reduce costs. Many of these possibilities and opportunities for optimization of costs reduction essentially result from the positive effects of an individually networked flexible rehabilitation treatment. A prerequisite is readiness of all those participating in the treatment process to cooperate. The Königsfeld (Ennepetal) model enables individual and differential shortening of cardiac rehabilitation, and in some of the patients a partial or complete outpatient/partially inpatient cardiac rehabilitation. In conjunction with more intensive postrehabilitation care for patients unable to work, this can lead to a major improvement in rehabilitation treatment using available resources without loss of quality and in particular without risk for patients. Consistently intensified postrehabilitation care entails the greatest possibilities of lowering costs, since saving of sickness benefit, reduction of sick pay, recommencement of work and above all prevention of early retirement are of particular economic advantage.

[Individual outcome-oriented cardiologic rehabilitation treatment]. / Individuelle ergebnisorientierte kardiologische Rehabilitationsbehandlung.

Cardiac rehabilitation and subsequent intensified aftercare is capable, of increasing the rate of occupational reintegration not only over the short-term, but also over a period of two years. In addition to improving physical performance, this enhances the patient's self-confidence, decreases anxiety and reduces depression. Since, two years after completion of cardiac rehabilitation and aftercare, the percentage of those lost to gainful employment and in need of an early pension is appreciably less in the interventional group as compared with controls, this program would appear to be of particular economic importance for social security/national insurance carriers. For this reason, the Westphalian Social Security Carrier has initiated the regular use of this concept in its cardiological hospitals.

Comparable short-term prognosis in diabetic and non-diabetic patients with acute coronary syndrome after cardiac rehabilitation.

BACKGROUND: Patients with pathological glucometabolism are at increased risk of recurrent cardiovascular events after acute coronary syndrome (ACS). The goal of this study was to investigate the association of glucometabolism and the one-year outcome of cardiac rehabilitation patients. DESIGN: Prospective multicentre registry from four German rehabilitation clinics. METHODS: During 2005-2006, 1614 consecutive patients (85.9% male, mean age 55 ± 10.3 years) were included after the first ACS (mean 18.9 days) and classified into group 1 (apparent diabetes mellitus, n = 268), group 2 (no diabetes, impaired oral glucose tolerance [OGT], n = 185), and group 3 (normal fasting glucose and normal OGT, n = 1161). The mean follow-up was 13.4 months and the follow-up events were analysed by multivariate logistic regression models with backward elimination. RESULTS: The overall mortality was 1.3% (group 1: 1.2%; group 2: 1.8%; group 3: 1.5%; p(Trend) = NS). The target blood pressure values at discharge (<140/90 mmHg) were achieved by 88.7%, 89.1% and 90.8% of patients in groups 1, 2 and 3, respectively (p(Trend) = NS). The target value for LDL cholesterol (<100 mg/dl) was attained by 87.0%, 80.8% and 81.5% of the patients in groups 1, 2 and 3, respectively (p(Trend) = NS). There was a trend of a lower proportion of patients reaching the target values for HDL-C of 46.1%, 51.4% and 60.8% (p(Trend) < 0.001) and triglycerides of 65.1%, 79.9% and 74.6% (p(Trend) = 0.004) for groups 1, 2 and 3, respectively. The strongest multivariate predictors for overall mortality were patients experiencing a previous stroke (OR, 6.29 [95% CI: 1.06-37.19]; p = 0.042) and, with a trend, peripheral arterial disease (OR, 3.60 [95% CI: 0.95-13.68]; p = 0.061). In the multivariate analysis, the diabetic state had no association with poor outcomes (i.e. death or rehospitalization). CONCLUSION: The short-term prognosis for both diabetic and non-diabetic patients was good and was determined by end organ damage rather than by glucometabolic status. Diabetic patients received comparable (and not more aggressive) pharmacotherapy and therefore achieved target values for cardiovascular risk factors to a lesser extent than the non-diabetic and pre-diabetic patients.

[Improvement of worklife participation through vocationally oriented cardiac rehabilitation? Findings of a randomized control group study]. / Lässt sich die Teilhabe am Arbeitsleben durch eine berufsorientierte kardiologische Rehabilitation verbessern? Ergebnisse einer randomisierten Kontrollgruppenstudie.

PURPOSE: Although acute medical care of cardiac patients has clearly improved, vocational integration and vocational outlook of patients after MI and/or cardiac surgery did not improve substantially over the last few decades. This study is intended to evaluate a programme aimed at enhancing the return to work of cardiac rehabilitands. The programme is applied in addition to the usual rehabilitation programme and includes job-related interventions by the Social and Psychological Services as well as standardized application of the functional capacity evaluation (FCE). METHODS: This prospective randomized controlled trial is intended to evaluate the effects of the intervention programme on return to work. 150 patients who received the job-related programme (the intervention group) were compared to 150 patients who received the usual rehabilitation interventions (the control group). The study includes cardiac patients insured under the workers' pension insurance scheme and not older than age 56. Before coming to the clinic they had been unable to work, and problems with their returning to work were anticipated. Exclusion criteria were heart surgery less than three months ago, a cardiac capacity below 75 Watt, and reduced left-ventricular function. Follow-up data collection was performed 12 months after rehabilitation using a mail questionnaire. RESULTS: At the beginning of the rehabilitation programme, comparison of the groups showed no significant differences in biological, psychological and social variables. At 12-months follow-up, the data of 212 participants (70.6% of the participants) were available. Up to this time, 79.1% of the patients from the intervention group had returned to work, whereas in the control group only 62.9% had returned to work (chi(2) test, p<0.05). CONCLUSION: The results of the 12-months follow-up underline the positive effects of a job-oriented rehabilitation programme for patients' return to work.

[Rehabilitation and Diagnosis Related Groups (REDIA Study): impact of DRG introduction in the acute sector on medical rehabilitation in Germany]. / Rehabilitation und Diagnosis Related Groups (REDIA-Studie): Auswirkungen der DRG-Einführung im Akutbereich auf die medizinische Rehabilitation.

As experiences from other countries show, introduction and use of Diagnosis Related Groups (DRG), as of January 2004 now also mandatory in Germany, may have a significant impact on associated rehabilitation. The Institute of Hospital Management (IKM) in a multi-centre study promoted by Deutsche Rentenversicherung Bund and Deutsche Rentenversicherung Westfalen is conducting a study regarding potential diversion of healthcare expenditures from acute care towards rehabilitation as a result of DRG introduction in Germany. For documentation of potential short-term changes in patient populations and patient streams, extensive data have been collected in the first two phases in 2003/04 and 2005/06 for a total of 1342 cardiologic and orthopaedic patients. Indication-specific comparison of the two phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in an intake of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversion of treatment efforts from the acute to the rehabilitative sector, regarding increased nursing effort and potential changes in the therapeutic and medical treatment to be provided, has not been proven as yet. The increase in wound problems expected by practitioners was confirmed in the orthopaedic area by an increasing number of wound healing disturbances and haematomas; in bypass-patients, an increasing number of pericardium and pleura bruises was found. The analyses performed on the data collected revealed no limitations in the patients' ability to participate in rehabilitative measures when the first and the second phase of the study are compared. To be able to depict the further course and interdependencies of changes, continuous systematic observation of developments would be desirable. To ascertain a lasting impact of DRG implementation at least a third study-phase will be necessary, which should be placed at the end of 2008, at the time when the DRG convergence phase will end.

[Rehabilitation with the "Ennepetal model"]. / Rehabilitationsverfahren im "Ennepetaler Modell".

The rehabilitation model which is described in this paper shows that optimization of the goals of rehabilitation such as improvement of vocational reintegration is possible by means of a flexible rehabilitation process and that this can also be achieved using existing resources. The patients are cared for according to their disabilities and functional disorders along what can be described as a rehabilitation course, ranging from in-patient and outpatient/semi in-patient treatment to outpatient heart groups. It was possible to achieve marked improvements in vocational reintegration over a 2-year period by an intervention program (intensified aftercare treatment, INA). After completion of follow-up rehabilitation, the number of generally disabled pensioners was substantially lower in the intervention program than in the case of patients in the control group. It has also been shown clearly that flexible rehabilitation models require co-operation on the part of all those involved in the rehabilitation process.

[Goals in social medicine education for the practicing physician from the viewpoint of social security pensions]. / Sozialmedizinische Ausbildungsziele für den berufstätigen Arzt aus der Sicht der Rentenversicherung.

The tasks of a medical doctor employed by annuity insurance institutions, e.g. those of the Federal State, are complex. The doctors work in administration, in medical expert offices, and rehabilitation centres. Their tasks thus comprise the compilation of expert reports, consultation services for the administration, and modern rehabilitation diagnostics and therapy in specialised hospitals. In this context, thorough knowledge and understanding of general medicine as well as an open mind for comprehensive concepts are required. Education and training in social medicine or community health care are still far from perfect, and community medicine is not sufficiently developed as part of medical studies. Consequently, these areas must be strengthened. Annuity insurance institutions cooperate with academies for social medicine in order to improve postgraduate training in social medicine.

[Improving the transition between medical and vocational rehabilitation]. / Verbesserung des Uberganges zwischen medizinischer und beruflicher Rehabilitation. Wiedereingliederung chronisch Kranker ins Erwerbsleben.

In the framework of medical rehabilitation measures, cardiac patients' physical capacity was evaluated from an occupational medicine perspective, through vocational assessment in the workshops of a vocational retraining centre. Recommendations for vocational reintegration were derived on that basis, available at the end of the rehab measure for presentation to the financially responsible agency as a proposal for immediate implementation. The potential for actual realization of these proposals is further enhanced on account of preparatory clarification of the patients' motivational tendencies in individual and group talks. The vocational assessment performed not least provided an opportunity for strengthening the chronically ill patients' self-confidence regarding their return to work life.

[Identification of psychologically impaired patients in cardiologic rehabilitation]. / Identifikation psychisch auffälliger Patienten in der kardiologischen Rehabilitation.

As psychological factors have a substantial influence on the further medical, psychological and occupational career of a patient with somatic disease, early identification of patients with psychological disturbances is of special importance in medical rehabilitation. The share of psychologically disturbed patients in a cardiac rehabilitation clinic has been screened. Different methods for identification of anxious and depressive patients (by medical and psychological staff as well as a screening instrument) are compared. Concluding, the benefit of introducing a screening instrument as a routine procedure is discussed under the aspect of effectivity.

[Possibilities for greater flexibility in a cardiologic rehabilitation clinic by supplementary ambulatory/partial inpatient therapeutic services]. / Flexibilisierungsmöglichkeiten in einer kardiologischen Rehabilitationsklinik durch ergänzende ambulante/teilstationäre Therapieangebote.

This study shows that additional outpatient/partially inpatient treatment provided in a cardiological rehabilitation hospital effectively complements inpatient rehabilitation treatment but does not replace it. Our flexible system which comprises a shorter stay in hospital and subsequent partially inpatient treatment allows more intensive treatment of the patient in the early phase of rehabilitation. It supports patients when they have returned home and have to test out how they manage with their restricted physical and mental performance in their social environment. It appears possible to develop criteria to select the individually appropriate form of treatment. The introduction of outpatient/partially inpatient therapy in a cardiological rehabilitation hospital does not appear to entail disadvantages for the patients. It contributes to more flexible, and in particular to more individualized, treatment. The ongoing pilot projects will show whether in the final analysis this will also entail a saving of costs. Not only in view of their specialist competence are the cardiological rehabilitation hospitals suitable and able to participate in measures to increase the flexibility of cardiological rehabilitation. They should therefore either completely integrate outpatient/partially inpatient methods in their concept of therapy or after a shortened inpatient treatment. They should then evaluate these methods so as to be able to contribute to an informed discussion on this topic. This also would mean that available resources would be better utilized, which would in addition be of particular importance at present, in a situation dominated by discussions of costs.

[Prevalence of sleep apnea syndrome with primary arterial hypertension in a cardiologic rehabilitation clinic]. / Prävalenz des SAS bei Patienten mit primärer arterieller Hypertonie in einer kardiologischen Rehabilitationsklinik.

In a group of 132 randomly selected male patients with the admission diagnosis arterial hypertension in a cardiological rehabilitation clinic, nightly monitoring was performed with Mesam 4 with records of the metabolism laboratory values and sleep disturbances longitudinally. Desaturation indexes of > or = 10/h after manual correction for plausibility revealed a total prevalence of 27.3% in the case of breathing disturbances. The prevalence increased to 52% in the over 55 year-old patients with a Broca index of > or = 120% in comparison to merely 15.4% in standard weighted, comparable age group. No differences were found in the laboratory values. These results again show the frequent occurrence of the combination adiposity, hypertension, and sleep apnea syndrome which has often been missed previously in specialist rehabilitation clinics.

[Evaluation of the effectiveness of an ambulatory after-care rehabilitation program]. / Effektevaluation eines ambulanten nachstationären Rehabilitationsprogramms.

Effects of an outpatient cardiological rehabilitation programme that is offered to patients following their inpatient treatment in a rehab clinic are measured and compared with the data collected from an untreated group. The study group consists of 155 cardiological patients (after heart attack, bypass operation and heart-valve prosthesis) in the treatment group as well as 136 in the non-treatment group. The outpatient programme takes place twice a week in a cardiological rehab clinic, with patients participating for a maximum period of twelve weeks. Data are collected at the beginning, the end and three months after the end of the programme from the treatment group resp. twice with a six months interval from the non-treatment group. The used outcome measures are a number of medical variables (e.g. stress ECG, BMI, blood pressure), variables concerning vocational reintegration, plus a questionnaire. This questionnaire consists of a Functional Limitation Scale, a Mood Check List, a "Health Locus of Control"-Scale as well as a number of items regarding health-related behaviour and heart complaint symptoms. The project duration was 36 months, starting in June 1993. The funding source is the "Landesversicherungsanstalt Westfalen", a regional division of the German Statutory Old Age Insurance. As data concerning vocational reintegration indicate, the programme can be a meaningful complement to a larger amount of reintegrated patients (66.9%) compared to the non-treatment group (50.2%). To estimate the long-term effects of the programme, a 24-month-follow-up was started in January 1996.