[Involving patients in research]. / Beteiligung Betroffener an der Forschung.

Politics advocate the integration of patients in decision making processes as a means of individual participation. Patients' participation in research projects is a next step to fulfil this democratic goal.Concepts essential for rehabilitation are introduced that are germane in the context of participatory rehabilitation research. They are based on the results of 2 workshops where researchers, patients and those working in the field developed ideas for patients' participation in research and on a screening of relevant literature. Research traditions relevant for rehabilitation research are lined out, a stage model allowing design and documentation of patient participation is introduced, and recommendations for practice are given. The article ends with a list of open questions that need to be addressed in the future.

[Budget problems in rehabilitation]. / Budgetprobleme in der Rehabilitation.

The German Pension Insurance's spending for rehabilitative benefits is capped by a statutorily determined rehab budget, which is adjusted only in keeping with the development of gross income. Due to demographics and other factors rehabilitation need is increasing and it is getting more and more difficult to provide the necessary participation benefits. This can have an impact on the quality and effectiveness of rehabilitation and gives rise to the question whether prioritisation or even rationing of rehabilitation benefits will be necessary. Accordingly, a modified mechanism for adjustment of the rehab budget is discussed, which takes into account at least the main influences on rehabilitation need.

[A profile of requirements for the performance of work related medical rehabilitation from the perspective of the statutory pension insurance]. / Ein Anforderungsprofil zur Durchführung der medizinisch-beruflich orientierten Rehabilitation aus der Perspektive der gesetzlichen Rentenversicherung.

OBJECTIVES: Work-related medical rehabilitation (Work MR) is a specific part of medical rehabilitation, which is well-established and broadly investigated. In almost all indications there is evidence of benefit of Work MR in patients with distinctive work-related problems due to chronic disease or disability. Nevertheless, there is a lack of implementation in clinical practice. This is due to a variety of reasons, mainly a missing definition of the appropriate Work MR interventions. The development of a Profile of Requirements (PoR) for defining contents and patterns of Work MR on behalf of the Statutory Pension Insurance (SPI) therefore is a fundamental step towards evidence-based, needs-focused rehabilitation management. The article introduces such a PoR - for the present focused on somatic indications. METHODS: The PoR was developed by an SPI expert group and revised in an extensive discourse within the SPI. A strategy involved in this context was the dissemination of work-related therapeutical concepts in medical rehabilitation. RESULTS: In the PoR, Work MR is defined as a concrete work-related designing of therapeutical interventions as well as an integrated "philosophy" in thinking and practicing of the actors involved. Work MR is differentiated in 3 intervention levels: While work-related basic interventions (Level A) are provided in all facilities for all patients, core interventions (Level B) as well as specific interventions (Level C) are explicitly concentrated on patient subgroups with distinct work-related problems. In the PoR the relevant diagnostic and therapeutic work-related interventions are attributed to the different intervention levels and described concerning the concrete arrangement. The 3 central core interventions "Work-related psychological group interventions", "Work-related internal load test" and "Work conditioning" are presented. CONCLUSIONS: The decisive benefit of the PoR is to substantiate the requirements of Work MR on behalf of the SPI often worded in a rather unspecific manner in the past. In the current pilot study called "Work MR Management" the feasibility of Work MR in clinical practice based on the PoR is tested. The resultant recommendations will provide the basis for disseminating Work MR throughout Germany independent of setting and indication.

[Changes in medical rehabilitation of the German Statutory Pension Insurance Scheme]. / Veränderungstrends in der medizinischen Rehabilitation der gesetzlichen Rentenversicherung.

Medical rehabilitation in Germany has changed continuously since its inception following the Bismarck Legislation. This article describes its development up until the millennium and discusses quantitative and qualitative changes that followed. Central quantitative changes are demonstrated using the examples of rehabilitation utilization, spectrum of diseases, setting, and postacute rehabilitation. Important qualitative changes in medical rehabilitation pertain to the significance of research for the advancement of rehabilitation, the emphasis on work-related problems in rehabilitative concepts, patient orientation as a new paradigm, integration of rehabilitation into the health system, and prevention. The article ends with an outlook on future developments, such as the anticipated increase in rehabilitation need due to demographic changes and extended working life. Changes in the work environment lead to complex requirements for the development of rehabilitation. In view of increasingly scarce resources, continuous adaptation of rehabilitation concepts is mandatory to maintain health and earning capacity of the population.

[Quality Assurance in Rehabilitation under the German Pension Insurance Scheme]. / Stand der Qualitätssicherung in der Rehabilitation der gesetzlichen Rentenversicherung.

Ten years after its introduction, the German Pension Insurance's quality assurance programme is firmly established within the rehabilitation system. Regular, substantive reporting to rehabilitation centres and pension insurance organisations has contributed to improving the quality of rehabilitation. Legal codification of quality assurance stipulations has existed since 2001. The programme is in constant development, e. g. by optimization of patient interviewing and inclusion of evidence-based clinical practice guidelines. New programmes, e. g. in inpatient rehabilitation of children and youths or in outpatient rehabilitation, are being developed together with the German health care organizations. In the field of vocational rehabilitation quality assurance had started out with a conceptual study followed by projects concerning client interviewing, evaluation of documentation instruments, and analyses relative to the most important outcome factor, namely the vocational reintegration results achieved. External quality assurance is a mayor input factor for the rehabilitation centres' internal quality management. In future, rehabilitation centres will be asked to demonstrate the appropriate use of this information. It will remain the centres' decision which method of quality management system implementation they choose. Quality assurance results of every centre are planned to be made publicly accessible in the medium term, in particular to the insureds. Moreover, the results of the quality assurance programmes are intended to clearly impact the allocation of patients as well as the remuneration of the rehabilitation centres concerned. Quality assurance and quality management will continue to play a major role in the political discussion of health care.

[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.

Predictors of early retirement and rehabilitation for use in a screening to detect workers in need of rehabilitation.

In the German pension insurance sector a screening is being suggested to ensure the participation in rehabilitation measures of workers at risk of health-related early retirement. Screening presupposes empirical indicators of rehabilitation needs. A study is presented that determined predictors of early retirement and rehabilitation from longitudinal data for use in a screening for the selection of workers likely to be in need of rehabilitation. We gathered longitudinal data by conducting a second survey with a cohort for which the first survey had delivered clinical findings, lab. values, medical diagnoses and self reports regarding morbidity, medication, health-related behavior, family- and occupational-related strains, and sociodemographic information (first survey T0: 1975/76, n = 3.968; second survey T1: 1992/93, n = 28.463). The survey of T1 also comprised inquiries of the pension insurance institutions concerning the retirement and rehabilitation status for pension-insured study subjects (n = 1.794). Based on these subjects, using multi- and bivariate regression analysis, we determined those T0 variables which were significantly related to the events of early retirement (98 cases/357 controls), rehabilitation (127 cases/200 controls) and early retirement or rehabilitation (185 cases/270 controls) in the period T0-T1. The significant T0 variables were subsequently used for the definition of a selection index which measured rehabilitation need by a simple sum score (number of significant T0 variables present). We tested the discriminative power of this index for a subsample of the cohort (cases who retired early or underwent rehabilitation and controls). The index classified 68% of the cases correctly. The sensitivity reached 57% and the specificity 76%. In connection with this result, the long prognostic time interval (up to 17 years) has to be considered. In the case of screening the preselection of workers via the index would occur at the same time as the medical assessment of the actual need for rehabilitation. An earlier study showed that this would raise sensitivity and specificity of an index based on predictors of early retirement substantially.

[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.

["Index for rehabilitation eligibility" for screening social insurance workers]. / Ein "Index der Rehabilitationsbedürftigkeit" für ein Screening rentenversicherter Arbeitnehmer.

The principle "priority of rehabilitation over early retirement" might be realised by a screening by which employees in need of rehabilitation are detected in time and rehabilitation measures are purposively started. With the "Index of Rehabilitation Need" we continued our efforts to develop an applicable screening tool on an epidemiological basis. To this end (1) longitudinal data were established by repeating an epidemiological survey of a population sample in the Nordenham/Brake region (T0 = 1975/76, T1 = 1992/93); (2) T0-variables were identified which correlated significantly with the events of early retirement and/or rehabilitation in the period of T0 to T1 (98 cases of early retirement/357 controls; 127 cases of rehabilitation/200 controls; 185 cases of early retirement of rehabilitation/270 controls) using bivariate and multivariate regression analysis; (3) significant T0-variables were used to construct a questionnaire index (based on self assessment of symptoms/complaints, consumption of medicaments, smoking, and work load--16 items), a medical examination index (based on clinical/laboratory findings and medical diagnoses--10 items), and an overall index (sum of both indices--26 items); (4) the index values were calculated for cases of early retirement of rehabilitation and controls of the cohort (185/270), for each index significant differences between cases and controls tested, and the screening characteristics of the overall index analysed; (5) possible reasons for incorrect classifications were examined using a subsample of cases and controls (n = 96/78), for which additional data on medical and work history, stressful life events, and attitudes towards rehabilitation had been collected. All indices showed significant differences between cases of early retirement or rehabilitation and controls. These differences proved to be stronger with the questionnaire and overall indices (p < .0000 each) than with the medical examination index (p < .0006). The overall index did not detect 18% of the cases in need of rehabilitation (false negatives). The proportion of the false positives was 14%; sensitivity and specificity amounted to 57% and 76%. The analysis of the subsample revealed only two possible and plausible reasons for incorrect classifications: the time span between the first survey and the year of early retirement as well as injuries. The index detected cases of early retirement or rehabilitation more easily where the time span between T0 and the year of early retirement was shorter. The index cannot detect cases of early retirement and rehabilitation caused by injuries between T0 and T1, since it is based on chronic disorders and stresses to be the reason for both events. With respect to the sensitivity and specificity of the index the relatively long prediction period needs to be taken into consideration--between T0 and the time of the events there could have been a period of up to 17 years. However, the objective of a screening is not to predict the long-term outcome but to preselect persons who are likely to need rehabilitation and should be invited to a socio-medical examination in order to clarify their rehabilitation need and to start appropriate rehabilitation measures. The chance to detect true positive candidates and to exclude false negative candidates is essentially higher when the measurement of the predictors and the examination are carried out at the same time as has been shown in a former study. With regard to further proceedings we suggest to apply the index in a screening and to investigate the cost effectiveness and other aspects of the screening in a demonstration project.