A mixed-methods approach to understanding partnership experiences and outcomes of projects from an integrated knowledge translation funding model in rehabilitation.

BACKGROUND: Integrated knowledge translation (IKT) can optimize the uptake of research evidence into clinical practice by incorporating knowledge users as equal partners in the entire research process. Although several studies have investigated stakeholder involvement in research, the literature on partnerships between researchers and clinicians in rehabilitation and their impact on clinical practice is scarce. This study described the individual research projects, the outcomes of these projects on clinical practice and the partnership experiences of an initiative that funds IKT projects co-led by a rehabilitation clinician and a researcher. METHODS: This was a sequential explanatory mixed methods study where quantitative data (document reviews and surveys) informed the qualitative phase (focus groups with researchers and interviews with clinicians). Descriptive analysis was completed for the quantitative data and thematic analysis was used for the qualitative data. RESULTS: 53 projects were classified within multiple steps of the KTA framework. Descriptive information on the projects and outcomes were obtained through the survey for 37 of the 53 funded projects (70%). Half of the respondents (n = 18) were very satisfied or satisfied with their project's impact. Only two (6%) projects reported having measured sustainability of their projects and four (11%) measured long-term impact. A focus group with six researchers and individual interviews with nine clinicians highlighted the benefits (e.g. acquired collaborative skills, stronger networks between clinicians and academia) and challenges (e.g. measuring KT outcomes, lack of planning for sustainability, barriers related to clinician involvement in research) of participating in this initiative. Considerations when partnering on IKT projects included: the importance of having a supportive organization culture and physical proximity between collaborators, sharing motives for participating, leveraging everyone's expertise, grounding projects in KT models, discussing feasibility of projects on a restricted timeline, and incorporating the necessary knowledge users. Clinicians discussed the main outputs (scientific contribution, training and development, increased awareness of best practice, step in a larger effort) as project outcomes, but highlighted the complexity of measuring outcomes on clinical practice. CONCLUSION: The study provides a portrait of an IKT funding model, sheds light on past IKT projects' strengths and weaknesses and provides strategies for promoting positive partnership experiences between researchers and rehabilitation clinicians.

An economic evaluation of an integrated care pathway in geriatric rehabilitation for older patients with complex health problems.

BACKGROUND: Integrated care pathways which cover multiple care settings are increasingly used as a tool to structure care, enhance coordination and improve transitions between care settings. However, little is known about their economic impact. The objective of this study is to determine the cost-effectiveness and cost-utility of an integrated care pathway designed for patients with complex health problems transferring from the hospital, a geriatric rehabilitation facility and primary care. METHODS: This economic evaluation was performed from a societal perspective alongside a prospective cohort study with two cohorts of patients. The care as usual cohort was included before implementation of the pathway and the care pathway cohort after implementation of the pathway. Both cohorts were measured over nine months, during which intervention costs, healthcare costs, patient and family costs were identified. The outcome measures were dependence in activities of daily living (measured with the KATZ-15) and quality adjusted life years (EQ-5D-3L). Costs and effects were bootstrapped and various sensitivity analyses were performed to assess robustness of the results. RESULTS: After nine months, the average societal costs were significantly lower for patients in the care pathway cohort (€50,791) versus patients in the care as usual cohort (€62,170; CI = -22,090, -988). Patients in the care pathway cohort had better scores on the KATZ-15 (1.04), indicating cost-effectiveness. No significant differences were found between the two groups on QALY scores (0.01). CONCLUSIONS: The results of this study indicate that the integrated care pathway is a cost-effective intervention. Therefore, dissemination of the integrated care pathway on a wider scale could be considered. This would provide us the opportunity to confirm the findings of our study in larger economic evaluations. When looking at QALYs, no effects were found. Therefore, it is also recommended to explore if therapy in geriatric rehabilitation could also pay attention to other quality of life-related domains, such as mood and social participation.

Experiences and needs of carers of Aboriginal children with a disability: a qualitative study.

BACKGROUND: Australian parents/carers of a person with a disability experience higher rates of depression, more financial stress, and are twice as likely to be in poor physical health than the general population. Aboriginal and Torres Strait Islander peoples experience worse health, social and economic outcomes than other Australians, and those with a disability face 'double disadvantage'. This study aimed to better understand the experiences and needs of parents/carers/families of Aboriginal children with a disability. METHODS: Semi-structured in-depth interviews were conducted with parents or primary carers of Aboriginal children aged zero-eight with disability. Interviews were analysed using thematic analysis. RESULTS: Nineteen women (sixteen mothers and three grandmothers) were interviewed. More than half were lone carers (without a partner or spouse). Participants described their experiences, including challenges and facilitators, to providing and accessing care, impacts on their health and wellbeing, and associated economic and non-economic costs of caregiving. Financial strain and social isolation was particularly prominent for lone carers. CONCLUSIONS: Tailoring services to the needs of carers of Aboriginal children with a disability means supporting kinship caregiving, facilitating engagement with other Aboriginal families, and streamlining services and systems to mitigate costs. The experiences described by our participants depict an intersection of race, socio-economic status, gender, disability, and caregiving. Services and funding initiatives should incorporate such intersecting determinants in planning and delivery of holistic care.

Rehabilitation - a new approach. Part four: a new paradigm, and its implications.

This editorial proposes changes in healthcare services that should greatly improve the health status of all patients with disability. The main premises are that: rehabilitation usually involves many actions delivered by many people from different organisations over a prolonged period; specific rehabilitation actions cover a wide range of professional activities, with face to face therapy only being one; and the primary patient activity that improves function is practice of personally relevant activities in a safe environment. This editorial argues that: rehabilitation should occur at all times and in all settings, in parallel with medical care in order to maximise recovery and to avoid loss of fitness, skills and confidence associated with rest and being cared for; hospitals and other healthcare settings should adapt the environment to encourage practice of activities at all times; and that measuring rehabilitation, whether in research or for re-imbursement, should not simply consider face-to-face 'therapy time' but must include: all the other important activities undertaken by the team; 'structures' such as the appropriateness of the environment; and a process measure of the time spent by patients undertaking activities.

Inpatient paediatric rehabilitation in chronic respiratory disorders.

Inpatient pulmonary rehabilitation programs have evolved from tuberculosis sanatoriums to modern medical centres providing standardized comprehensive care in a multidiciplinatory environment. Goals of rehabilitation programs for children and adolescents include restoration of professional activity, improvement of health condition, compliance and disease management as well as restoration of quality of life. Eligibility for an intervention is assessed by defined social and medical criteria. Comprehensive pulmonary rehabilitation programs provide a wide range of health care recourses, including diagnostic procedures, specific medical care, educational interventions and a multiprofessional team. Paediatric rehabilitation programs for chronic respiratory diseases, such as asthma or cystic fibrosis, have been shown to reduce symptoms, increase aerobic fitness and physical strength, improve pulmonary function and inflammation and enhance compliance, self-management, quality of life and psychological symptoms. Regional climatic effects have demonstrated an additional positive effect on the rehabilitation outcome. In addition, first evidence suggests an overall reduction of health care costs.

[Interest and costs of neurorehabilitation of brain injury patients]. / Intérêt et coût de la réadaptation neurologique des patients cérébrolésés.

The severity of the initial deficit and the improvement in the first weeks are the strongest indicators for a favorable outcome after stroke. Meta-analyses attempt to evaluate the efficacy of neurorehabilitation, but the results are unconclusive due to the heterogeinity of the groups of patients and therapies. However, there is sufficient data to conclude that repetitive, high intensity, task orientated training is efficacious. New approaches (mental imagery, robotics, virtual therapies...) are also useful but are not better than physiotherapy. It is as important to individualize the approach in a multidisciplinary well organised and communicative setting and to treat early complications. Cerebral plasticity is an individualized process and limited in time, so therapy should be regularly adapted and stopped if the deficit remains stable.

Complexity, case-mix and rehabilitation: the importance of a holistic model of illness.

Rehabilitation is not cheap. It depends upon personal interactions between rehabilitation staff and the patient and their families, and salaries for staff are always expensive. Rehabilitation depends upon learning, which takes time. The more complex the problems presented by patients the more resources are likely to be needed. This editorial reviews briefly the nature of complexity, emphasizing that it encompasses both the number of factors impinging upon the outcome of interest and the non-linear nature of many of the relationships between different factors and inputs. It describes briefly the holistic biopsychosocial model of illness that underlies much rehabilitation practice and a model of the rehabilitation process, and it then considers how complexity might be measured. It concludes that measures exist, such as the INTERMED, although they can probably be improved. But evidence derived using the INTERMED already both validates the biopsychosocial model of illness, and provides a sound basis for further developments.

[Integrated case fees in cardiosurgery--a pilot project for fast-track rehabilitation]. / Komplexfallpauschalen in der Herzchirurgie--ein Modellprojekt zur Frührehabilitation.

BACKGROUND: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care. METHODS: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups. RESULTS: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days. CONCLUSION: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

[Incidence and socioeconomic burden of hip fractures in Italy]. / Incidenza e costi delle fratture di femore in Italia.

OBJECTIVES: The aim of this study was to evaluate the trend of the incidence and costs of hip fractures in Italy. METHODS: The incidence of hip fractures after 45 years of age in both females and males during the years 1999-2002 was obtained by analyzing the Italian Ministry of Health national hospitalization database, according to the diagnosis codes of International Classification of Diseases, Clinical Modification, 9th edition (IDC-9-CM) that indicate femoral fracture. We have computed all direct costs sustained by the National Health Service for hospitalization and treatment of hip fractures on the basis of the value of the Diagnosis Related Groups (DRG) referring to hip fractures. The expenses of rehabilitation and indirect expenses were based on estimates. RESULTS: In 2002, more than 86,000 hip fractures were registered in Italy in male and female patients over 45 years old, with 9% progression compared to 1999; 77% were female and 80% were over 75 years of age. In 2002 the direct costs of hospitalization, in the patients over 65 years alone, were almost 400 million euros, with an increase of 15% as compared to 1999. Considering also estimated rehabilitation costs, social aid and indirect costs, we estimate that hip fractures due to age-related osteoporosis created over a billion euros in expenses in 2002. CONCLUSIONS: Preventive intervention regarding the risk of hip fracture in elderly patients is urgent.

Opiate addiction and the entanglements of imperialism and patriarchy in Manchukuo, 1932-45.

In the Japanese colonial state of Manchukuo, opiate addiction was condemned by officials and critics alike. But the state-sponsored creation of a monopoly, opium laws, and rehabilitation programs failed to reduce rates of addiction. Further, official media condemnation of opiate addiction melded with local Chinese-language literature to stigmatise addiction, casing a negative light over the state's failure to realise its own anti-opiate agenda. Chinese writers were thus transfixed in a complex colonial environment in which they applauded measures to reduce harm to the local population while levelling critiques of Japanese colonial rule. This paper demonstrates how the Chinese-language literature of Manchukuo did not simply parrot official politics. It also delegitimised Japanese rule through opiate narratives that are gendered, consistently negative, and more critical of the state than might be expected in a colonial literature.

[New forms of remuneration and care delivery: their impact on rehabilitation]. / Neue Vergütungs- und Versorgungsformen und ihre Auswirkungen auf die Rehabilitation.

Current health policy reform efforts in Germany include introduction of a DRG (Diagnosis Related Group) based funding system in the hospital sector as well as integrated delivery of health care and disease management programs, developments that will directly affect the medical rehabilitation sector. Decreasing lengths of hospital stay induced by the DRG system will inter alia entail a shifting of cases and costs to subsequent sectors. Moreover, hospitals might not least seek compensation for shorter hospital stays by extending their scope to include rehabilitation and long-term care services. Introduction of the DRG system in acute-hospital care has resulted in major changes in respect of early rehabilitation. Existing specialized early rehabilitation facilities providing high-quality care face serious funding problems on account of the newly introduced early rehabilitation DRGs. For hospitals previously not involved in early rehabilitation on the other hand, incentives arise to set up new early rehabilitation structures although the need for these additional capacities obviously is questionable. Introduction of the DRG-based funding system has reinforced the discussion about applying a flat-rate system also in the rehabilitation sector. This form of remuneration however is inappropriate to medical rehabilitation concepts. On the other hand, a remuneration system incorporating cross-institutional per-diem fees and "treatment time" budgets might enable using essential advantages of flat-rate payment without having to expect repercussions for the quality of care. In the context of integrated care and disease management programs the issue at stake for rehabilitation primarily is to be able to contribute its specific competencies appropriately. Also, integrated health care is bound to result in stronger competition among the various health care sectors. If rehabilitation is set to face this competition, further research efforts will urgently have to be made along with ongoing development of clinical practice guidelines.

[Naturopathy in rehabilitation--a logical option in the German health system]. / Naturheilkunde in der Rehabilitation--eine sinnvolle Option im deutschen Gesundheitswesen.

The present restructuring of the German health system is a reaction to the changing demands resulting from demographic and financial developments. In this context, an increase in patients autonomy is urgently needed which is only possible in cooperation with this group. The rehabilitative sector of the health system with its biopsychosocial model of diseases offers still heavily overlooked solutions, in particular because of its extensive use of complementary medicine, which has a high degree of acceptance among patients and the general population.

[DRGs of musculoskeletal diseases: consequences for orthopaedics and accident surgery]. / DRGs der muskuloskelettalen Erkrankungen: Konsequenzen für die Orthopädie und Unfallchirurgie.

The introduction of the new prospective payment system for inpatient care entails considerable changes for hospitals in Germany. The Australian Refined Diagnosis Related Groups (AR-DRGs), which form the basis for the German system, give the chance to estimate the consequences and implications for the specialty of orthopaedic surgery in Germany. Our study aims at highlighting the most important musculoskeletal diagnoses and to provide an initial economic forecast for them. The comparison with Australian data gives hints for operative and conservative-rehabilitative orthopaedic departments in respect to potentials and focal points for the development of novel patient management tools. The success of orthopaedic departments will depend in the future much more than now on organisational and management issues.

[The future of medical rehabilitation in accordance with SGB V and SGB XI in the context of changes in the German Medical Care System]. / Die Zukunft der medizinischen Rehabilitation gemäss SGB V und SGB XI im Kontext des Wandels des bundesdeutschen medizinischen Versorgungssystems.

During recent years the German federal social welfare system has been subject to several changes due to structural reforms. The hospital sector--as an element of this system--has also been affected. Based on various legislation the financial framework has been reduced which has led to tendencies of economic limitation and rationalization. From this background considerable risk selection and changes in emphasis might result. Cost intensive patients with a high need for treatment are referred as quickly as possible and discharged to outpatient services despite unknown domestic follow-up care. Mostly the elderly are affected. Medical rehabilitation can be found in this system at the cut between SGB V and SGB XI. However, this division raises problems and discussions concerning benefit payment (rehabilitation before nursing, priority of home, etc.). Right in rehabilitation the most important thing is an overlap of sectors. Various medical, nursing and other social supplies have to be put into a network to achieve an integral treatment of patients that focuses on the individual situation.

[Differential indications for ambulatory and inpatient medical rehabilitation--results of an expert survey]. / Differentielle Indikation für ambulante und stationäre medizinische Rehabilitation--Ergebnisse einer Expertenbefragung.

Medical rehabilitation in the Federal Republic of Germany has been provided in an almost exclusively inpatient setting up to now. However, in view of an intensified development of outpatient rehabilitation programs there are new challenges to confront. As to indication criteria, new preconditions and handling directives have to be defined in order to refer patients to those rehabilitation programs from which they can profit the most. Up to now, there has been a considerable lack of knowledge as to what kind of criteria must be considered in the transfer process. The present study represents results of expert interviews (Delphi method) regarding this topic. 50 experts from inpatient and outpatient rehabilitation facilities, from the Medical Services of health insurance funds and the pension insurance system, from rehabilitation agencies as well as rehabilitation research, have been questioned since they take important stands on these questions and since their assessment has a guiding quality. An additional study had been directed at the factors which determine present decision-making in terms of inpatient vs. outpatient rehabilitation. The results show that the experts stress the importance of a multitude of different aspects; however, there still is but little consensus concerning the criteria that should invariably be considered in making these rehabilitation decisions.

Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial.

The aim of this cost-effectiveness study was to compare a combined operant programme plus cognitive/relaxation programme with an operant programme plus attention-control and to compare both programmes with a waiting-list control group and with operant rehabilitation provided, as usual, by the same rehabilitation centre. One hundred and forty eight patients with chronic low back pain were randomly assigned to the different conditions. The economic endpoints were the costs of the programme and other health care utilisation, costs for the patient, and indirect costs associated with production losses due to low back pain. The effects were measured in terms of global assessment of change and utilities, using rating scale and standard gamble methods. The 3-year study determined that adding a cognitive component to an operant treatment did not lead to significant differences in costs and improvement in quality of life when compared with the operant treatment alone. Compared with the common individual rehabilitation therapy it can be concluded that the same effects can be reached at the same or lower costs with a shorter, more intense standardised group programme. The operant treatment alone is more effective than providing no treatment in the waiting-list control group.

[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.

[Geriatric rehabilitation needs in Cologne: the concept of "integrated geriatric rehabilitation"]. / Geriatrischer rehabilitativer Versorgungsbedarf in Köln: Das Konzept "Integrierte Geriatrische Rehabilitation".

Given a growing number of elderly people and the related consequences for the health care system, such as increasing numbers of persons with chronic diseases or in need of long-term nursing care, the present rehabilitation system must be extended and new services be introduced. Hospitals in Cologne report that an average 48% of their geriatric patients are in need of rehabilitation measures. Taking into account the patients' willingness and capacity to undergo rehabilitation treatment, the figure reduces to 30%. Based on the number of geriatric patients treated in hospital each year, rehabilitation facilities for 15416 geriatric patients a year have to be provided. About two thirds of the patients require continued hospital treatment after the acute phase. Obviously, these treatments are not only performed in the geriatric departments of the hospitals, as only 161 geriatric beds are available in Cologne. One third of the patients could be taken care of on a partial hospitalization or outpatient basis after the acute phase. Thus, limiting a patient's length of stay in hospital could have a cost-containment effect. As partial hospitalization and outpatient rehabilitation facilities are lacking, the Cologne "Geriatrics" study group has developed a concept of "integrated geriatric rehabilitation", suggesting the establishment of mobile rehabilitation teams. The concept aims at developing a cooperative network linking outpatient with partial hospitalization and inpatient services, and including the physicians at community level.