[Social Inequalities in Access to and Utilization of Medical Rehabilitation - Results of the Third German Sociomedical Panel of Employees (GSPE-III)]. / Soziale Ungleichheiten im Zugang und in der Inanspruchnahme von medizinischen Rehabilitationsmaßnahmen.

AIM OF THE STUDY: The influence of social status on health is well documented. Preliminary research provides initial evidence for social inequalities in rehabilitation care. Our study examines the role of social inequalities with respect to access and utilisation of medical rehabilitation services by analysing a risk cohort of the German Statutory Pension Insurance Scheme (Deutsche Rentenversicherung Bund). METHODS: Data for the analysis consists of questionnaire data from the first two waves of the Third German Socio-medical Panel of Employees (GSPE-III) and administrative data of participants (2013-2016). This risk cohort comprises 40-54-year-old employees receiving sickness benefits in 2012. Using logistic regression models, the application for medical rehabilitation, its approval and rejection, possible opposition proceedings and its subsequent utilisation were analysed. The social status was measured by an index as well as by the single dimension of education. The analyses were carried out separately by gender. Age, employment status and subjective health status were considered as covariates. RESULTS: A total of 2.376 insured employees, 1.092 men and 1.284 women, were included in the analysis. 639 (26.9%) submitted at least one application for medical rehabilitation. The chance of submitting an application was higher for men with low socioeconomic status (OR=1.8; 95%-CI=1.3-2.5) or lower (OR=1.9; 95%-CI=1.3-2.8) and medium education (OR=1.5; 95%-CI=1.1-2.2) in relation to the high status or education group. For women, low education (OR=1.6; 95%-CI=1.1-2.5) raised the chances of an application. When adjusted for health status and current employment situation, all significant differences disappeared. Regarding approval and utilisation, there were no significant differences between socioeconomic status groups, but women with a medium level of education were significantly more likely to have their application approved on the basis of an opposition proceeding (OR=3.0; 95%-CI=1.1-8.2) than women with a high level of education. CONCLUSION: The analyses provided no evidence of a socially unequal access to or utilization of medical rehabilitation. However, insured persons with a low social status more frequently applied for rehabilitation, especially because of their poorer subjective health. Further research is needed to ensure that this meets the objective needs of this status group.

'Learning to shape life' - a qualitative study on the challenges posed by a diagnosis of diabetes mellitus type 2.

BACKGROUND: Diabetes mellitus type 2 is a central challenge for health policy and healthcare in all advanced countries. For the affected persons, living with a diagnosis of type 2 diabetes is difficult because the disease and its treatment have a considerable effect on daily life. The aim of this study was to investigate the challenges associated with a diagnosis of type 2 diabetes for those affected and the range, depth and complexities of the subjective perspectives of the patients under the conditions of the German healthcare system. METHODS: A cross-sectional qualitative study was conducted using a sample of 19 adult patients with type 2 diabetes mellitus. Patients were recruited successively from two specialized diabetological practices, three general practitioner's offices, and two hospitals. The patients were interviewed once in person using semi-structured interviews. All interviews were recorded, transcribed, and analysed based on grounded theory. RESULTS: Persons affected by diabetes mellitus type 2 seem to feel responsible for managing their disease. Two strategies of action could be identified: 1) patients strictly followed the recommendations of the physicians, or 2) they showed that they are knowledgably managing their diabetes mellitus type 2. The action strategy to address the disease seemed to be influenced by patients' confidence in themselves, the effectiveness of the interventions, or the patients' locus of control. Minor differences in educational status could be discovered, and patients who were less educated tended to follow the recommendations of the physicians very strictly and seemed to place more emphasis on being compliant, which goes hand in hand with a life with prohibitions and restrictions. In contrast, being perceived as competent patients who make their own rules to manage the disease in daily life appeared to be more important for people with higher education levels. CONCLUSION: Patient education and self-management programmes for diabetes mellitus type 2 should take different types of learners into account. Giving less-educated patients specific recommendations for successful diabetes self-management is particularly important. TRIAL REGISTRATION: German clinical trial register (DRKS-ID: DRKS00007847 ).

Trans-sectoral care in patients with colorectal cancer: Protocol of the randomized controlled multi-center trial Supportive Cancer Care Networkers (SCAN).

BACKGROUND: Managing therapy-related side-effects and improving health-related quality of life in patients with colorectal cancer is still challenging. The need for an effective management of adverse events and unmet supportive care needs have been widely discussed. In the past decade, interventions by nursing staff gained more and more importance. Evidence suggests that a majority of patients even in early stages of the disease experience substantial impairments potentially resulting in diminished therapy adherence as well as impaired quality of life. However, evidence for the effectiveness of nurse-led interventions on symptom management and quality of life is still very limited. This especially applies to care transitions between different inpatient and outpatient health care providers throughout the course of treatment and aftercare. METHODS/DESIGN: Supportive Cancer Care Networkers (SCAN) is a prospective randomized controlled trial conducted in eight large and middle-sized German cancer centers and municipal hospitals. The target population is adults with colorectal cancer UICC I-III after initial R-0 resection scheduled for adjuvant chemotherapy or guideline-based aftercare only. 370 patients will be randomly assigned to either intervention or control group. Patients in the intervention group will receive an additional support by specialized oncology nurses for eight weeks after discharge from hospital by telephone, consisting of symptom monitoring, counselling on self-assessment and self-management and dealing with individual resources for coping and psychosocial well-being. The primary endpoint will be health-related quality of life (HRQoL) at eight weeks after discharge from the initial treating hospital. DISCUSSION: The presented SCAN trial is to provide information that will be useful to advance our understanding of complex interdependencies between symptom severity, supportive care needs, functioning and the risk for diminished HRQoL. Most importantly, these patient-reported outcomes are not fully implemented in today's clinical routine practice potentially resulting in therapy cessations and lower chemotherapy treatment rates for colorectal cancer especially in older patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01651832.

Healthcare needs among unaccompanied minor refugees: a study protocol of a qualitative study explaining access and utilisation across place and gender.

INTRODUCTION: Several studies have identified that unaccompanied minor refugees (UMRs) are allegedly 'vulnerable' and belong to a high-risk group in terms of psychological distress and post-traumatic stress disorder due to their preflight, periflight and postflight experiences. Psychosocial care (PSC) is of high importance for UMRs, but little is known about barriers to access and utilisation of PSC across place and gender. The aims of this gender-sensitive qualitative study will be to build on the existing body of literature and to provide qualitative evidence on the contexts and mechanisms of PSC for male and female UMRs in Germany by comparing two German regions. METHODS AND ANALYSIS: Following the study preparing realist review, a qualitative study will be undertaken in Berlin and Central German cities. Approximately 24 experts from the field of PSC and 12 lay UMRs will participate in face-to-face, semistructured interviews. Data will be transcribed and analysed based on the grounded theory research paradigm. ETHICS AND DISSEMINATION: Only participants who have been informed in both German and their native tongue and who have signed a declaration of consent will be included in the study. The study will comply rigorously with German data protection standards. Approval from the Ethical Review Committee at Martin Luther University Halle-Wittenberg, Germany has been obtained and granted. The results of the study will be presented at several conferences and will be published in high-quality, peer-reviewed international journals. The results will display a differentiated picture of the PSC of UMRs in Germany. Such knowledge is a precondition for a 'science of change' that translates explanations into practical recommendations on how to improve healthcare policies. TRIAL REGISTRATION NUMBER: DRKS00018080.

[Trans-sectoral care for patients with colorectal cancer: Design of a prospective randomized controlled multi-center trial (FKZ 01GY1143)]. / Sektorübergreifende Versorgung von Darmkrebspatienten: Design einer randomisierten kontrollierten Multicenter-Studie (FKZ 01GY1143).

BACKGROUND: Health-related quality of life (HrQoL) is an increasingly focused aim in the care for patients with colorectal cancer that are treated with curative intent. Achieving this aim partly depends on the quality of the transsectoral management of these patients throughout the entire treatment course. However, recent population-based surveys have shown that HrQoL in patients with colorectal cancer is significantly impaired over a long time following initial diagnosis. This also applies to patients for whom adjuncant chemotherapy is not indicated according to the German medical S3 guideline. In addition, the patients' need for medical and psychosocial support has repeatedly been reported to persist at a significantly increased level - despite the extensive establishment of certified cancer centres which has apparently failed to solve this problem sufficiently. AIM: The SCAN intervention aims to increase the percentage of patients reaching an enhancement of their HrQoL by at least 12 points (range: 0-100 pts.) within eight weeks after hospital discharge by 15 percent compared to standard care. DESIGN AND METHODS: The SCAN intervention is carried out as a randomised controlled multicentre trial in seven large- and middle-sized hospitals all over Saxony-Anhalt. 370 patients have been enrolled, 185 of whom are offered additional nurse-led outpatient counselling. INTERVENTION: Patients in the intervention group are offered transitional guidance and support consisting of routine symptom assessment and patient counselling regarding self-management, informed therapy-related decision-making and psychosocial support. ENDPOINTS: The primary endpoint of the study is the patients' global health-related quality of life (HrQoL), assessed by the EORTC Quality of Life Questionnaire QLQ C-30 V3.0, item 30. Disease-free survival within eight months, the utilisation of indicated adjuvant chemotherapies as well as therapy-related side effects, e. g., anxiety and depression and the patients' symptom burden are monitored as secondary endpoints. EXPECTED RESULTS: We assume that the SCAN intervention will be effective in increasing the percentage of patients reaching a clinically relevant enhancement of their HrQoL within eight weeks after hospital discharge by 15 percent compared to standard care.