Question prompts to empower cancer patients: results of a randomized controlled trial.

OBJECTIVE: In addition to question prompts for information transfer, we also used prompts to facilitate the expression of emotions. Our aim was to investigate how a question prompt list (QPL) is accepted by patients and whether it enhances interactional empowerment of the patients in the consultation with the radio-oncological treatment team before the beginning of radiotherapy. METHODOLOGY: Adult cancer patients before the beginning of radiotherapy were randomly assigned to the intervention group (IG) or control group (CG). The patients in the IG received a QPL with predefined subsets and subject areas. After the physician's consultation, both groups completed a self-developed, content validated questionnaire on interactional empowerment. The IG evaluated the QPL using a self-developed instrument. RESULT: A total of 279 adult cancer patients participated in the study (IG n = 139/CG n = 140). The participants of the IG reported a significantly higher interactional empowerment compared with those of the CG (t(277) = - 2.71, p = .007, 95% CI [- 1.61, - 0.26], d = 0.29). 60.4% of the IG agreed "rather" or "very" that they used the QPL in consultation with the medical team. CONCLUSION: The QPL used in the consultation improved the self-assessed competence for interaction with the medical team and strengthened the interactional empowerment. The QPL was well accepted by the patients and is to be introduced into a routine as a practicable and simple instrument in the future. The support of patients in addressing concerns and fears is an important innovation.

[Desired place of death, living will and desired care at end of life: initial results of a survey of nursing home residents]. / Gewünschter Sterbeort, Patientenverfügungen und Versorgungswünsche am Lebensende: erste Ergebnisse einer Befragung von Pflegeheimbewohnern.

BACKGROUND AND PURPOSE: There is little information about the desired place of death of nursing home residents because they are usually not interviewed in population-based representative surveys. In preparation of support services for advance care planning the kind of care and support that nursing home residents desire needs to be systematically determined. METHOD: From October 2016 to January 2017 the residents of 5 nursing homes, municipally owned by Würzburg, were interviewed face-to-face. RESULTS: Of the residents 42.7% could not be interviewed due to cognitive limitations or dementia. The legal guardians of 63 residents declined participation in the study and 68 residents took part in the survey. Of the respondents 43 stated they wanted to pass away in the nursing home (63.2%). If interviewees had a person of trust or felt at home there, the number of those wanting to pass away in a nursing home was significantly higher. A total of 25 interviewees had either a living will, power of attorney for care, or a health care proxy (36.7%) and 55.3% had informed a person of trust in the nursing home about their desired care, usually a nurse (52.8%) or co-resident (36.1%). A total of 50.0% of respondents had informed their general practitioner and 23.5% had not spoken to anyone about their desired care. Especially nurses were specifically mentioned as the appropriate contact person to record desired care (70.4%). DISCUSSION: Residents view their nursing home as the place for dying in a much more positive light compared to frequent discussions contrasting population surveys and actual places of death. End of life prearrangements should be designed as a dynamic process that include persons of trust, nurses and general practitioners.

[Formative Evaluation of the "MBO® Kompakt-Neurowoche" - An Intensified Work-Related Rehabilitation Program for Neurological Patients]. / Formative Evaluation der "MBO® Kompakt-Neurowoche" ­ Eine intensivierte berufsbezogene Behandlungsmaßnahme für neurologische Patienten.

Objectives: The MBO® Kompakt-Neurowoche is offered as a work-related medical rehabilitation measure (based on allocation by a physician) following a regular neurological rehabilitation program with a duration of 7 days. Program access, process, and outcomes were examined in terms of a formative evaluation. Method: Pre-post-questionnaire data from 5 data points were used: start of regular rehabilitation (T0); start of work-related rehabilitation (T1); end of work-related rehabilitation (T2); 6-months follow-up (T3); 12-months follow-up (T4). Results: N=252 patients (75% male, 48±10 years) were included. Participants report a higher work-related treatment motivation and a more positive subjective return-to-work prognosis as compared to nonparticipants (N=215). At T4, 76% are (very) satisfied with the program. Patients rate therapy elements focusing on the assessment and improvement of work-related capacity and memory as especially useful. Assistance in developing job-related alternatives should be optimized. Conclusions: Patients participating in the work-related program report both vocational problems and a high motivation to deal with these problems during rehabilitation. The program is rated as useful with regard to return to work and the management of workplace issues.

[External quality assurance in inpatient medical rehabilitation and prevention centers for mothers, fathers and children: comparative outcome quality analyses across rehabilitation/prevention centers]. / Externe Qualitätssicherung in Einrichtungen der stationären Vorsorge und Rehabilitation für Mütter und Väter einschließlich Mutter-/Vater-Kind-Einrichtungen: Einrichtungsvergleichende Analysen im Bereich Ergebnisqualität.

To date, there are no programs for external quality assurance for inpatient prevention and rehabilitation programs for mothers, fathers and children. Instruments for outcome quality assessment were evaluated with the goal of determining their ability to document differences between prevention/rehabilitation centers in quality-relevant outcome parameters. Referring to the ICF, relevant outcome variables were specified and operationalized using established questionnaires. Data from 45 inpatient prevention and rehabilitation centers for mothers, fathers and children were analyzed using multilevel modeling with risk adjustment. Intra-class correlations were computed to determine in which parameters differences between institutions could be found. The percentage of variability accounted for by patient vs. institution characteristics was computed while statistically controlling for relevant confounders. For prevention centers, substantial variation on the institutional level was found in 9 out of 15 parameters. Almost all institutions did not deviate significantly from the grand mean of the respective parameter. For rehabilitation centers, significant variability was found in 2 out of 10 parameters. The differences between most institutions remained within a range of expectable variability. The results imply that comparative analyses across hospitals are better suited to identify institutions with low quality rather than establish quality-based rankings of institutions.

[The 'ideal therapy process': testing a new approach for assessing process quality in inpatient parent-child facilities]. / Der "ideale Behandlungsprozess": Erprobung eines neuen Ansatzes zur Prüfung der Prozessqualität in Mutter-/Vater-Kind-Einrichtungen.

Instruments for external quality assurance in inpatient parent-child rehabilitation and prevention facilities were developed in 2 projects. For the assessment of process quality, we sought an alternative test to the peer review procedure which also places a stronger emphasis on patient perspectives. The aim was to define an "ideal process" as a standard, to develop quantifiable criteria, and to test a multimethod approach which involves different data levels. On the basis of different sources, the "ideal process" for parent-child rehabilitation and prevention and associated criteria were defined by involving an accompanying expert group during a consensus process. Criteria were assessed on different levels: on the rehabilitation/prevention centre level, a questionnaire of process-relevant structural features was used; on the patient level, a case-related routine documentation filled in by clinic staff and an incident-related patient questionnaire were applied. Data were collected in 37 centres (prevention: 19; rehabilitation: 11; 7 offering both types of programmes). Analysis of patient-related data is based on a sample of 1 513 prevention patients and 286 rehabilitation patients. The resulting "ideal process" consists of the stages "preparation", "arrival", "treatment planning", "treatment", "completion of treatment", and "organisation", each containing specific criteria. Exemplarily, the outcomes for the stages "treatment planning" and "treatment" are presented. There is variability both between features and between clinics. The majority of the patients report that the criteria are fulfilled while there are medium to high levels of fulfillment regarding the routine documentation. The criteria of the questionnaire of process-relevant structural features are mostly fulfilled according to the clinics. Agreement between the 3 data levels can be observed. On the basis of the defined "ideal process", the methods that were tested seem to be appropriate to illustrate process-relevant features from different perspectives. The exemplary measured process quality of the pilot clinics can be judged as predominantly good. Individual deficits of process quality and limitations of the chosen methods are discussed.

[Specific work-related problems: do they matter in access to work-related medical rehabilitation?]. / Besondere berufliche Problemlagen: Spielen sie eine Rolle beim Zugang in die medizinisch-beruflich orientierte Rehabilitation?

BACKGROUND: The study determined if need for rehabilitation in work-related medical rehabilitation (WMR) is more frequently characterised by specific work-related problems than in conventional medical rehabilitation (MR). METHODS: In 6 rehabilitation centres, persons with back pain (M50, M51, M53, M54) were surveyed about work-related restrictions of work ability at begin of their rehabilitation. RESULTS: Differences in work ability of WMR and MR patients confirmed need-related access. However, these differences were exclusively explained by screening-based access decisions. If access was not supported by a screening, WMR and MR patients did not differ. Decisions by rehabilitation centres compared with decisions by insurance agencies resulted in similar differences between WMR and MR patients. CONCLUSION: Screening-based decisions about access enable a more need-related access to WMR. As there were no differences between access decisions by rehabilitation centres and insurance agencies, access decisions can be realised already by the insurance agency.

[Is the guideline for work-related medical rehabilitation successfully implemented?]. / Gelingt die Umsetzung des Anforderungsprofils zur Durchführung der medizinisch-beruflich orientierten Rehabilitation?

BACKGROUND: The guideline for work-related medical rehabilitation (WMR) in responsibility of the German Pension Insurance describes standards of work-related measures in medical rehabilitation. We investigated if contents and recommended amount of treatment were successfully implemented and which improvements were associated with the implementation. METHODS: Implementation of the WMR guideline was evaluated at 7 inpatient orthopaedic rehabilitation centres. Patients completed questionnaires at beginning of rehabilitation, at dis-charge and 3 months after discharge. Details -regarding the treatments provided were extracted from the standardised discharge report. RESULTS: The recommended amount of social counselling and work-related psychosocial therapy measures were appropriate. However, there were discrepancies regarding the recommended amount of functional capacity training. The standardised mean difference (SMD) between baseline and 3-month follow-up sick leave duration indicated an almost medium-sized effect (SMD=0.47; 95% CI: 0.28-0.66). An additional 5 h of work-related therapy was associated with a 1.2-week decrease in sick leave duration (95% CI: -2.38 to -0.03). CONCLUSION: The guideline was for the most part successfully implemented and sets important standards for the roll-out of WMR. The nationwide implementation of the WMR guideline requires a continuous quality assurance that -enables promptly feedback about the achieved implementation level.

[Psychosocial patient education groups focusing on work-related issues - results of a survey of German medical rehabilitation centers]. / Patientenschulungen mit arbeits- und berufsbezogener Thematik - Ergebnisse einer bundesweiten Befragung deutscher Reha-Einrichtungen.

INTRODUCTION: Psychosocial patient education programs focusing on work-related issues are a core element in the German statutory pension insurance's profile of requirements (POR) regarding inpatient vocationally oriented medical rehabilitation (VOMR). AIM: This study aims at analyzing the prevalence of patient education programs focusing on work-related issues in German rehabilitation centers with regard to their content and quality.Data were collected in a national survey on the current state of patient education within medical rehabilitation programs in Germany in 1473 inpatient and outpatient medical rehabilitation centers. METHOD: Data were analyzed both quantitatively and qualitatively, with free text responses being assigned to categories, drawing upon criteria developed by the German Center of Patient Education and the pension insurance's POR. RESULTS: 283 of the 908 institutions participating in the survey provided information on 454 psychosocial patient education programs focusing on work-related issues. "Unemployment and job training", "work hardening", "stress"/"relaxation" were named most frequently. The criteria derived from the POR regarding group content and from the Center of Patient Education regarding group size and education methods were largely fulfilled. CONCLUSIONS: There is a need for existing group programs in VOMR to be further manualized, evaluated and published. More patient education programs focusing on work-related issues should be developed specifically for relevant indications.

[Development of methods and instruments for external quality assurance in inpatient parent-child rehabilitation and prevention]. / Entwicklung von Verfahrensweisen und Instrumenten zur externen Qualitätssicherung in Einrichtungen der stationären Vorsorge und Rehabilitation für Mütter und Väter einschließlich Mutter-/Vater-Kind-Einrichtungen.

OBJECTIVE: There so far is no standardized program for external quality assurance in inpatient parent-child prevention and rehabilitation in Germany. Therefore, instruments and methods of external quality assurance were developed and evaluated on behalf of the federal-level health insurance institutions. METHODS: On the level of structure quality, a modular questionnaire for assessing structural features of rehabilitation/prevention centers, basic and allocation criteria as well as a checklist for visitations were developed. Structural data were collected in a nationwide survey of parent-child prevention and rehabilitation centers. Process and outcome quality data were collected in n=38 centers. Process quality was assessed using multiple methods (process-related structural features, case-related routine documentation, and incident-related patient questionnaires). Outcome quality was measured via patient questionnaires (n=1 799 patients). We used a multi-level modelling approach by adjusting relevant confounders on institutional and patient levels. RESULTS: The methods, instruments and analyzing procedures developed for measuring quality on the level of structure, processes and outcomes were adjusted in cooperation with all relevant stakeholders. Results are exemplarily presented for all quality assurance tools. For most of the risk-adjusted outcome parameters, we found no significant differences between institutions. CONCLUSIONS: For the first time, a comprehensive, standardized and generally applicable set of methods and instruments for routine use in comparative quality measurement of inpatient parent-child prevention and rehabilitation is available. However, it should be considered that the very heterogeneous field of family-oriented measures can not be covered entirely by an external quality assurance program. Therefore, methods and instruments have to be adapted continuously to the specifics of this area of health care and to new developments.

[External quality assurance in inpatient medical rehabilitation and prevention centers for mothers, fathers and children: development of instruments for assessing structural quality]. / Externe Qualitätssicherung in Mutter-/Vater-Kind-Einrichtungen: Entwicklung von Instrumenten im Bereich Strukturqualität.

AIM OF THE STUDY: As required by German law, inpatient institutions offering prevention and rehabilitation measures for mothers, fathers and children are obliged to implement external quality assurance measures. In 2 pilot projects funded by the German federal association of health insurance funds, external quality assurance procedures for in-hospital prevention and rehabilitation of mothers and fathers were analyzed with the aim of developing a set of instruments for the description of structural characteristics in this area of health care and to evaluate its appropriateness. Concerning structure-related quality, the project included a) designing and evaluating a questionnaire, b) the definition of assessment criteria for subsequent comparative data analyses, and c) the description and documentation of the current state in the field of rehabilitation and prevention for mothers, fathers and children. METHOD: To document structural quality comprehensively, a modular questionnaire was developed and tested in a survey of 115 inpatient prevention and rehabilitation institutions for mothers, fathers and children. Involving an expert panel, preliminary basic and selection criteria were defined in order to assure a conducive assessment with regard to structural attributes. RESULTS: The majority of institutions had provider agreements for both prevention and rehabilitation. Measures for mothers/fathers with children were predominant; only 7 institutions exclusively treated mothers and fathers. Institution sizes varied strongly. Major indications included psychosomatics, dermatology, and pneumology. Overall, structural conditions of the institutions showed a high standard. Potential for development was found with regard to some aspects of the conceptual framework of institutional practice and the implementation of the International Classification of Functioning, Disability and Health (ICF) in diagnostics. In this article, the degrees of fulfillment with relation to the structural dimensions are presented, referring to the analysis of the preliminary basic criteria. CONCLUSIONS: The developed modular questionnaire tapping structural features of inpatient mother/father-child institutions has proven to be a useful instrument to describe the structural quality in future routine practice of quality assurance. In addition, the data can be used for the definition of the final set of criteria.

[Scientific monitoring of the visitation procedure in inpatient rehabilitation centres of the German statutory pension insurance fund--the "Visit II" Project]. / Wissenschaftliche Begleitung der Weiterentwicklung des Visitationsverfahrens für Reha-Kliniken der Deutschen Rentenversicherung Bund--Das Projekt "Visit II".

Visitation procedures are an established method of external quality assurance. They have been conducted for many years in the German statutory pension insurance's medical rehabilitation centres and have continuously been refined and standardized. The overall goal of the visitation procedure implemented by the German statutory pension fund is to ensure compliance with defined quality standards as well as information exchange and counselling of rehabilitation centres. In the context of advancing the visitation procedure in the German statutory pension funds' medical rehabilitation centres, the "Visit II" Project was initiated to evaluate the perspectives and expectations of the various professional groups involved in the visitations and to modify the materials used during visitations (documentation form and manual). Evaluation data from the rehabilitation centres visited in 2008 were gathered using both written surveys (utilization analysis) and telephone-based interviews with administration managers and chief physicians. The utilization analysis procedure was evaluated with regard to its methodological quality. In addition, the pension insurance physicians in charge of patient allocation during socio-medical assessment were surveyed with regard to potential needs for revision of the visitation procedure. Data collection was complemented by expert panels with auditors. Interviews with users as part of the formative evaluation of the visitation procedure showed positive results regarding acceptance and applicability of the visitations as well as of the utilization analysis procedures. Various suggestions were made with regard to modification and revision of the visitation materials, that could be implemented in many cases. Documentation forms were supplemented by current scientifically-based topics in rehabilitation (e. g., vocationally oriented measures), whereas items with minor relevance were skipped. The manual (for somatic indications) was thoroughly revised. The transparent presentation of visitation processes and visitation criteria has proven to be a useful basis for strengthening the cooperation between the statutory pension insurance funds and the rehabilitation centres. Moreover, it is a helpful tool for the systematic and continuous advancement of this complex method by including all parties involved.

[Vocational orientation in medical rehabilitation: development of a practice handbook and a homepage as user-oriented media for rehabilitative practice]. / Entwicklung eines Praxishandbuchs und einer Homepage zur arbeits- und berufsbezogenen Orientierung in der medizinischen Rehabilitation als nutzerorientierte Medien für die rehabilitative Versorgungspraxis.

Vocational orientation in medical rehabilitation has become an important issue in rehabilitation science and practice in Germany. Although a variety of vocationally oriented interventions has been developed in recent years, there is still a lack of consensus with regard to the definition of specific types of interventions as well as relevant criteria (e. g., methods; instruments; duration/frequency; patient groups). Building on preliminary definitions, basic types of vocationally oriented measures/interventions were conceptually modified and refined in the context of a consensual process. 39 experts of various professions were contacted during a 2-stage Delphi survey to evaluate existing definitions of vocationally oriented interventions using key questions. Standardized descriptions of 5 vocationally oriented basic interventions were specified in cooperation with an interdisciplinary panel of experts. Descriptions were published in a workbook and a homepage for researchers and clinicians, which also contain information on the implementation of measures into rehabilitative care as well as good practice examples. The media developed in this project may contribute to the transfer of research results on vocationally oriented rehabilitation into health care practice.

[Current approaches in vocationally oriented medical rehabilitation]. / Neue Ansätze zur arbeitsplatzbezogenen Rehabilitation.

Stressors and demands related to changes in work environment may result in impairments of employees' health and ability to work. In the context of the German statutory pension insurance's inpatient medical rehabilitation, these aspects are increasingly taken into account within the concept of vocationally oriented medical rehabilitation (VOMR). Nonetheless, a comprehensive implementation of diagnostic and therapeutic concepts in rehabilitative practice has not yet been realized. In this article, a profile of requirements for VOMR which has been developed by the German pension insurance is introduced that shall contribute to aligning rehabilitative measures for patients with work-related problems with occupational demands. Moreover, approaches for implementing vocationally oriented measures in diagnostics (e.g., screenings) and therapy (e.g., job training) as well as good practice examples are presented. In addition, user-oriented media (handbook, homepage) which enable researchers and clinicians to learn about the current state of research in this area are highlighted. Starting points for further development of vocational orientation in rehabilitation are discussed.

[Integration of hospital social services in the rehabilitation of accident patients by the statutory accident insurance. Results of a one-year model project]. / Einbindung des Kliniksozialdienstes in die rehabilitative Versorgung unfallverletzter Patienten durch die gesetzliche Unfallversicherung - Ergebnisse eines einjährigen Modellprojektes.

In accident patient care, there is a substantial overlap between the scope of duties of hospital social services and tasks fulfilled by the German statutory accident insurances' visiting staff that regularly takes care of accident patients. Therefore, a project on the integration of hospital social services into the organizational structures of the German statutory accident insurance was initiated which aimed at optimising communication and realising synergy effects. A formative evaluation of the project was conducted that provided process- and outcome-related data for a comprehensive evaluation of the strengths and potentials of the project. Report forms containing patient-related information were completed by hospital social services. Forms were evaluated in terms of their utility for case management by accident insurance administrators using a checklist. Project implementation and procedures were documented and evaluated using semi-structured interviews with social services staff and accident insurance employees. Through the model, a comprehensive care for accident patients could be reached. In one third of all cases reviewed, rehabilitation management could be improved by including hospital social services. Moreover, in one third of all cases, care-related activities initiated by accident insurance funds could be reduced by involving local hospital social services. The report form used by hospital social services was evaluated as a useful tool in the context of patient care and rehabilitation management. The model was evaluated by interview participants as a highly targeted approach in accident patients' care management. Implications of the study for improving health care are discussed.

[Evaluation of an indicator-based screening procedure for identifying quality problems in medical rehabilitation of the German statutory accident insurance]. / Evaluation eines indikatorenbasierten Screening-Verfahrens zur Identifizierung potenzieller Qualitätsprobleme in der medizinischen Rehabilitation der gesetzlichen Unfallversicherung.

In the context of medical rehabilitation quality assurance, the use of screening procedures aims at specifically screening for rehabilitative cases that might be affected by quality problems. These may then be subjected to more elaborate quality management procedures. In the study presented, a criteria-based screening checklist designed to tap potential quality problems among rehabilitative cases in the German statutory accident insurance medical rehabilitation system was evaluated regarding its validity and suitability for routine use. Checklists were filled out by accident insurance administrators in three regional insurance funds who were instructed to evaluate all current rehabilitation cases (n=189) with regard to potential quality problems. For validation of the instrument, case reviews by physicians familiar with medical and administrative features of the accident insurance rehabilitation system were used. About a fifth of all cases reviewed using the screening checklist (22%) were classified as potentially problematic in terms of quality. Absence of relevant documents, delays in document receipt, and complications during treatment were cited as the most frequent problems. Concordance between the screening checklist and physicians' ratings concerning the quality of rehabilitative cases was moderate. Sensitivity and specificity were insufficient when using physicians' ratings as a validation criterion (0.53 and 0.56, respectively). Accident insurance administrators rated the screening checklist as a useful and practical quality management instrument. Concerning its insufficient validity using physicians' ratings as a validation criterion, the suitability of the checklist as a screening instrument is questionable. The instrument's potential of introducing the accident insurance administrators' expertise and knowledge into medical rehabilitation quality management strategies is highlighted. Further research on methodological aspects of the instrument as well as its content features is warranted. Starting points for modifications are outlined.