[Total Hip and Knee Arthroplasty - Utilization of Postoperative Rehabilitation]. / Implantation einer Hüft- oder Knietotalendoprothese und die Inanspruchnahme einer Anschlussrehabilitation.

BACKGROUND: After total hip and knee arthroplasty, patients have different options of subsequent treatment: an early postoperative rehabilitation, with or without a period at home, or only outpatient services. The aim of this study was to identify factors predicting the utilization of an early postoperative rehabilitation. METHODS: This cross-sectoral analysis is based on claims data of AOK Baden-Württemberg (Statutory Health Insurance), Deutsche Rentenversicherung Bund and Deutsche Rentenversicherung Baden-Württemberg (German Pension Insurance). Predictors for participation in an early postoperative rehabilitation and for an interim period were determined using logistic regression analysis. RESULTS: 82.6% of 9 232 patients were going to an early postoperative rehabilitation after total hip arthroplasty. After total knee arthroplasty, 83.9% of 7 656 patients were utilizing postoperative rehabilitation. Moreover, there was less utilization of postoperative rehabilitation in young, male and foreign patients. The analysis shows that the utilization of post-acute rehabilitation was significantly predicted by sociodemographic variables (age, sex, nationality) as well as comorbidity, outpatient treatment and medication. CONCLUSION: The results provide an indication of higher severity of patients in group "postoperative rehabilitation without a period at home". Nevertheless there are some indications for under-utilization of certain patient groups.

[Associations of the Employment Status during the First 2 Years Following Medical Rehabilitation and Long Term Occupational Trajectories: Implications for Outcome Measurement]. / Zusammenhänge zwischen dem Erwerbsstatus in den ersten 2 Jahren nach Rehabilitation und langfristigen Erwerbsverläufen: Implikationen für die Outcome-Messung.

Study Objectives: The aim was to investigate the predictive value of the employment status measured in the 6th, 12th, 18th and 24th month after medical rehabilitation for long-term employment trajectories during 4 years. Methods: A retrospective study was conducted based on a 20%-sample of all patients receiving inpatient rehabilitation funded by the German pension fund. Patients aged <62 years who were treated due to musculoskeletal, cardiovascular or psychosomatic disorders during the years 2002-2005 were included and followed for 4 consecutive years. The predictive value of the employment status in 4 predefined months after discharge (6th, 12th, 18th and 24th month), for the total number of months in employment in 4 years following rehabilitative treatment was analyzed using multiple linear regression. Per time point, separate regression analyses were conducted, including the employment status (employed vs. unemployed) at the respective point in time as explanatory variable, besides a standard set of additional prognostic variables. Results: A total of 252 591 patients were eligible for study inclusion. The level of explained variance of the regression models increased with the point in time used to measure the employment status, included as explanatory variable. Overall the R²-measure increased by 30% from the regression model that included the employment status in the 6th month (R²=0.60) to the model that included the work status in the 24th month (R²=0.78). Conclusion: The degree of accuracy in the prognosis of long-term employment biographies increases with the point in time used to measure employment in the first 2 years following rehabilitation. These findings should be taken into consideration for the predefinition of time points used to measure the employment status in future studies.

[Outcome Quality in Medical Rehabilitation: Relationship Between "Patient-Reported Outcomes" (PROs) and Social Security Contributions]. / Ergebnisqualität medizinischer Rehabilitation: Zum Zusammenhang zwischen "Patient Reported Outcomes" (PROs) und geleisteten Sozialversicherungsbeiträgen.

Aim of the Study The outcome quality of medical rehabilitation is evaluated often by "Patient Reported Outcomes" (PROs). It is examined to what extent these PROs are corresponding with "hard" or "objective" outcomes such as payments of contributions to social insurance. Methods The "rehabilitation QM outcome study" includes self-reports of patients as well as data from the Rehabilitation Statistics Database (RSD) of the German pension insurance Baden-Wurttemberg. The sample for the question posed includes N=2 947 insured who were treated in 2011 in 21 clinics of the "health quality network" and who were either employed or unemployed at the time of the rehabilitation application (e. g. the workforce or labour force group, response rate: 55%). The sample turned out widely representative for the population of the insured persons. Results PROs and payment of contributions to pension insurance clearly correspond. In the year after the rehabilitation improved vs. not improved rehabilitees differed clearly with regard to their payments of contributions. Conclusions The results support the validity of PROs. For a comprehensive depiction of the outcome quality of rehabilitation PROs and payments of contributions should be considered supplementary.

[Effects of a Combined Orthopedic and Psychosomatic Rehabilitation Concept]. / Effekte einer Verbund-Rehabilitation Orthopädie-Psychosomatik.

Objective: Effects of a combined orthopedic and psychosomatic rehabilitation (VOP) concept are evaluated in contrast to psychosomatic and orthopedic rehabilitation. Therefore both mental and physical health of rehabilitants are compared. Methods: A prospective case-control study was performed in order to gather psychic strain and bodily constitution. Covariance analysis was conducted to expose significant differences between groups. Results: An equal clinically relevant reduction of psychological distress could be achieved with psychosomatic rehabilitation (N=322) and VOP (N=511). Moreover, bodily constitution could be increased by the same amount through VOP and orthopedic rehabilitation (N=135). In conclusion the therapy concept is successful in patients with both somatic and psychic problems.

[Recommendations for the Stepwise Occupational Reintegration: Can the Characteristic of the Patients Explain the Differences Between the Rehabilitation Centers?]. / Nachsorgeempfehlungen zur stufenweisen Wiedereingliederung: Inwieweit erklären Rehabilitandenmerkmale die bestehenden Unterschiede zwischen den Einrichtungen?

BACKGROUND: The first step to initiate a stepwise occupational reintegration (SOR) is the recommendation of the rehabilitation centers. Therefore rehabilitation centers have a significant impact on the use of SOR. There is evidence that the recommendation rate between the rehabilitation centers differs clearly. The present survey therefore analyses in detail the differences of the recommendation rate and examines which patient-related factors could explain the differences. METHODS: This study is based on analysis of routine data provided by the German pension insurance in Baden-Württemberg (Rehabilitationsstatistikdatenbasis 2013; RSD). In the analyses rehabilitation measures were included if they were conducted by employed patients (18-64 years) with a muscular-skeletal system disease or a disorder of the connective tissue. Logistic regression models were performed to explain the differences in the recommendation rate of the rehabilitation centers. RESULTS: The data of 134 853 rehabilitation measures out of 32 rehabilitation centers were available. The recommendation rate differed between the rehabilitation centers from 1.36-18.53%. The logistic regression analysis showed that the period of working incapacity 12 month before the rehabilitation and the working capacity on the current job were the most important predictors for the recommendation of a SOR by the rehabilitation centers. Also the rehabilitation centers themselves have an important influence. DISCUSSION: The results of this survey indicate that the characteristic of the patients is an important factor for the recommendation of SOR. Additionally the rehabilitation centers themselves have an influence on the recommendation of SOR. The results point to the fact that the rehabilitation centers use different criteria by making a recommendation.

[The User Survey on the Revision of the Classification of Therapeutic Procedures]. / Die Anwenderbefragung zur Aktualisierung der Klassifikation therapeutischer Leistungen (KTL).

INTRODUCTION: An extensive user survey was conducted in the context of updating the Classification of Therapeutic Procedures (KTL 2015). This paper reflects the results of the user survey and raises critical discussion points. METHODS: The user survey was sent to all rehabilitation centers contracted by the German pension insurance as well as professional associations. The user survey was available both as a paper questionnaire and as an online version. The feedback of the user survey provided an important basis for the revision of the KTL. RESULT: The survey yielded 1,868 suggestions from 360 users. Most of them related to chapters E ("occupational therapy, work therapy, other functional therapy") and C ("information, motivation, training"). The change from German diplomas to the international Bachelor's and Master's degrees, and the inclusion of diagnostic and work-related procedures were the main focus of the user feedback. CONCLUSION: For the revision of the KTL, the user survey provided valuable information. Only by the inclusion of practitioners can the KTL meet the requirements of realistic and comprehensive acquisition of data on therapeutic procedures also in future.

[Return to work after total hip arthroplasty]. / Rückkehr in das Erwerbsleben nach Hüfttotalendoprothese.

BACKGROUND: Return to work is an important prerequisite to achieve subjective success of an operation. The analysis of the routine data from the German Federal Pension Fund allows a comprehensive evaluation and investigation of factors which influence reintegration into employment. METHODS: A random 2 % sample of rehabilitants was drawn from the scientific use file "Abgeschlossene Rehabilitation im Versicherungsverlauf 2002-2009" (completed rehabilitation in the course of health insurance 2002-2009) of the German Federal Pension Fund. Patients were included if they were 18-60 years old and had participated in rehabilitation due to the diagnosis arthritis of the hip. To obtain information on employment status the national insurance contributions and labor force groups in the year before and 2 years after rehabilitation were used. Using regression analysis the influence of sociodemographic factors was analyzed. RESULTS: Of the 736 patients included in the survey 625 (84.9 %) were employed again 2 years after rehabilitation. Out of these 519 (83.0 %) returned to their previous profession and 228 (36.5 %) paid less insurance contributions. Increasing age and a manual job were identified as risk factors for re-entry into employment. CONCLUSION: In Germany a high percentage of 84.9 % of patients return to work after joint replacement due to coxarthrosis. Nevertheless, the results indicate that the social situation becomes worse for approximately one sixth of the patients.

[Return to Work after Fractures of the Pelvis and the Acetabulum]. / Berufliche Wiedereingliederung nach Becken- und Azetabulumfrakturen.

BACKGROUND AND INTRODUCTION: Pelvic and acetabular fractures are severe injuries with serious consequences that mainly happen to young people. Therefore it is highly interesting to find out to what extent affected patients succeed in returning to work, which is an important factor concerning quality of live. Thus, the objective of this study was to estimate the "return to work" in a two-year follow-up after rehabilitative treatment of patients with pelvic and acetabular fractures and to identify influencing factors. METHODS: A retrospective cohort study was conducted using population-based administrative data of the Baden-Württemberg statutory pension fund. All patients (age 18 to 63 years) who had participated in a rehabilitation programme between 2004 and 2009 due to a pelvic or acetabular fracture were included. Return to work was modelled using multivariate logistic regression analysis. Rehabilitants were classified as "returned" if they have paid at least one monthly contribution due to employment during 13 to 24 months after rehabilitation. Age, gender, diagnostic group, type of rehabilitation programme, fractures of the spine, nerve injuries of the lumbosacral area and/or the lower limb and employment status before the fractures were considered as prognostic covariates. RESULTS: Two-thirds of the 249 researched patients returned to work. This corresponds to a reduction of employment amounting to 16.6 % for patients with a pelvic fracture and 20.8 % for patients with an acetabular fracture. Main predictor for a return to work was the employment status before the fracture. Younger patients had a better chance to return to work than older ones. Patients with fractures of the spine or nerve injuries of the lumbosacral area and/or the lower limb had a 73 % or, respectively, 78 % higher risk of not returning to work. CONCLUSION: Fractures of the pelvis and the acetabulum currently lead in one of five patients to loss of employment. Thereby the trauma threatens the social security of the young patients. Follow-up care should be intensified to increase recovery rates and reduce the burden of long-term work disability.

[The ICF in use: testing of a new concept in four clinics]. / Praktische Nutzung der ICF: Erprobung eines neuen Ansatzes in vier Kliniken.

The International Classification of Functioning, Disability and Health (ICF) consists of more than 1 400 items. Due to its size and complexity, using the ICF is hardly feasible in practice. Moreover, the severity of problems is given only on a five-point scale (qualifiers), which seems too insensitive for measurement of changes. Thus, in cooperation with four rehabilitation hospitals, Jacobi, Urban & Kaluscha have identified 148 relevant items for musculoskeletal diseases. For easier usage we assigned mnemonic three letter codes to these items, e. g. WAL for the item "Walking" (ICF d450). Then the physician assigns those few items which he and/or the patient consider most important. The severity of the problem is judged on a scale from 0 (no restriction) to 100 (maximum restriction) for each item. By drawing a bar on the scale the physician gives an interval instead of just a single point (fuzzy judgement). The centre of the interval represents the severity of the problem and the width represents the uncertainty of judgement, e. g. when there is no gold standard for measurement or when the problem varies with time. As both the assignment of descriptors from an item pool and the fuzzy judgements are a new approach to medical documentation, we carried out this pilot study to examine acceptance and feasibility of the approach. In the pilot study, 264 in-patients in four rehabilitation clinics have been included. 138 (94%) of the 148 descriptors in the item pool have been used. Altogether there were 1,764 single judgements. On average six descriptors per patient have been assigned, giving an efficient and precise individual documentation. This is an advantage of the documentation principle called combination of terms compared to the principle of classification. In contrast to the ICF core sets patients may get individual sets of descriptors as appropriate. On discharge, the judgements were about 25 points better compared to admission. During treatment the fluctuations of disorders decreased and the certainty of the judgements increased, resulting in reduction of interval width of 2.8 points. The feedback of the rehabilitation clinics involved showed good acceptance and feasibility. Our data can easily be mapped into the ICF. In addition to ICF core sets, our approach could facilitate the use of the ICF in practical settings.

[Prediction of premature pension after stationary rehabilitation due to adipositas--a prognostic model based on routinely collected data of the State Insurance Institution of Baden-Württemberg]. / Vorhersage vorzeitiger Berentung nach stationärer Rehabilitation wegen Adipositas -- ein Prognosemodell basierend auf Routinedaten der Landesversicherungsanstalt Baden-Württemberg.

Up to 60 % of the German population can be marked as obese. Due is to its frequency and its associated diseases like cardiovascular disorders and disorders of the musculoskeletal system adipositas is a severe burden on the German health care system. This burden is caused by costs of the disease and costs due to premature pensioning. In this study logistic regression modelling has been performed by means of routinely collected data of patients of the regional statutory pension insurance institute Landesversicherungsanstalt Baden-Württemberg (LVA-BW) rehabilitated due to adipositas (n = 599). The aim was to detect influential variables for the prognosis of premature pensioning (n = 135). The data of the patients were obtained from a research database of the "RehaNet" project which includes data of the standardized discharge report of the Federation of German Pension Insurance Institutes and quality assurance questionnaires of the LVA-BW. Three variables remain in the model after a step-down procedure for modelling by logistic regression. The selected variables are age (in years), the physician's statement about the patients limitations of movement after rehabilitation (yes/no) and about the patients ability to work in future (more/less than half-day). After internal validation of the model by bootstrap methods the model achieves a sensitivity of 73 %, a specificity of 87 %, a positive and a negative predictive value of 57 and 93 % respectively. The area under the curve (AUC) of the ROC analysis is 0.87, so the model achieves a good prognostic value. Thus, this model is a valuable test for the exclusion of possible premature pension while or after rehabilitation due to adipositas. It was found that the situation of "no premature pensioning" of patients rehabilitated due to adipositas can be predicted quite accurately with little information (three variables). This reveals a perspective for further research in the possibility of an early, risk-adapted and individualised intervention after stationary rehabilitation for adipositas to keep employment.

[The patient's signature of the physician's report at discharge from rehabilitation]. / Die Patientenunterschrift im ärztlichen Reha-Entlassungsbericht.

What follows for the outcome of rehabilitation, patients' satisfaction and work organisation in a rehabilitation hospital if the patients obtain their discharge reports for signature before they leave? This has been investigated in a pilot study at the University Rehabilitation Hospital in Bad Wurzach, Germany. The pilot study was so successful that the hospital continued to use the new procedure. Only very few refused their signature, most patients were happy to obtain their discharge reports immediately and to have the opportunity to discuss the report with their physician if desired. Physician judged patients' participation slightly more pointly while the known discrepancies between physicians' and patients' point of view remained, i. e. the physician doesn't "touch up" knowing the patient will read his report. Integrating the patient in the process is a major step towards patients' empowerment. Both the influence on patients' satisfaction and changes in work organisation are discussed in the paper. A timely discharge examination and an optimised computer-supported workflow, transformation of loosely coupled activities in a process managed by time frames are preconditions for being able to have the discharge report ready before the patients leave. Monitoring the timely delivery then becomes obsolete.