Quality of patch testing patient's own material in patients with suspected occupational skin diseases throughout Germany: Interim results of the German Social Accident Insurance (DGUV) research project FB 317b.

BACKGROUND: Due to limited availability of commercial test preparations, patch testing patient's own material (POM) is of great importance to diagnose occupational allergic contact dermatitis. OBJECTIVES: To assess the quality of performance and documentation of patch testing with POM in patients with suspected occupational skin diseases (OSD) in Germany. METHODS: Retrospective-prospective analysis of protocols of patch tests with POM was conducted between 2013 and 2021 in patients with suspected OSD and submitted to statutory accident insurance institutions. Assessments were done by predefined criteria. RESULTS: Three thousand and four patch tests with POM from 460 patients were included. A full description of the POM was provided in 73.3% of all tests. The test concentration, test vehicle and pH value were documented in 74.3%, 70.5% and 42.2% of tests, for which the respective parameters were considered relevant. One hundred and sixty-one positive reactions to POM were documented. In 72%, sufficient patch testing with commercial test substances was conducted to investigate the positive reaction. In 30.4%, consecutive patch testing of all ingredients of the POM was done. CONCLUSIONS: The results not only show considerable shortcomings mainly in documentation but also to some extent performance of patch tests with POM in patients with suspected OSD in Germany.

[The Significance of Chronic Fatigue in the Post-Covid Consultation and its Consequences for Outpatient Rehabilitation in the Context of Statutory Accident Insurance]. / Die Bedeutung der Chronischen Fatigue in der Post-COVID-Sprechstunde und ihre Konsequenzen für die ambulante Rehabilitation im Kontext der gesetzlichen Unfallversicherung.

OBJECTIVE: The post-COVID consultation (PCC) is offered as part of a comprehensive range of treatment services provided by the statutory accident insurance for post-COVID patients to determine individual recommendations for further care. The aim of the study was to record the main symptoms and the associated restrictions on social and occupational participation in order to derive consequences for outpatient rehabilitation. METHOD: In addition to a medical examination and a psychological consil, numerous assessments were carried out to evaluate the biopsychosocial state of health. 373 female (82.2%) and 81 male patients aged between 40 and 60 years from the professions of health and care services, education and pedagogy participated in the PCC since April 2021. RESULTS: Nearly all patients (98.2%) reported fatigue as a cardinal symptom of their post-COVID complaints, in combination with subjectively experienced limitations in brain functioning in over 73% of cases. The duration of the symptomatology persisted for an average of 14-15 months in both female and male insured persons. Thus, over 85% of the total sample can be classified as cases of chronic fatigue (Fatigue Scale). The severity of fatigue also proportionally affects quality of life (SF-36), feelings of anxiety and depression (HADS), psychological resilience (RS-13), and motor parameters such as maximum grip strength and endurance capacity. 54.3% of the patients also received a suspected mental diagnosis and 38.1% a recommendation for further neuropsychological diagnostics. CONCLUSION: For further treatment of the leading symptom of chronic fatigue, a multimodal and interdisciplinary outpatient rehabilitation is recommended, which should be oriented towards the treatment of the diagnosis of chronic fatigue syndrome (ME/CFS) and thus in particular towards a psychoeducational and rather than a curative therapeutic approach, and should consider aftercare strategies. Confirmed mental disorders and neuropsychological deficits are to be treated in addition.

[Inpatient and Outpatient Treatment in the German Social Accident Insurance]. / Stationäre und ambulante Heilverfahren der Deutschen Gesetzlichen Unfallversicherung.

It is one objective of German Social Accident Insurance (DGUV) to restore the health and performance of insured persons after an accident "using all appropriate methods". Because of the legal requirements, possible rehabilitation may greatly differ from that provided by sickness or pension insurance. This article provides an overview of the available treatments after accidents at work and the rehabilitation phase in which they may be used.

[Reduction in Earning Capacity (MdE) Statutory Accident Insurance]. / Minderung der Erwerbsfähigkeit (MdE) in der gesetzlichen Unfallversicherung.

Changes in the employment market and improvements in the current prosthetic treatment have encouraged German Statutory Health Insurance e. V. (DGUV) to re-examine the standard values for reduced earning capacity after work related accidents. The new standard values for reduced earning capacity came into force on 01.11.2019. The present article summarises the consensus paper of the group of independent experts.

[New assessment recommendations for disability in private accident insurance, part 1 : An interdisciplinary consented approach-Basics]. / Neue Bemessungsempfehlungen zur Invalidität in der PUV, Teil 1 : Ein fachübergreifend konsentierter Ansatz ­ Grundlagen.

The centerpiece of a private accident insurer is the benefit promise in cases of disability, which must be determined by a doctor in due time. The insurer specifies the rates of the compensation scheme for loss or inability to function and the medical expert must then fall back on generally recognized, revised or updated assessment recommendations in order to be able to apply the given framework to the specific, individual situation of the insured person. In four steps (basics, upper and lower extremities [disability within the compensation scheme] and disability outside the compensation scheme) interdisciplinary consensus benchmarks for disability assessment are presented, which should form the basis of a uniform medical assessment of accident-related functional disorders in private accident insurance compensation.

[Assessment of traumatic hearing loss]. / Begutachtung von traumatischen Gehörschäden.

Expert assessment of traumatic damage in the head and neck area by the adjuster broadly comprises two main questions: does a causal relationship between the complaint and the specific insured event exist, and what is the extent of the damage? A relationship is probable if the trauma is quantitively and qualitatively suitable to have caused the existent damage. A particularly difficult scenario is represented by cases lacking pre-accident findings or when the claimant claims that pre-existing hearing loss or tinnitus has been worsened by the event or that the accident was the cause of the impairment. It must also be taken into account that claimants frequently relate their complaints to an insured event due to causal thinking. Comprehensive tables are available for evaluation of the extent of the damage in otorhinolaryngology. In statutory accident insurance, the health damage is "considerable" if it leads to a reduced earning capacity of at least 10%. In private accident insurance, physical damage is financially regulated at below 10% invalidity, e.g., 2-3%, although this is hardly possible to calculate using conventional tables. These and other difficulties are discussed in the article based on examples.

[Video Consultation Hours in the Statutory Accident Insurance - Application Possibilities and Economic Evaluation]. / Videosprechstunden im berufsgenossenschaftlichen Heilverfahren ­ Anwendungsmöglichkeiten und ökonomische Evaluation.

OBJECTIVES: Video consultations are becoming more and more important for health care providers as they enable new treatment options. Since 2017 video consultations have been used by the public health insurance companies in Germany. However, similar options are lacking in the employer's liability insurance association (BG in Germany) health insurance system. The aim of this article is to present and discuss possible applications of video consultations in the latter system and to evaluate economic advantages. METHODS: Possible applications of video consultations are discussed in the context of feasibility, potential benefits and the existing scale of fees for physicians (in Germany UV-GOÄ). RESULTS: Video consultations can be used for follow-up evaluations as well as preparation for initial medical examinations especially in complex cases and for case conferences. Even though video consultations are not included in the reimbursement system, similar CPT codes (current procedural terminology) already do exist. CONCLUSIONS: Video consultations might help improve the quality and reduce the costs of the public health insurance system. Furthermore, since video consultations can be expected to become more important in the future, they should be included as a standard tool in the employer's liability insurance association insurance system and an adequate reimbursement system be established.

[Evaluation of medical insurance consultant reports within the German Statutory Accident Insurance-Methodology and results of a peer review procedure]. / Evaluation der Durchgangsarztberichte in der Deutschen Gesetzlichen Unfallversicherung ­ Methodik und Ergebnisse eines Peer-Review-Verfahrens.

BACKGROUND: Accident insurance consultants (D-physicians) are qualified specialists with particular expertise in occupational medicine. Within the medical treatment procedure of the German Statutory Accident Insurance (DGUV), D­physicians must make a report on the medical care after occupational accidents. This nationwide evaluation aimed to systematically measure the quality of documentation of these medical reports. Peer review is a common method to ensure process quality. MATERIAL AND METHODS: For each included D­physician 30 reports of more severe cases from 2017 were randomly selected. The reports were anonymized and randomly assigned to a peer reviewer. Peer reviewers used a web-based checklist with nine rating categories and dichotomous response format (deficiency/no deficiency). To evaluate overall quality each report was rated with an overall grade from 1 (very good) to 6 (insufficient). RESULTS: A total of 30,384 reports were evaluated by 82 peer reviewers. One third of the reports contained no deficiencies. Most deficiencies were found in the category on information about the accident. The mean overall grade for each D­physician was 2.6 and ranged from 1.5 (best) to 4.1 (worst). All evaluated D­physicians were given an individual quality report which described the main findings. CONCLUSION: The first nationwide peer review of the DGUV proved to be a practical and valid quality assurance procedure to evaluate the medical reports of D­physicians. The quality of the reports was in general good. The DGUV plans to repeat the peer review process taking further groups of D­physicians into consideration.

[Investigation of the reduction in the disability after fractures in children and adolescents]. / Ermittlung der Minderung der Erwerbsfähigkeit nach Frakturen bei Kindern und Jugendlichen.

The student accident insurance has been part of the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV) for 50 years. In order to assess the reduction in working capacity (Minderung der Erwerbsfähigkeit, MdE) in the event of permanent consequences of accidents and injuries, the recommendation to treat the affected child or adolescent "as an average adult" is currently still valid. The present work deals with the everyday practice of the MdE assessment in children and adolescents and their weaknesses through the transfer of the principles from adulthood. In addition, proposals for the adaptation of the assessment principles for the growth age are drawn up.

[Medical assessment in the field of Social Act VII: pre-existing damage and causality of apophyseal injuries and detachments]. / Begutachtung im Bereich des SGB VII: Vorschaden und Kausalität bei apophysären Verletzungen und Lösungen.

The medical assessment of affections of the apophyses frequently presents the assessor with problems in causality testing and estimation of functional impairment. Apophyses are the insertion of tendons and are therefore at the center of an acting parallelogram of forces. They fuse via an apophyseal plate in the second decade of life. Depending on the age there is a reduced mechanical load-bearing capacity of the apophyseal plates in the last 1-2 years before complete mineralization of the joint. Two types of injury must be distinguished in an expert opinion: apophyseal detachment as a result of repetitive microtrauma in the event of chronic overload and apophyseal avulsion fracture as an acute injury due to sudden maximum muscle tension. While chronic overload leads to exclusion from insurance cover by the statutory accident insurance, apophyseal avulsion fractures fulfil the necessary requirements for acceptance as an insurance case. The apophyseal avulsion fracture is subject to a time-limited force, which directly leads to damage to health and avulsion of the tibial tuberosity including its tension system. The sudden jerky maximum muscle pull leads to an overload of the tension system and avulsion of the apophysis in cases of an age-related vulnerable apophyseal plate. Once the mineralization is complete, this type of fracture no longer occurs. Osgood-Schlatter disease, an insertion tendinosis of the patellar tendon, occurs in around 20% of all sport-active adolescents but it is questionable whether it can be associated with the acute avulsion fracture. Knowledge of the pathogenesis of affections and injuries of the apophysis can provide the assessor with good foundations for the estimation of a causal association.

[Assessing ear noise in expert opinion: Possibility, plausibility and probability]. / Ohrgeräusche zutreffend begutachten: Möglichkeit, Plausibilität und Wahrscheinlichkeit.

Tinnitus as a subjective, individual sensation defies objective proof. In the assessment situation, tinnitus must also be distinguished from physiological or spontaneous hearing sensations.With regard to the new German "Königsteiner Recommendation" and the verdicts of the last few years, against the background of the different concepts of causality in the statutory and private accident insurance, a stringent examination to determine whether there is a sufficiently high probability of an accident-related subjective ear noise is necessary in the assessment. In order to create a comprehensible and comparable basis, the proposal of a plausibility check with the recording of 5 criteria - appropriate event, immediacy, reproducibility on the basis of today's examination methods of tinnitus masking and matching, persistence and fixation and the recording with a non-suggestive question was subjected to a review.The review shows that the requirements for the respective standard of proof can be fulfilled with the given steps of proof. The simple possibility of the presence of ringing in the ears can be systematically led to the probability of the presence by means of the plausibility criteria, which include psychoacoustic procedures, as well as open questions. This creates the prerequisites for a comprehensible causal consideration between the event and the reported tinnitus according to current medical-scientific knowledge.

[Joint arthrodesis in functionally favorable position : Considerations on measurement of disability in private accident insurance]. / Gelenkversteifung in gebrauchsgünstiger Stellung : Überlegungen zur Invaliditätsbemessung in der privaten Unfallversicherung.

If an accident results in a functional disorder that persists and permanently restricts physical and/or mental capacity, this is referred to as a disability. In private accident insurance it is the task of the medical expert to assess this disability by examining the medical findings and produce an assessment taking account of the literature and comparing against generally acknowledged guidance values. The priority dismemberment disability rating schedule initially provides loss values. For the "next lowest" disability levels for arthrodesis of extremity joints, the assessment recommendations are based on a functionally favorable position although this functionally favorable position is not more precisely defined.In this article the authors have defined these functionally favorable positions based on the information available in the literature. In particular, the operatively favorable settings for arthrodesis of the affected joint that are stated in the literature on trauma and orthopedic surgery were consulted. Of course, the functional perspective has been especially emphasized.A difficulty in achieving this was that the literature on arthrodesis is now almost only of historical value due to modern endoprosthetics. The knowledge gained was checked against medical experience and is expounded here.

[Effects of the new injury type catalogue of the German statutory accident insurance on a center for severe injury type procedures]. / Auswirkungen des neuen Verletzungsartenverzeichnisses der DGUV auf ein SAV-Zentrum.

The development of the numbers of cases involved in accident insurance consultant procedures (DAV), injury type procedures (VAV) and severe injury type procedures (SAV) after the introduction of the new injury type catalogue from 1 July 2018 is presented. Furthermore, possible alterations to organizational aspects, such as operating room times and average duration of hospitalization are presented. A first critical assessment of the modifications in the new catalogue was carried out, particularly with reference to the newly introduced section on complications (section 11). METHODS: A retrospective study of all inpatients treated in the context of the DAV, VAV and SAV procedures at a SAV center from the 2nd and 3rd quarters of 2018 was carried out. The development of the number of cases, the case mix index (CMI), the mean number of operations, the mean time in the operating room and the length of hospitalization were analyzed. Furthermore, an assessment of the SAV cases was carried out with respect to the new developments and with particularly reference to complications. RESULTS: The total number of inpatients in the context of the DAV, VAV, SAV procedures changed only slightly. There was a clear decrease in DAV cases and a relevant increase in SAV cases. The CMI increased by 47%, the number of surgical procedures by 15%, the mean time in the operating room by 36% and the length of hospitalization by 43%. When converted to a daily operating room unit of 7 h (Tagestischeinheit, TTE) the operating room time increased from 89 to 108 TTE and the length of hospitalization increased from 1028 to 1358 days. Of the 111 SAV cases in the 3rd quarter, 52% were assigned to the catalogue number 11 "complications". In comparison to the previous version of the VAV/SAV catalogue, it was now possible to assign all inpatients to a single category. CONCLUSION: The modifications of the VAV in the observational period led to an enormous increase in SAV cases. It remains to be seen whether this development is confirmed in subsequent quarters. The increase in CMI, the number of necessary operations, operating room times and duration of hospitalization showed the necessity of these innovations on structural changes of hospitals involved in the treatment of SAV cases.

[The ophthalmological expert opinion in different fields of law]. / Das augenärztliche Gutachten in unterschiedlichen Rechtsgebieten.

The ophthalmological appraisal differs significantly in the different areas of law, so there are some different causalities and standards of proof and, above all, the assessment is very different. For the three important sub-areas of private accident insurance, statutory accident insurance as well as disability law and social compensation law, there are abstract tabular guidelines which form the essential basis for a comparable and thus fair assessment. The basics of the assessment in these fields of law are presented in a comparative way, with particular emphasis on causality.

Contextual Assessment of Retinal Injuries - Tasks of the Ophthalmological Expert. / Zusammenhangsgutachten bei Verletzungen der Netzhaut ­ Aufgaben des augenärztlichen Sachverständigen.

The ophthalmologic assessment of causal relationships is subject to formal guidelines, depending on the legal field (social law in the statutory accident insurance, civil law in the private accident insurance). After determining all objective and subjective findings of the individual case with complete recording of the medical facts, the ophthalmologist has the task of making a summarizing assessment of the existing cause-and-effect relationship. With regard to the distinction between retinal damage caused by an accident or retinal disease not caused by an accident, it is necessary to weigh up the natural causality according to the state of medical experience on the basis of the criteria strength of association, consistency, specificity, temporal sequence, dose dependence, agreement with previous findings, experimental reliability and analogous consideration. All records of medical findings from the patient's medical history and the individual description of the accident must be included in the expert opinion. In the case of several competing causes (often accident and pre-existing damage), the social law in the statutory accident insurance must present the causal contributions with roughly estimated probabilities. In civil law, valid for the private accident insurance, the existence of partial causality (approx. 25, 50, 75%) must be evaluated.

Self-inflicted long bone fractures for insurance fraud.

Self-inflicted fractures simulating traffic accident represent a new social fraud opportunity for criminality. Recognising scams through an increase of awareness of existence of self-inflicted arm fractures for insurance fraud could help community health workers to report these injuries to the competent authorities. In this article, authors have recognised an unusual but consistent pattern of upper and lower limb fractures whose incidence does not coincide in numerical terms with what is reported in literature. The aim of the present study is to describe fracture patterns observed over the past 2 years. Further, authors describe clinical presentations of these fractures and attempt to define a possible mechanism of these types of injuries.

Direct Health Care Cost and Work Incapacity Related to Complex Regional Pain Syndrome in Switzerland: A Retrospective Analysis from 2008 to 2015.

OBJECTIVE: First, to determine the number of accident-related complex regional pain syndrome (CRPS) cases from 2008 to 2015 and to identify factors associated with an increased risk for developing CRPS. Second, to analyze the duration of work incapacity and direct health care costs over follow-up periods of two and five years, respectively. DESIGN: Retrospective data analysis. SETTING: Database from the Statistical Service for the Swiss National Accident Insurances covering all accidents insured under the compulsory Swiss Accident Insurance Law. SUBJECTS: Subjects were registered after an accident between 2008 and 2015. METHODS: Cases were retrospectively retrieved from the Statistical Service for the Swiss National Accident Insurances. Cases were identified using the appropriate International Classification of Diseases, 10th Revision, codes. RESULTS: CRPS accounted for 0.15% of all accident cases. Age, female gender (odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.47-1.60), and fracture of the forearm (OR = 38, 95% CI = 35-42) were related to an increased risk of developing CRPS. Over five years, one CRPS case accumulated average insurance costs of $86,900 USD and treatment costs of $23,300 USD. Insurance costs were 19 times and treatment costs 13 times the average costs of accidents without CPRS. Within the first two years after the accident, the number of days lost at work was 20 times higher in patients with CRPS (330 ± 7 days) than in patients without CRPS (16.1 ± 0.1 days). Two-thirds of all CRPS cases developed long-term work incapacity of more than 90 days. CONCLUSION: CRPS is a relatively rare condition but is associated with high direct health care costs and work incapacity.

[Involvement of nonaccident-related diseases and ailments in assessments for private accident insurance : A problem discussion and assistance]. / Mitwirkung unfallfremder Krankheiten und Gebrechen in der Begutachtung für die private Unfallversicherung : Eine Problemdiskussion und Hilfestellung.

With the clarification by the Federal Court of Justice, the distinction between the principle of equivalence and the principle of adequacy for assessment has again come to the fore. In contrast to the equivalence principle for assessments in the German statutory accident insurance (DGUV), the principle of adequacy applies in private accident insurance. This means that an accident is always present whenever it does not lie completely outside the probability and the assessor has to carry out a further examination of the liability-based causality. Therefore, not only the accident occurrence has to be assessed but also the observance of the deadlines and, in the case of affirmation of the occurrence of a disability, whether or not unrelated ailments or diseases contributed to the accident. There are so far no points of reference for the estimation of participation. With the help of the theory of equivalence from linguistics, an attempt was made to provide assistance through definitions of the extent of participation.

To What Extent Are Main Accident-Insurer Cases Representative of All Significantly Injured? A Swiss Monocenter Perspective.

Background and Objectives.-Even though Switzerland has a compulsory insurance system, there is a lack of detailed information on the treatment and outcome following trauma. The objective of this evaluation was to examine to what extent cases insured by the largest accident-insurer (Suva) are representative of all significantly injured. Methods.-Trauma center analysis of all ≥16 year old trauma patients with a New Injury Severity Score (NISS) ≥8, comparing the characteristics of Suva- vs non-Suva cases (chi-square; univariate explained variance R2; multivariate logistic regression analysis, Nagelkerke R2). Results.-Over 7 years, 2233 trauma patients were treated at the hospital, of whom 29.4% were Suva-insured. Compared to non-Suva-insured, Suva cases were younger (41.6 vs 64.2, R2 = 0.23) and more often male (88.0% vs 59.4%; R2 = 0.08). In multivariate analysis, these two factors together explained 37.5% of the differences between groups. No other investigated factor explained more than 2%. If only those patients of obligatory working age were analyzed (n = 1264), Suva cases (50.6%) were more often male than non-Suva-insured (n = 562 [87.8%] vs n = 393 [63.0%], resp.; p<0.001, R2 = 0.08). In multivariate analysis, other factors taken together were only 2.6% of the variance. Conclusions.-Significantly injured patients in Switzerland may be considered comparable from a statistical point of view whether insured by the main accident-insurer or not, provided groups are adequately controlled for age and gender. Other differences appear to be only marginal. Respecting these limitations such data can justifiably be given as Swiss reference statistics and the relevant insurer outcome information used for international comparison.

[Telephone-Based Psychological Counselling of Accident Victims: Initial Evaluation of a Pilot Project of the German Statutory Accident Insurance in the Healthcare and Welfare Services]. / Pilotprojekt "Telefonisch-psychologische Beratung Unfallverletzter" der Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege ­ Wie wird das Angebot bewertet?

A telephone-based psychological counselling service was implemented and evaluated in four regional offices of the German statutory accident insurance in healthcare and welfare services (BGW). Insurance employees/caseworkers, psychotherapists, and insured persons were asked to rate the counselling service in terms of their experiences and satisfaction. 15.5% of all insured persons initially contacted made use of the counselling service. Those using the service reported a slightly higher level of psychological distress, were less likely to be able to work 3 months after using the service and were more likely to attend a subsequent psychotherapy session. Telephone-based counselling by psychotherapists was rated as helpful by most insured persons. Caseworkers and psychotherapists also rated the concept favorably. All in all, the implementation can be regarded as successful. In a next step, the approach should be evaluated regarding its efficacy in a randomized, controlled trial.