[Quality assurance of rehabilitation by the German pension insurance: an overview]. / Ein aktueller Überblick zur Reha-Qualitätssicherung der Rentenversicherung.

The German pension insurance has in recent years developed a comprehensive programme for quality assurance in rehabilitation, and has implemented the programme into routine practice. Different aspects of rehabilitation are evaluated with differentiated instruments. Issues dealt with inter alia include the quality of rehabilitative care in a narrower sense, the structure and organisation of the rehabilitation centres, as well as quality from the patients' perspective. On the whole, positive results predominate. Big differences in quality however have been found between the rehabilitation centres. The data collections and data evaluations carried out make a continuous process of quality assurance reporting possible for use by rehabilitation centres and pension insurance agencies. This will enable targeted initiatives for quality improvement. The methods and procedures of quality assurance are enhanced at regular intervals, and the scope of quality assurance is extended. Thus, rehab quality assurance is also expanded to cover ambulant rehabilitation or rehabilitation of children and young people.

[Transfer of research findings into the practice of rehabilitation and effects on the development and stabilization of the infrastructure of rehabilitation sciences--the pension insurance perspective]. / Umsetzung von Forschungsergebnissen in die Rehabilitationspraxis und Effekte auf den Ausbau und die Stabilisierung der rehabilitationswissenschaftlichen Infrastruktur aus der Sicht der Rentenversicherung.

The programme for research in rehabilitation has been established by the Federal Ministry of Education and Research and the German Pension Insurance scheme in 1998 to further develop the methodology in this field. In addition to other effects, the large number of projects has strengthened the research structure in Germany. An important aim of the programme is the transfer of the research findings into the practice of rehabilitation. The initiators also organize this transformation process in terms of a long-term task. The paper describes the transfer of findings in the topics selected by the Pension Insurance scheme: patient education, access to rehabilitation, and vocational orientation in medical rehabilitation. Furthermore, additional activities concerning the transfer are outlined. To improve the practice of rehabilitation by transferring research findings is of great importance for the Pension Insurance scheme.

[The "rehabilitation sciences" research funding programme: research findings -- implementation -- impact and perspectives]. / Förderschwerpunkt "Rehabilitationswissenschaften": Ergebnisse -- Umsetzung -- Erfolge und Perspektiven.

In 1998, the German Federal Ministry of Education and Research (BMBF) and the German pension insurance scheme established a funding programme for research in rehabilitation. This "Rehabilitation Sciences" research funding programme comprises eight regional research networks for eight years in two periods (1998-2002, 2001-2005). In our paper we review the findings of the first funding period in five of the research fields: patient education, need for and access to rehabilitation, vocational training in medical rehabilitation to enhance return to work, comorbid mental disorders in patients with somatic diseases, and gender differences. Several activities aimed at transferring research findings into practice are outlined. Finally, the impact of the funding programme is summarized and perspectives for further funding are given.

[Development of guidelines for rehabilitation of patients with stroke: analysis of therapeutic procedures]. / Aktueller Stand der rehabilitativen Versorgung von Patienten nach Schlaganfall.

The Federal Insurance Institute for Salaried Employees (BfA, Bundesversicherungsanstalt für Angestellte) in Berlin took the initiative to develop evidence-based guidelines for rehabilitation including stroke rehabilitation. In the present study we performed a systematic survey of the scientific literature on stroke rehabilitation and deduced 8 evidence-based therapeutic modules. They were supplemented by 5 practice-based modules to cover the full range of interventions currently applied in stroke rehabilitation. Modules are clusters of various interventions which were aggregated according to the rehabilitative goal they have in common. Data were analysed from 8,876 BfA patients, the total population of "neuro"-patients in 2001 and 2002 with 142,951 interventions and 1,071,885 appointments. Stroke diagnoses covered ICD-10 codes I60, I61, I62, I63, I64 or were coded by G45, G81 and one of these I-codes. Stroke rehabilitation as provided in daily practice was found to be a complex multimodal treatment programme in all hospitals which were studied. On average, patients receive treatments from 7.3 therapeutic modules. A dominating role is played by "motor modules". Obviously, they play a major role in acute stroke rehabilitation in all hospitals compared to cognitive retraining, language therapy and especially improvement of psychic functions, which were significantly less applied. A dramatic variation could be shown to exist between the rehabilitation hospitals (1) with respect to the number of patients who were treated with a given module (e. g., some modules showed variations between 18 % and 100 %), and (2) with respect to treatment intensity and treatment duration per week. Several factors can be taken into account for interpretation of this high variance. Intrinsically, the high variation in symptomatology after stroke can play a major role, as both the deficit profile and the level of severity of a given deficit and the combined severity level can vary from patient to patient. On the other hand, extrinsic factors such as lack of staff may also account for some of the differences. In any case, the results show the necessity to optimize stroke rehabilitation by development and implementation of guidelines. Yet, they also point to a need for further research into rehabilitation interventions and procedures to yield evidence for the approximately 30 % of "only" practice-based interventions.

[Outpatient rehabilitation as mirrored by the users--findings on the quality of outpatient orthopaedic rehabilitation provided by the Federal Insurance Institute for Employees, BfA]. / Ambulante Rehabilitation im Spiegel der Nutzer--Ergebnisse zur Qualität der Regelversorgung in der ambulanten orthopädischen Rehabilitation der Bundesversicherungsanstalt für Angestellte.

This article presents the central results of a survey including all persons insured by the BfA (Bundesversicherungsanstalt für Angestellte, German Federal Insurance Institute for Employees) who had participated in outpatient orthopaedic rehabilitation between March and August of 2002. A total of 3838 insured persons were addressed, 69 % replied (n = 2660 questionnaires). The standardized survey included an appraisal of the outpatient rehabilitation measure, the care provided by physicians, psychologists and therapists, the organisation and performance of the rehabilitation measure, as well as of the stressors and general conditions specific to various outpatient measures. The assessment of treatment outcome, physical and psychosocial improvements, and the attainment of therapy goals were of particular importance. Overall, the results show a positive appraisal of outpatient rehabilitation but also indicate the necessity for optimisation--particularly with regard to resting rooms, physician and psychological care, as well as the suitability of the therapy for everyday life. Above all, however, the comparison of the rehabilitation centres shows a great variance in quality of care. Some rehabilitation centres show extraordinary results in many aspects of quality, whereas others reveal systematic deficits of quality.

[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.

[Subjective health, need for rehabilitation and utilization in a West-East comparison--results of a survey of insured clients of the federal insurance office for employees and the Saxony federal insurance office]. / Subjektive Gesundheit, Rehabilitationsbedürftigkeit und -inanspruchnahme in West-Ost-Vergleich--Ergebnisse einer Versichertenbefragung der BfA und der LVA Sachsen.

There were substantial changes within the rehabilitation framework due to new laws as well as internal need for more flexibility. In connection with this process, the BfA and the LVA Sachsen initiated a survey among their insured persons, the main points being the need for and use of rehabilitative care. The results of a West/East comparison are presented. A questionnaire was send to approximately 29,000 insured persons, the overall response rate was 43%. White collar workers in the East reported a better state of health compared with those in the West, with the most profound differences found in females. Subjective health status and subjective working capability were highly associated. The proportion of persons who reported a need for rehabilitation amounts to 24% among the insured with the LVA Sachsen (blue collar workers, East) and 12% among the white collar workers in the East. Independent of the state of health there was also an association between work stress and the need for rehabilitation. Persons from the East were less informed about rehabilitative care than persons from the West. Financial and workplace problems were among the major reasons not to apply for a rehabilitation measure even if there is a need. These reasons were mentioned more often in the East. In conclusion, there are substantial differences between West and East concerning the rehabilitative health sector. A prominent role is played by the employment situation.

[The "rehabilitation sciences" promotional emphasis--a promotional program and its implementation]. / Der Förderschwerpunkt "Rehabilitationswissenschaften"--ein Förderprogramm und seine Umsetzung.

The German Federal Research Ministry and the German pension insurance have set up a special funding programme for medical rehabilitation research. Eight regional research networks with about 70 projects receive funds for a first three year period. Rehabilitation experts from several countries selected the promising networks and studies from more than 100 proposals. In these networks medical and social scientists from universities and other research units cooperate with rehabilitation centers and pension insurance institutes in order to combine forces for the development of German rehabilitation science. The programme aims at improving the research structures and at tackling the major challenges of medical rehabilitation research. The following subjects represent the main fields of the ongoing research: a) etiology, course and prognosis of chronic diseases and their consequences to rehabilitation, b) diagnostics in rehabilitation, c) evaluation and improvement of rehabilitation therapy, d) the patient's perspective in rehabilitation and e) rehabilitation system research. As yet funding is limited to the year 2001. Further support of the networks will depend on the results of a thorough evaluation of the progress of their research and their structural perspective.

[Assessment of long-term needs and expenditures development for rehabilitation services of the BfA with reference to the growth and occupational rehabilitation regulation (WFG)]. / Abschätzung der langfristigen Bedarfs- und Ausgabenentwicklung für die Rehabilitationsleistungen der BfA unter Berücksichtigung des Wachstums- und Beschäftigungsförderungsgesetzes (WFG).

Based on a Prognos Model projection (1998 to 2040), the number of medical and occupational rehabilitation service treatments required will increase by about 70,000 between 1998 and 2015, reaching 500,000. Thereafter, the situation improves and the number drops to between 370,000 and 430,000. The WFG law provides a 2.7 billion DM budget for the entire time period which results in a growing deficit, reaching 1.7 billion DM by 2015, and enabling the provision of only 50% of the treatments required in the western states, if it is assumed that a reduction of treatment in the eastern states is precluded. This service deficit makes an increase in early retirements probable, thereby, generating costs on balance which exceed any potential savings in the areas of rehabilitation. It is, therefore, necessary to adapt the WFG law to the demands of real needs so that the BfA may continue to fulfill its legal obligation, "rehabilitation before retirement" to the accustomed and necessary extent.

[Cost-benefit evaluation of medical rehabilitation by social security pensions and effects of the growth and occupational rehabilitation regulation (WFG)]. / Kosten-Nutzen-Bewertung der medizinischen Rehabilitation der Rentenversicherung (RV) und die Auswirkungen des Wachstums- und Beschäftigungsförderungsgesetzes (WFG).

The retirement insurers, within the scope of their responsibility for health care, have already adopted the standard that calls for quality control, cost-efficiency, and outcome-focusing. For a start, the BfA (Federal Insurance Agency for Salaried Employees) has compiled a pilot evaluation presented here, based solely on its own costs and returns on costs. This evaluation demonstrates that rehabilitation "pays off". With regard to the WFG, this means that cost-saving in rehabilitation generates significant cost increases through loss of premium payments and necessary early-retirement outlays. The analysis presented shows that future investment in rehabilitation is required to ensure positive returns for the RV.