[Quality of care of acute ischemic stroke in Germany 2018]. / Versorgungsqualität des akuten ischämischen Schlaganfalls in Deutschland 2018.

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed a high level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

Stroke recurrence in patients with recently symptomatic carotid stenosis and scheduled for carotid revascularization.

BACKGROUND AND PURPOSE: Patients with symptomatic carotid stenosis (sCS) have a higher risk of stroke recurrence following the first ischaemic event. Guidelines recommend that patients undergo carotid revascularization (CR), preferably within 2 weeks of the event. We aimed to determine the rate of stroke recurrence during hospitalization in patients who were admitted to the hospital with an acute ischaemic event and who underwent CR for recently sCS. METHODS: As part of the stroke registry in Schleswig-Holstein, Germany (QugSS2; Qualitätsgemeinschaft Schlaganfallversorgung in Schleswig-Holstein), over a 4.5-year period (starting 2007) all patients (N = 15,797) who were admitted to the hospital with an acute cerebral ischaemic event were included and prospectively evaluated. RESULTS: A total of 597 (3.8%) patients (mean age, 71 ± 10 years; 30% women) underwent a CR. The median time between symptom onset and admission to hospitals was 6 h. During the mean hospitalization of 10 days, 30 patients (5%) suffered a stroke. The rates of stroke recurrence were higher, albeit non-significantly, in men compared with women (6% vs. 2.3%, respectively; P = 0.059), and in patients admitted with ischaemic stroke compared with patients admitted with transient ischaemic attack (6.1% vs. 2%, respectively; P = 0.052). The risk of stroke recurrence did not show any association with the other demographic and clinical parameters. CONCLUSION: The rate of stroke recurrence was 5% in patients with recently sCS who scheduled for CR. This suggests that CR should be performed immediately after presenting event to prevent stroke recurrence.

[Predicting gainful employment in a population sample of 4225 statutory pension insurance members covering a prognostic period of five years using a brief subjective prognostic employment scale (SPE Scale)]. / Vorhersage der Erwerbstätigkeit in einer Bevölkerungsstichprobe von 4225 Versicherten der LVA über einen Prognosezeitraum von fünf Jahren mittels einer kurzen Skala (SPE-Skala).

PURPOSE: Vocational (dis-)ability is a key concept in social medicine. It plays a major role in the realm of statutory pension funds (e. g. appraisal of applications for early retirement) as well as in epidemiologic or rehabilitation research. In a former population-based survey reliability of a short scale assessing the subjective prognosis of gainful employment (SPE-Scale, range = 0 - 3) had been tested. We now wanted to explore whether the SPE-Scale allows a prediction of vocational outcomes (early retirement) in the population sample over longer periods of time. METHODS: Statutory pension insurees from Luebeck and surroundings aged between 40 and 55 were surveyed by questionnaire in 1999/2000. For 4225 subjects (= 95% of the original cohort) we obtained the following outcome data from pension fund records: dates of any applications for early retirement and beginning of retirement, date of death. The follow-up period covers 4.75 years on average. During this period 323 applications for early retirement (= 7.6%) were filed, and 200 subjects (= 4.7%) actually retired. RESULTS: First analysis including age and sex as covariates showed a threefold (SPE = 2) and eightfold (SPE = 3) risk of early retirement. Multivariate analysis (covariates: overall health status, number of chronic conditions, approved disability, subjective vocational ability, and length of sick leave measured at study onset) yielded a twofold risk of filing an application for early retirement (SPE = 3). CONCLUSIONS: The SPE-Scale is an appropriate screening instrument for hazards regarding gainful employment. It also can be recommended for use in epidemiologic or rehabilitation surveys.

Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS).

Vertebral fracture is one of the major adverse clinical consequences of osteoporosis; however, there are few data concerning the incidence of vertebral fracture in population samples of men and women. The aim of this study was to determine the incidence of vertebral fracture in European men and women. A total of 14,011 men and women aged 50 years and over were recruited from population-based registers in 29 European centers and had an interviewer-administered questionnaire and lateral spinal radiographs performed. The response rate for participation in the study was approximately 50%. Repeat spinal radiographs were performed a mean of 3.8 years following the baseline film. All films were evaluated morphometrically. The definition of a morphometric fracture was a vertebra in which there was evidence of a 20% (+4 mm) or more reduction in anterior, middle, or posterior vertebral height between films--plus the additional requirement that a vertebra satisfy criteria for a prevalent deformity (using the McCloskey-Kanis method) in the follow-up film. There were 3174 men, mean age 63.1 years, and 3,614 women, mean age 62.2 years, with paired duplicate spinal radiographs (48% of those originally recruited to the baseline survey). The age standardized incidence of morphometric fracture was 10.7/1,000 person years (pyr) in women and 5.7/1,000 pyr in men. The age-standardized incidence of vertebral fracture as assessed qualitatively by the radiologist was broadly similar-12.1/1,000 pyr and 6.8/1,000 pyr, respectively. The incidence increased markedly with age in both men and women. There was some evidence of geographic variation in fracture occurrence; rates were higher in Sweden than elsewhere in Europe. This is the first large population-based study to ascertain the incidence of vertebral fracture in men and women over 50 years of age across Europe. The data confirm the frequent occurrence of the disorder in men as well as in women and the rise in incidence with age.

Falls explain between-center differences in the incidence of limb fracture across Europe.

There is important geographic variation in the occurrence of the major osteoporotic fractures across Europe. The aim of this study was to determine whether between-center variation in limb fracture rates across Europe could be explained by variation in the incidence of falls. Men and women, aged 50-79 years, were recruited from population-based registers in 30 European centers. Subjects were followed by postal questionnaire to ascertain the occurrence of incident fractures, and were also asked about the occurrence and number of recent falls. Self-reported fractures were confirmed, where possible, by review of the radiographs, medical record, or subject interview. The age- and gender-adjusted incidence of falls was calculated by center using Poisson regression. Poisson regression was also used to assess the extent to which between-center differences in the incidence of limb fractures could be explained by differences in the age- and gender-adjusted incidence of falls at those centers. In all, 6302 men (mean age 63.9 years) and 6761 women (mean age 63.1 years) completed at least one questionnaire concerning fractures and falls. During a median follow-up time of 3 years, 3647 falls were reported by men and 4783 by women. After adjusting for age and gender, there was evidence of significant between-center differences in the occurrence of falls. There was also between-center variation in the occurrence of upper limb, lower limb, and distal forearm fractures. Variation in the age- and gender-adjusted center-specific fall rates explained 24%, 14%, and 6% of the between-center variation in incidence of distal forearm and upper and lower limb fractures, respectively. Given the constraints inherent in such an analysis, in men and women aged 50-79 years, variation in fall rates could explain a significant proportion of the between-center variation in the incidence of limb fracture across Europe.

Survey response rates: national and regional differences in a European multicentre study of vertebral osteoporosis.

STUDY OBJECTIVE: This analysis aimed to compare the response rates of those invited to attend for screening in a multicentre, multinational study within Europe. DESIGN: This was a population survey. SETTING: Thirty four centres in 16 European countries. SUBJECTS: Men and women aged 50 years and over were recruited from population based sampling frames to participate in a prevalence survey of osteoporosis. Subjects were invited by post to attend for radiological screening and interview, and non-responders were followed up by repeat mailing. RESULTS: There was a substantial variation between centres in response rates: the mean was 49% and the range 5-83%. Adjusting for those known to have died or moved house did not affect the overall ranking. The response rates to each mailing also varied between centres: first mailing 45% (range 5-83%) and second mailing mean 10% (range 0-23%). The response rates varied in relation to age and sex and were higher in women than men. Rates fell gradually with age in women but rose in men until the age of 65 years. Response rates varied regionally. These were highest in countries from northern Europe and lowest in southern European countries, but there was wide variation both within regions and within countries. CONCLUSIONS: Multicentre, multinational studies within Europe will probably become increasingly popular. In this study, despite a standardised approach, the range in response rates between centres both within and between countries was substantial. Attempts at cross national standardisation in survey design can have only a limited effect on yielding uniformity in response.

[Fractures in the elderly: are postal questionnaires sufficiently sensitive?]. / Frakturen im höheren Lebensalter: Wie sensitiv sind postalische Fragebögen?

Within the European Prospective Osteoporosis Study the validity of a postal questionnaire concerning fractures in the elderly was assessed. A sample of 144 men and women aged 50 to 84 hospitalized in an urban hospital due to fractures within the past 12 months was investigated. Eight percent of the respondents denied any recent fracture and turned out to be false negatives, less than previously recorded. Mode and frequency of questioning seem to influence the results. To assess fracture localisation, we used a graphical method (mannequin). Due to various factors, one third of all localisations were incorrect.

[Current musculoskeletal symptoms in peri and postmenopausal women: results of a multicenter population epidemiological study. The EVOS Study Group]. / Aktuelle muskuloskeletale Beschwerden bei peri- und postmenopausalen Frauen: Ergebnisse einer multizentrischen bevölkerungsepidemiologischen Studie. EVOS-Studiengruppe.

Within the European vertebral osteoporosis study four stratified systematic samples of German residents aged 50-79 in Lübeck, Heidelberg, Jena and East Berlin have been drawn. Overall 4628 subjects were included, of whom 4385 were contactable and 3106 (71%) responded to the postal questionnaire enquiring about rheumatic complaints "today". 2348 (54%) followed an invitation to a medical examination in which a specific gynaecological history was taken. The prevalence of current back-, neck- and joint-pain is consistently higher in females than in males in all age groups. Females show a peak prevalence in the age group 55-64. 104/1134 women were pre- or perimenopausal. 1030 women had not had their period for at least 13 months and were classified as "postmenopausal". Neither the menopausal status nor the duration of the postmenopause were statistically significantly associated with the frequency of the three rheumatic complaints.

[Burden of illness in vertebral deformities. EVOS group in Germany]. / Krankheitslast bei vertebralen Deformitäten. EVOS-Gruppe in Deutschland.

BACKGROUND: In the course of the European Vertebral Osteoporosis Study (EVOS) 4060 men and women (target age 50 to 79 years; age and sex-stratified random samples from official population registers) were examined according to the standardized study protocol in 8 German study centres. METHODS: The study programme comprised an initial postal health questionnaire, a medical interview concerning risk factors and health impact and lateral X-rays of the thoracic and the lumbar spine. Vertebral deformities were defined morphometrically. The association between prevalent deformities and subjective health impairments was investigated using 2 different morphometric classifications. The following variables were included as indicators of reduced health: back pain ever/within the last 12 months/currently, back pain intensity, functional capacity (ADL-list), graded back pain, subjective health, depression and grip strength. RESULTS: Bivariate analyses (chi(2) test, t-Test) as well as logistic regression analysis revealed significant associations between vertebral deformities and several negative health outcomes (odds ratios between 0.75 and 4.65, depending on definition of deformity). The associations were stronger in women.

[European Study of Vertebral Osteoporosis (EVOS): design and implementation in 8 German study centers]. / Die europäische Studie zur vertebralen Osteoporose (EVOS): Design und Durchführung in acht deutschen Studienzentren.

BACKGROUND: The European Vertebral Osteoporosis Study (EVOS), a multinational multicenter cross sectional study, was aimed to determine the prevalence of vertebral deformities, their risk factors and health impact. METHODS: Between 1991 and 1993 4487 men and women aged 50 to 79 years were examined in 8 German study centres. Health impact, back pain and functional capacity were assessed in postal questionnaires. In medical interviews data was also collected on putative risk factors for osteoporosis including details on personal and medical history, drug use, diet, smoking, alcohol, exercise and gynaecological characteristics. Four thousand one hundred and twenty-two persons underwent a lateral X-ray examination of the thoracical and lumbar spine, representing a quarter of the 16,000 European participants.

[European Study of Vertebral Osteoporosis (EVOS): cooperation of participants and selection bias in Germany]. / Die europäische Studie zur vertebralen Osteoporose (EVOS): Teilnahmebereitschaft und Selektionsverzerrung in Deutschland.

BACKGROUND: In population-based studies non-participation rates of about one third of the sample can be expected. The number of refusals may even be higher, if personal attendance of the subjects is requested. A different participation behaviour of the diseased and non-diseased may affect the prevalence estimation of a disease as well as the risk factor association. METHODS AND RESULTS: The European Vertebral Osteoporosis Study (EVOS) is an international, multicenter, cross-sectional survey in men and women aged 50 to 79 years. Within Europe 36 centres recruited 17,342 participants. The 8 German centres contribute about one forth of the data. In Germany subjects were recruited in several steps: random sample drawing from population registries, initial postal questionnaire, medical interview, lateral X-rays of the thoracic and lumbar spine. Depending on the extent of participation a variable amount of sociodemographic data and information on subjective health is available from the non-reachable, non-responders, and responders with incomplete and with complete examination. A comparison of the different participation groups showed, that especially old women were lost from the study. Compared to those, who only answered to an initial questionnaire, subjects, who were interviewed and X-rayed, more often suffered from back pain but reported a better functional capacity. This could be a hint on a selection of a population of the "worried well". CONCLUSION: On the whole the selection processes seem to have a minor influence on the outcome. The initial postal questionnaire turned out to be effective in collecting basic information from those who refused to attend a personal examination.

[The reliability of radiologic findings for differential diagnosis of vertebral osteoporosis]. / Die Reliabilität radiologischer Befunde zur Differentialdiagnose der vertebralen Osteoporose.

BACKGROUND: Radiologically identified vertebral deformities, e.g. wedge-, fish-, or crush-vertebrae are not always a consequence of local osteoporosis. Other frequent pathomechanisms include Morbus Scheuermann, degenerative changes, overt trauma, and congenital dysplasia. This requires differential diagnosis of vertebral deformities. Radiological classification criteria have to satisfy various methodological requirements to ensure reliability of the results. METHODS: Inter-rater reliability of more than 30 radiological findings was assessed in 4 German centres of the European Vertebral Osteoporosis Study (EVOS). One hundred randomly selected EVOS cases from the West-Berlin population, each contributing 2 lateral X-rays from the thoracic and lumbar spine respectively, were independently evaluated by 7 observers. All observers were medical doctors, 4 of them heads or members of clinical radiological departments. Thus each observer read 200 radiographs. Radiological alterations in the form and structure of 13 vertebrale which were considered to be relevant for the differential diagnosis of osteoporosis were recorded in a standardized documentation form. Additionally global judgements (e. g. "osteoporotic spine" yes/no) were required. To quantify agreement Fleiss' kappa (kappa) for nominal data and multiple observers was used.

The prognostic impact of the stroke unit care versus conventional care in treatment of patients with transient ischemic attack: a prospective population-based German study.

BACKGROUND AND PURPOSE: The risk of a stroke after a transient ischemic attack (TIA) is high in the short time following a TIA. The German Stroke Society recommends an early hospitalization of patients with TIA preferably in a stroke unit (SU). This study aims to compare the impact of SU care with conventional care (CC) in patients with TIA. METHODS: In a prospective study, during a 36-month phase (starting November 2007), patients with TIA who were admitted to the hospital within 48 h of symptom onset were enrolled. Stroke rate during hospitalization and the 90-day rates of stroke and mortality were studied. Logistic regression analyses were used to estimate the odds ratio (OR). RESULTS: Of 2,200 patients (mean age, 17.6 ± 12 years, 49% female), 1,347 (61%) treated in a SU and 853 (39%) received CC at general departments. Patients treated in SU were significantly younger than those received a CC (69.9 vs. 71.7 years; P = 0.001). TIA patients treated on SU received more ultrasound investigations of the neck arteries (98 vs. 96%; P = 0.003) and of the brain arteries (97 vs. 82%; P < 0.001) than those of CC. The primary outcomes (stroke during hospitalization, stroke after 90 days, and mortality after 90 days) did not show a difference between the SU and CC groups. In patients of male sex, the 90-day stroke rate was significantly lower in the SU group than the CC group (1.8 vs. 4.5%; P = 0.033). Using the adjusted logistic regression analysis, treatment in a SU revealed a reduction of 90-day stroke rate in patients of male sex (OR 0.38; 95% CI 0.15-0.95; P = 0.04). CONCLUSION: The impact of evaluation and treatment of patients with TIA in SU and CC appears to differ only among patients of male sex. Further randomized trials are necessary.

Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study.

INTRODUCTION: Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age. METHODS: Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models. RESULTS: In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010). CONCLUSION: We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

[The need for rehabilitation services: concept and data]. / Bedarf an rehabilitativen Leistungen: Theorie und Empirie.

Whether rehabilitation services are initiated, applied for and (granted by German statutory pension funds) according to objectifyable need is uncertain as long as we lack a scientifically valid and operationally defined concept of "rehabilitation need". Traditionally three criteria are mentioned: neediness, ability, and prognosis. The text extends and specifies these criteria based on theoretical grounds, research evidence, and sociolegal considerations. It introduces a screening algorithm to objectify and assess individual rehabilitation needs focusing, as far as they are risk factors for participation restrictions, on a central disorder and its complications, risk and prognostic factors, comorbidities, motivational and other context factors. It proposes to relate more or less complex disturbances of functional health to more or less complex rehabilitation programmes and to indicate the typically complex ("holistic") in-patient rehabilitation only for equally complex health impairments and participation restrictions. Illustrative empirical data relate to three disorders, diabetes mellitus type 2, chronic disabling back pain, and chronic obstructive lung disease.

[Missing data in the somatisation subscale of the scl-90-R due to a 'checklist effect': occurrence in different surveys and results of various imputation methods]. / Fehlende Werte in der Somatisierungsskala des SCL-90-R durch "Listenfragen-Effekt": Häufigkeit in verschiedenen Surveys und Vergleich unterschiedlicher Imputationsmethoden.

Item non-response is a potential threat to the validity of study results. Taking the somatisation subscale of the SCL-90-R as an example, we hypothesise a specific response pattern ("checklist-effect") that is characterised by symptom-free persons not checking the "not at all"-category. The present study analyses the extent and relevance of this postulated "checklist-effect". Our data is derived from a survey of n = 228 blue-collar workers who previously had filed applications for medical rehabilitation benefits (A1-study), and two additional surveys as well. We defined the "checklist-effect" by the following response pattern: (1) at least one missing value and (2) at least one valid item response and (3) no "not at all"-responses. Occurrence of the "checklist-effect" in the three datasets differed widely. 75 % of the responders in the A1-Study had complete data, 16.2 % a postulated "checklist-effect". Imputation of missing values under the assumption of a "checklist-effect" led to a reduction of missing data in the somatisation-subscale from 12.3 % to 0.4 %. Ignoring the "checklist-effect" would overestimate the symptom level. Possible explanations for the effect are discussed. However, the validity of this effect has yet to be proven via methodological studies.

[Theories and models of chronicity: on the way to a broader definition of chronic back pain]. / Theorien und Modelle der Chronifizierung: Auf dem Weg zu einer erweiterten Definition chronischer Rückenschmerzen.

Chronic back pain is one of the most common and costly disorders. An overview shows that chronicity has various definitions, of which purely temporal ones predominate. Back pain is said to be "chronic" if it lasts for a variable number of weeks or months. Our attempt to refine such definitions is based on three previous works: Loeser's multidimensional pain model, the oncological TNM model and the International Classification of Functioning, Disability and Health of WHO (ICF). We suggest an unidirectional process of pain in the back to a complex pain syndrome including other types of pain, various bodily complaints and cognitive as well as emotional impairments, and propose an empirically testable research model.

[Accompanying research of the major project of public health offices--AIDS: the status and future prospects]. / Begleitforschung zum Grossmodell Gesundheitsämter--AIDS: Stand und Ausblick.

The "Model project 'Public Health Departments' ", part of the West German government's AIDS Action Programme, supports the employment of an AIDS counsellor in every local public health department. The Institute for Health Systems Research Kiel designed a reporting system for the model project. After reaching an agreement with the State Authorities and the Federal Ministry of Youth, Family, Women and Health, the reporting system was implemented. The purpose of the reporting system is to provide a comprehensive survey of the model process. The reporting system will be supplemented by further surveys. The evaluation of the programme elements will focus on the conceptual goals of the model project.

[Chronic back pain: more than pain in the back. Findings of a regional survey among insurees of a workers pension insurance fund]. / Chronische Rückenschmerzen: Mehr als Schmerzen im Rücken. Ergebnisse eines regionalen Surveys unter Versicherten einer Landesversicherungsanstalt.

BACKGROUND: Surveys with a main focus on back pain tend to isolate the complaint from possibly concomitant pains, other symptoms and disorders. Severe chronic back pain is assumed here to imply more than pain in the back. PARTICIPANTS AND METHODS: We report results from a two stage survey conducted in 1998 - 2000. The initial postal questionnaire addressed all 10,000 actively employed blue collar workers from a regional pension fund (Landesversicherungsanstalt Schleswig-Holstein) aged 40 - 54 and residing in or around Luebeck/Germany (68 % males). Subjects reporting severe and disabling back pain were invited to a socio-medical examination. The response and participation rates were 58 % and 65 % respectively. Non-response and non-participation seem to result in minor though opposite, effects. RESULTS: The prevalence of current back pain (back pain of any severity within the past 7 days) is high (68 %; including 16 % with severe, disabling back pain) despite the preponderance of males and a probable healthy worker effect. 82 % of subjects participating in the second round reported recurrent or persisting back pain on the day of examination, in the majority with a chronic fluctuating and overall deteriorating course pattern. 18 % reported no current back pain and hence gave prospective (and additionally retrospective) evidence of an episodic-intermittent course of the disorder. The former group showed significantly more pains, bodily complaints, dysfunctional cognitions, emotional distress and concomitant disorders. 35 % of them indicated back pain as their dominant health problem; 49 % identified back pain and another disorder as dominant, and 16 % reported other prominent health problems. More than 70 % of "other" disorders originated from the musculoskeletal system often involving the extremities. SUMMARY AND CONCLUSION: Back pain is very common among blue collar workers. Severe disabling back pain is usually associated with numerous other pains, bodily complaints, disorders, and indicators of psychological distress ("amplified back pain"). However, even amplified back pain is not always the sole or dominant health problem. Assessing the degree of "amplification" seems helpful in splitting a previously homogeneous group of severely affected back pain sufferers-with possible prognostic and therapeutic consequences.

[Determining the need for medical rehabilitation services of employed members of the legal pension fund. A recommendation from social medicine and social legal viewpoints]. / Zur Feststellung von Bedarf an medizinischen Rehabilitationsleistungen unter erwerbstätigen Mitgliedern der Gesetzlichen Rentenversicherung. Ein Vorschlag aus sozialmedizinischer und sozialrechtlicher Sicht.

Assessing health care needs in populations has become a major activity of public health medicine worldwide. Its methodology has been developing mainly in the English-speaking world. Concept, methods, and techniques have not yet reached Germany though recently the national expert advisory council for the concerted action in health care (Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen) provided first "official" definitions of demand, supply, and need to identify over- and undersupply in health care. This article aims at defining, from a combined sociolegal and sociomedical perspective, the need for medical rehabilitation measures among insurees of German pension funds. According to section 15 SGB VI rehabilitation is conceived as a medically coordinated multimodal-multidisciplinary intervention with a cognitive-behavioural orientation. To objectify the need for rehabilitation a series of 9 questions was developed enquiring inter alia about the presence of a disease or disability, the extent or "amplification" of the disorder, its course pattern, the implied risk of permanent work disability and likely success of rehabilitation. Nonspecific back pain served as a paradigmatic condition. One of the main problems encountered is the presently small evidence base to arrive at the necessary prognostic and therapeutic judgements.