[Work place health promotion programmes of the statutory German Pension Insurance]. / Betriebsnahe Präventionsprogramme der Deutschen Rentenversicherung.

BACKGROUND: In 2009, the amendment of § 31 Abs. 1 Nr. 2 SGB VI gave the German Pension Insurance the opportunity to provide outpatient medical treatments for insured people who have an occupation with particularly high risk of health. Ever since, the German Pension Insurance has developed various work place prevention programmes, which have been implemented as pilot projects. This article aims at systematically recording and comparatively analyzing these programmes in a synopsis which meets the current state of knowledge. METHODS: We developed an 8 page questionnaire focusing on work place prevention programmes by the German Pension Insurance. This questionnaire was sent to people in charge of all programmes known to us. RESULTS: All programmes have been drafted -across indications. They are aiming at insured people who already suffer from first health disorders but who are not in imminent need of rehabilitation. However, the concrete target groups at which the specific programmes are aimed differ (shift workers, nurses, elderly employees). Another difference between the various programmes is the setting (in- or outpatients) as well as the duration. CONCLUSION: All programmes are using existing structures offered by the German Pension Insurance. They provide measures in pension insurance owned rehabilitation centers. It would be desirable to link these performances with internal work place health promotion and offers of other social insurances.

[Restrictions in participation in women with fibromyalgia syndrome. An explorative pilot study]. / Beeinträchtigungen der Teilhabe bei Patientinnen mit Fibromyalgiesyndrom. Eine explorative Pilotstudie.

BACKGROUND: Patients with fibromyalgia syndrome are often severely restricted in their ability to participate in everyday activities and in social interaction. The aim of this study was to document female patients' subjectively-perceived limitations in participation and to develop material to generate items for a specific participation questionnaire. MATERIAL AND METHODS: We collected data from 8 groups of women with fibromyalgia syndrome (n=38), and developed a hierarchical system of categories using the patients' statements (ATLAS.ti; Qualitative Data Analysis). RESULTS: Our final group of categories contains 10 superordinate categories. Women with fibromyalgia syndrome often describe restrictions in their relationships with other people, and the impaired ability to engage in social and leisure activities. They speak of difficulties at the workplace, while doing housework, and complain about a lack of understanding and awareness on the part of the general public. CONCLUSION: Fibromyalgia syndrome patients admit to be extremely impaired in a variety of social roles. Their statements have enabled us to develop a questionnaire that reflects the range of factors restricting participation from the patient's perspective.

[Quality assurance and quality management in medical rehabilitation]. / Qualitätssicherung und Qualitätsmanagement in der medizinischen Rehabilitation.

External quality assurance in medical rehabilitation is characterized by the programs of Germany's two largest providers of rehabilitation (the German pension insurance and the statutory health insurance). The programs were developed with considerable input from scientific institutes. Their strengths lie in measuring several relevant dimensions of quality, the comprehensive implementation for nearly all illnesses treated, integration of the patient perspective, and realization of prospective study designs with follow-up. Weaknesses include low relevance for patient allocation and compensation, the absence of systematic evaluations, and a lack of published patient information on the results of the quality measurements. Internal quality management in medical rehabilitation is regulated by sweeping legal guidelines. Since 2009, a statutory agreement has been in effect which includes a provision that all inpatient rehabilitation centers must be certified by October 2012. Areas for potential improvements in internal quality management processes include an improved theoretical basis, higher specificity for rehabilitation, and a more transparent, methodically improved structure of certification procedures.

[Pay for performance in rehabilitation after stroke - results of a pilot project 2001-2008]. / Ergebnisorientierte Vergütung der Rehabilitation nach Schlaganfall - Entwicklungsschritte eines Modellprojekts 2001-2008.

The project aimed at developing and testing a new payment system which provides financial incentives for rehabilitation centers to achieve the best outcomes possible for their patients but does not create additional costs for the insurance funds. The system is conceived as a "quality competition" organized by the centers among themselves with a scientific institute acting as a "referee". Centers with outcomes above average receive a bonus financed by a corresponding malus from the centers below average. In a stepwise process which started in 2001 and was continually accompanied by a scientific institute, we developed the methodological and organizational prerequisites for the new payment system and tested them in two multicentric studies with large case numbers (n=1,058 and n=700, respectively). As a first step, a new assessment instrument (SINGER) was developed and validated in order to measure the outcomes in a reliable, valid, and change-sensitive way. In the second phase, we developed a regression analytic model which predicted the central outcome variable with >84% variance explained. With this model, the different case-mix in the participating centers can be controlled, so that comparisons of outcomes across centers can take place under fair conditions. In the recently completed third phase, we introduced an internet-based programme SINGER-online into which the centers can enter all relevant data. This programme ensures a high quality of all data and makes comparisons of outcomes across all centers possible at any chosen time. The programme contains a special module accessible to the medical services of the health insurance only, which allows sample checks of the data entered by the clinics and helps to ensure that all centers keep to the principles of a fair competition for better quality for their patients. After successful testing of these elements, a functioning model of pay-for-performance in rehabilitation after stroke is now available.

[Systematic literature analysis on therapies applied in rehabilitation of hip and knee arthroplasty: methods, results and challenges]. / Systematische Literaturanalyse zu Therapien in der Rehabilitation nach Hüft- und Kniegelenks-Total-Endoprothesen: Methoden, Ergebnisse und Herausforderungen.

Evidence-based medicine is a central issue in medical practice. This also applies to rehabilitation services. The German Statutory Pension Insurance meets this need in its guideline programme. Amongst others a guideline for rehabilitation following hip or knee arthroplasty is currently being developed. In this context a hierarchic, systematic literature analysis was conducted summarising the current state of evidence with reference to the effects and the treatment requirements (frequency and duration) of different rehabilitative therapies following total hip or knee replacement. In the first step, a search for evidence-based guidelines, systematic reviews and health technology assessments was conducted. Secondly, search strategies for primary literature in the following databases were designed: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and PsychINFO (01/1997-09/2007). Additionally, a handsearch of several German journals not listed in the databases was conducted. Randomized trials were preferred, however, non-randomized trials were included if the intervention and control groups were comparable with regard to the baseline parameters. Results can be classified into three categories: (1) therapies for which evidence for (positive) effects was found, (2) therapies for which evidence was found, however, their transferability onto rehabilitation in Germany should be discussed (e. g., studies on immediate post-surgery interventions), and (3) therapies for which no methodologically appropriate trials could be found. The literature reviewed does not allow for final conclusions as to frequency and duration of different therapeutic interventions within the rehabilitation time frame in Germany (usually the first three weeks post discharge from hospital). Overall, there is a need for further research.

[Burden of illness. First routine report on socio-medical consequences of inflammatory rheumatic disease in Germany]. / Krankheitslast. Erste Routineberichterstattung zu sozialmedizinischen Folgen entzündlich-rheumatischer Erkrankungen in Deutschland.

A synopsis of different socio-medical consequences of inflammatory rheumatic diseases is not yet available for Germany. Therefore, the data reported during the past decade for rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, systemic sclerosis, systemic lupus erythematodes, and Wegener's granulomatosis are summarized in this article. Apart from clinical studies, relevant data sources were the national data base of the German collaborative arthritis centres, statistical figures from the compulsory health insurance and the national pension insurance scheme. Data were mainly available for sick leave and work disability showing limitations, which frequently occurred during the early course of diseases and increased with disease duration. Furthermore, different risk factors were identified. Measures to maintain continued participation in the labour force, such as part-time employment, partial work disability instead of full work disability, were not being adequately utilized. Only few data regarding the need of help and care were available. The proportion of patients in need of help and care increased with the duration of rheumatoid arthritis to more than 50% after more than 2 decades. This review presents detailed information concerning aspects of the burden of rheumatic diseases, which are frequently not adequately taken into account. They may be useful for the advice and care of individual patients as well as for decision processes concerning the health care system.

[Development and psychometric testing of a patient questionnaire for medical rehabilitation (IRES-3)]. / Entwicklung und psychometrische Testung eines Patientenfragebogens für die medizinische Rehabilitation (IRES-3).

BACKGROUND: Re-analyses of extensive datasets as well as theoretical considerations have led to the conclusion that the patient questionnaire "Indicators of Rehabilitation Status" (IRES) should be revised in several respects. The new version IRES-3 was developed on the basis of a theoretical model of rehabilitation following the ICF (International Classification of Functioning, Disability and Health) as well as of elements of the earlier version IRES-2. In addition, we included the results of expert panels on the definition of treatment goals in medical rehabilitation. METHODS: The IRES-3 was tested in 453 patients in rehabilitation clinics of seven diagnostic areas. To compare the IRES-3 with other generic instruments, the SF-36 and the HADS were employed at the same time. For purposes of cross-validation, an external sample could be used. The dimensional structure was tested in confirmatory factor analyses. RESULTS: With rare exceptions, the tests showed good values for item difficulties, ceiling and floor effects, internal consistencies and test-retest-reliability. Convergent validity could be established for the IRES-3 when compared to relevant scales of the SF-36 and the HADS. Indices of sensitivity to change were comparable, if not somewhat superior to the effects on comparable scales of the SF-36. The assessment of the construct validity and the dimensional structure of the questionnaire led to the definition of eight dimensions which can be interpreted as somatic, emotional, functional, occupational, social, pain, coping, as well as health information and behaviour. The dimensional structure of the IRES-3 can be regarded as theoretically meaningful as well as empirically proven. STANDARDIZATION: For purposes of standardization, data were collected on a sample representative of the population aged 30-75 years in Germany. These data allow a norm-oriented interpretation of scales and dimensions of the IRES-3 for patients in rehabilitation. APPLICATION: The questionnaire is ready for application, including a computer programme for data entry and analysis.

[Quality assurance in rehabilitation: where do we stand today?]. / Qualitätssicherung in der Rehabilitation: Wo stehen wir heute?

In the sector of medical rehabilitation in Germany, a quality assurance programme has been established over the last decade. What distinguishes this programme in comparison to other sectors of the health care system is its comprehensive approach (including quality of structures, processes and outcomes), the special attention given to patients' needs, its scientific foundation, and its implementation throughout the sector. Participation in this programme is obligatory for all in-patient rehabilitation facilities. For out-patient rehabilitation, a specific programme is currently being developed. The feedback report to the facilities gives them concrete indications of existing strengths and weaknesses and thus offers them a start for developing their quality by means of internal quality management. The article begins with a presentation of the instruments and procedures applied as well as selected results of the previous surveys in the context of external quality assurance. Subsequently, the most important approaches to internal quality management are explained. The article ends with a description of the strengths and weaknesses of the existing quality assurance programmes and proposes steps to be taken for their further development.

Quality assessment in rehabilitation centres: the indicator system 'Quality Profile'.

PURPOSE: An indicator system for measuring the quality of rehabilitation centres ('Quality Profile' of rehabilitation centres) is presented. The implementation of the concept is explained with the aid of results regarding structural, process and outcome quality in 26 cardiac and orthopaedic rehabilitation centres. METHOD: In each centre, structural, process and outcome quality, including patient and employee satisfaction, are measured. Process quality is determined by means of a peer review procedure that includes examination of 20 randomly selected cases on the basis of discharge reports and therapy plans. The medical outcome is measured by a prospective study with three measurement time points and a sample of approx. N=200 patients per centre. RESULTS: Overall, the level of quality of the medical rehabilitation in the institutions participating in the study must be considered high. However, on almost all quality dimensions, even after a risk adjustment there are clear differences between centres, which point to the usefulness of benchmarking analyses and the need for improvements in quality in some centres. CONCLUSIONS: The indicator system presented is a starting-point for comprehensive, comparative measurement of the quality of in-patient rehabilitation centres that, with regard to its principles, also appears applicable to other areas of health care.

[Evaluating the rehabilitation process by means of peer review: examination of the methods used and findings of the 2000/2001 data collection in the somatic indications]. / Die Bewertung des Rehabilitationsprozesses mittels des Peer-Review-Verfahrens: Methodische Prüfung und Ergebnisse der Erhebungsrunde 2000/2001 in den somatischen Indikationsbereichen.

This paper reports the results of a peer review system that was implemented in the context of the quality assurance programme of the statutory German Pension Insurance scheme. The data reported refer to the 2000/2001 data collection period for medical rehabilitation in the somatic indications. Examination of inter-rater reliability for judgements of individual raters shows satisfactory results only in orthopaedics. In the quality assurance programme, rehabilitation centres are usually evaluated by the mean of 20 rater judgements. The reliability of this aggregated measure is satisfactory in all indications. The results of 561 rehabilitation centres show that those quality criteria are in particular need of improvement that refer to subjective concepts of patients (e. g., subjective theories of illness). Between peer review procedures in 1998 and 1999, the quality scores of rehabilitation centres had improved whereas between 1999 and 2000/2001, no further improvement can be shown. However, those rehabilitation centres with a low quality score in 1999 (lowest quartile of the distribution) underwent a positive development between 1999 and 2000/2001. Reasons for this trend and possibilities for improving interrater reliability of the peer review process as an element of the quality assurance programme of the German Pension Insurance scheme are discussed.

[Initial status of patients and effects of rehabilitation after stroke--analysis of a patients' and a physicians' questionnaire in three neurological rehabilitation centres with a follow-up after 6 months]. / Eingangsbelastung der Patient(inn)en und Ergebnisqualität der Rehabilitation nach Schlaganfall--Resultate einer arztseitigen und patientenseitigen Untersuchung in drei neurologischen Kliniken mit Follow-up nach 6 Monaten.

Rehabilitation after stroke has to face specific problems when treating patients with more or less severe disabilities in cognition and communication. Correspondingly, stroke rehabilitation takes a special position within the larger field of rehabilitation, and relatively little is known outside the neurological scientific community about the status of patients at admission, the case mix in the centres and the short- and medium-term effects of rehabilitation. The present study describes in some detail the initial status in unselected samples of consecutive patients (n = 768) from three neurological rehabilitation centres. The description shows a very inconsistent picture in all centres, ranging from patients with no neurological deficits to patients needing intensive care. Across the centres, we found remarkable differences in case mix. In order to measure the effects of rehabilitation after stroke, an instrument was developed that combines a physicians' questionnaire aiming at an assessment of the severely disabled cases with a patients' questionnaire for the less severe cases for which the physicians' questionnaire would show "ceiling effects" so that improvements could no longer be depicted. The application of the instrument showed that about 50 % of the sample were not capable of answering the patients' questionnaire. For the patients with neurological deficits, the functional parameters of the physicians' questionnaire showed significant improvements at discharge that can be interpreted as "strong" effects (effect sizes 1.0-1.3). For the patients with less severe deficits (and usually in later stages of the rehabilitation process), the patients' questionnaire showed "strong" improvements on the somatic and psychosocial scales both at discharge and 6 months later. On the functional scales, however, only small improvements were found. Finally, predictors could be identified that explain a large amount of the variance for length of stay (R(2) =.42) as well as for the effects of rehabilitation (R(2) =.74). When comparing effects across rehabilitation units with differences of case mix, these predictors should be statistically controlled in order to assure fair comparisons.

[Development of a guideline for rehabilitation of patients with low back pain-- phase 2: analysis of data of the classification of therapeutic procedures]. / Leitlinienentwicklung in der Rehabilitation bei Rückenschmerzpatienten--Phase 2: Ergebnisse einer Analyse von KTL-Daten.

Initiated by the Federal Insurance Institute for Salaried Employees (BfA, Bundesversicherungsanstalt für Angestellte), the project is aimed at developing an evidence-based guideline for rehabilitation of patients with low back pain (LBP). Guideline development will be based on a systematic review of the literature, an analysis of the treatment procedures currently employed in rehabilitation, inclusion of the patients' perspectives as well as consultation of experts' panels of clinically experienced physicians and therapists. Formulation of the guideline will then be carried out in a structured consensus building process. This article is focused on analysing the present situation with regard to the treatments received by patients insured by the BfA, using data from routine documentation according to the Classification of Therapeutic Procedures (KTL, Klassifikation Therapeutischer Leistungen). The analysis is intended to provide indications of a basic need to implement a common guideline as well as, simultaneously, to explore possible deficits in present treatment practices, hence to define priorities requiring special attention in the framework of guideline development. As a result of a systematic literature review, the KTL-defined therapeutic procedures that had emerged as relevant in the rehabilitation of LBP patients were aggregated into so-called therapeutic modules which then formed the basis of the analysis. In all, more than 46,000 KTL-data of 2438 patients with a diagnosis of "low back pain" (M54.5 ICD-10) were included. In the rehab centres investigated, rehabilitation of patients with LBP follows a multidimensional, multiprofessional therapeutic strategy. More than 90 % of all patients receive treatments from the modules "medical training therapy", "health education", "physiotherapy", and "physical therapy". Treatments provided to a majority of the patients are massage (78 %), electrotherapy (67 %) as well as psychotherapy (68 %). Women more frequently than men receive therapies belonging to the "psychological treatments" and "occupational therapies" modules; younger patients receive more of the "training therapies", and more often. When treatments are compared across centres, a large variability in the therapeutic procedures provided becomes apparent. This high degree of variability suggests that development and implementation of a common clinical practice guideline for rehabilitation of patients with chronic low back pain should receive priority attention.

[Knowledge management in rehabilitation--proposal for a systematic development of clinical practice guidelines]. / Wissensmanagement in der Rehabilitation - Vorschlag zu einer systematischen Entwicklung von Leitlinien.

In the past ten years, the German pension scheme has launched several initiatives that can be regarded as milestones on the way to a scientifically founded rehabilitation system. These initiatives were: the Rehab Commission (1989 - 1991), the Quality Assurance Programme (since 1994), and the German Research Funding Programme "Rehabilitation Sciences" (in cooperation with the Federal Ministry for Education and Research, since 1996). As a next step on this way, we propose an initiative aiming at a systematic development and implementation of clinical practice guidelines for the main diagnostic groups in rehabilitation. Guidelines for diagnostic and therapeutic decisions are an instrument to sift through the abundance of fast changing knowledge in medicine, to assess the existing knowledge according to its scientific evidence, and to transform it into recommendations for clinical practice. In rehabilitation, guidelines seem to be particularly needed because specialized knowledge is mostly disseminated through an informal "training on the job". Our proposal intends to establish a reference centre for each of the main indications (cardiology, musculoskeletal diseases, etc.). These centres should cooperate with experts from clinical practice and research, as well as with representatives of the cost-carrying agencies and patient organisations, and should systematically analyse the processes of rehabilitation in the most important diagnostic groups. Guided by a "process matrix of rehabilitation", these analyses should identify the points at which far-reaching decisions are called for during the processes of rehabilitation. At these points, the knowledge base available for rational decisions should be examined. When there is no sufficient scientific knowledge, consensus conferences should be organized in order to collect and assess the available expertise of practitioners and to establish guidelines for clinical practice. Since compliance with such guidelines could be easily checked in the routine quality assurance programme, this proposal seems to be a promising way of improving the knowledge base in rehabilitation in a rather short time.

[Outpatient orthopaedic rehabilitation: treatment, outcomes and costs as compared to inpatient rehabilitation]. / Teilstationäre orthopädische Rehabilitation: Therapeutische Leistungen, Behandlungsergebnis und Kosten im Vergleich zur stationären Rehabilitation1.

In a parallel design the study examined an outpatient rehabilitation model project for patients of the pension insurance scheme of Rhineland-Palatinate (LVA Rheinland-Pfalz). In 6 centers for the rehabilitation of musculoskeletal diseases patients were assessed at the beginning and at the end of rehabilitation as well as six and twelve months after discharge. In this article the final results concerning therapeutic measures as well as health-related and economic outcomes are presented. Not included are aspects of differential utilization and the perception of the rehabilitation by the clients, which will be published in a separate article. No large differences were found concerning participation in the various therapeutic measures. As measured by the main score and the sub-dimensions of the IRES patient questionnaire, effects of the same magnitude were found for the parallelized samples. Equally, no differences in outcome quality were found concerning the great majority of medical parameters documented in a doctors' questionnaire, the rate of applications for pension, occupational status twelve months after rehabilitation, as well as the reduction of sick-leave. The economic evaluation was carried out only from the perspective of the pension insurance agency. Considerable differences were found in the net costs of rehabilitation: although there are no user charges for patients in outpatient rehabilitation, mean expenditure was about 970 EURO lower than in inpatient rehabilitation. The study findings demonstrate that the concept of interdisciplinary rehabilitation has been realized in the outpatient centers as well and that the centers have reached an effectiveness comparable to that of inpatient rehabilitation. At least those patients who actively choose the outpatient setting gain as much as patients in inpatient rehabilitation.

[The North American Spine Society Lumbar Spine Outcome Assessment Instrument: translation and psychometric analysis of the German version in rehabilitation patients with chronic back pain]. / The North American Spine Society Lumbar Spine Outcome Assessment Instrument: Ubersetzung und psychometrische Analyse der deutschen Version an einer Stichprobe von Rehabilitanden mit chronischen Rückenschmerzen.

The "Lumbar Spine Outcome Assessment Instrument", developed by the North American Spine Society (NASS), was translated into German. Its psychometric properties were tested in a group of rehabilitation patients with chronic, unspecific back pain, and in a comparison group of patients in cardiologic rehabilitation. With a Cronbach's alpha of 0.92, internal consistency was high. Principal component analysis revealed that the German version of the NASS instrument surveys the factors "back pain", "neurologic symptoms", and "impairments". A strong correlation with other measures of functional impairment (FFbH-R, IRES) indicates a high concurrent validity of the NASS instrument. After three weeks of inpatient rehabilitation, sensitivity to change could be demonstrated for the summary score of the instrument. This significant change was primarily due to moderate effects in the factor "back pain". In our study population, the factor "impairments" did not show a significant change. On the basis of these results, the German version of "The North American Spine Society Lumbar Spine Outcome Assessment Instrument" can be described as a reliable and valid instrument for measuring back pain, related neurologic symptoms, and back pain-induced impairments in rehabilitation patients. Because the factor "impairments" is not sensitive to change within three weeks of rehabilitation, the instrument is only partly suitable for measuring short-term outcome in rehabilitation patients. Further research is needed to determine if the instrument is useful for middle- and long-term outcome measurement in rehabilitation.

[Agreement and differences between reviewers in a peer review procedure]. / Ubereinstimmung und Unterschiede zwischen Beurteilern bei einem Peer-Review-Verfahren.

In Germany the statutory pension insurance institutions have started a quality assurance programme. Our institute developed a peer review procedure for screening the process quality of rehabilitation care. The peer review was tested in a pilot study. Our article refers to the examination of interrater reliability, intrarater reliability and reviewer bias. First of all, experienced doctors were trained in reviewing reports routinely written by rehabilitation doctors at discharge of their patients. The peers had to judge on 56 process criteria belonging to six categories (e.g. case history). The reliability coefficients were calculated for the overall judgement of each category and the overall judgement of the process quality of rehabilitation care. The coefficients of interrater reliability and the coefficients of average intrarater reliability range from sufficient to good. Only few reviewers showed a general tendency to harsh or lenient rating. The objectivity of the tested peer review procedure seems definitely higher than in American studies of peer review of hospital charts.

[Assessment of the effectiveness of inpatient rehabilitation measures in patients with chronic low back pain: a prospective, randomized, controlled study]. / Uberprüfung der Wirksamkeit stationärer Rehabilitationsmassnahmen bei Patienten mit chronischen Kreuzschmerzen: eine prospektive, randomisierte, kontrollierte Studie.

Chronic low-back pain is a frequent symptom causing considerable socioeconomic costs in many countries. Outpatient treatment of low-back pain often remains unsatisfactory. In our prospective study, one hundred patients on the five months waiting list were allocated randomly to attending the hospital either four months or six months later, the latter serving as a control group for those undergoing treatment. Health status was assessed using a multidimensional questionnaire, which had proven a reliable, valid and sensitive instrument in former studies. After four to six weeks of multidisciplinary inpatient treatment, a significant decrease in pain, anxiety and depression was found, whereas no improvement was observed in the control group. Multidisciplinary inpatient treatment therefore at least has short-term positive effects on patients' health status.