Minimisation of dialysis risk in hospital patients with chronic kidney disease (MinDial): study protocol for a multicentre, stepped-wedge, cluster-randomised controlled trial.

BACKGROUND: Early identification of patients with chronic kidney disease (CKD) and advancing kidney insufficiency, followed by specialist care, can decelerate the progression of the disease. However, awareness of the importance and possible consequences of kidney insufficiency is low among doctors and patients. Since kidney insufficiency can be asymptomatic even in higher stages, it is often not even known to those belonging to risk groups. This study aims to clarify whether, for hospitalised patients with advanced chronic kidney disease, a risk-based appointment with a nephrology specialist reduces disease progression. METHODS: The target population of the study is hospitalised CKD patients with an increased risk of end-stage renal disease (ESRD), more specifically with an ESRD risk of at least 9% in the next 5 years. This risk is estimated by the internationally validated Kidney Failure Risk Equation (KFRE). The intervention consists of a specific appointment with a nephrology specialist after the hospital stay, while control patients are discharged from the hospital as usual. Eight medical centres include participants according to a stepped-wedge design, with randomised sequential centre-wise crossover from recruiting patients into the control group to recruitment to the intervention. The estimated glomerular filtration rate (eGFR) is measured for each patient during the hospital stay and after 12 months within the regular care by the general practitioner. The difference in the change of the eGFR over this period is compared between the intervention and control groups and considered the primary endpoint. DISCUSSION: This study is designed to evaluate the effect of risk-based appointments with nephrology specialists for hospitalised CKD patients with an increased risk of end-stage renal disease. If the intervention is proven to be beneficial, it may be implemented in routine care. Limitations will be examined and discussed. The evaluation will include further endpoints such as non-guideline-compliant medication, economic considerations and interviews with contributing physicians to assess the acceptance and feasibility of the intervention. TRIAL REGISTRATION: German Clinical Trials Register DRKS00029691 . Registered on 12 September 2022.

[A German Survey of Goal Setting and Goal Agreement in Medical Rehabilitation]. / Reha-Zielvereinbarungen in der medizinischen Rehabilitation: eine bundesweite Bestandsaufnahme.

AIM: To describe the current practice of goal setting and goal agreement in the Medical rehabilitation in Germany. METHODOLOGY: Rehabilitation centers contracted by the German Pension Insurance and covering all indications were approached by a questionnaire survey. RESULTS: The percentage of questionnaires returned was 48.1% (N=716). 93.3% of the responders replied that the importance placed on "rehab goals" at their institution was "very high" (41.1%) or "quite high" (52.2%). Our findings, however, reveal the potential for improving the quality of setting rehab goals in the fields of "process orientation", "team orientation" and "patient orientation". CONCLUSION: Rehabilitation centers perceive current practice in goal setting and goal agreement as being on a high level. The rehabilitation centers name many positive aspects as well as barriers to goal setting. Those problems should be more frequently addressed in practice.

[Questionnaire "Coping Procedures - Goals and Appraisals": Development and First Psychometric Evaluation in Patients with Chronic Back Pain]. / Entwicklung des Fragebogens "Krankheitsbewältigung - Ziele und Bewertung" und erste psychometrische Prüfung bei Patienten mit chronischen Rückenschmerzen.

AIM: Development of a disease specific Common Sense Model of Self-Regulation (CSM) based questionnaire assessing 'coping procedures', and their 'appraisal'. In this article, we describe the questionnaire and conduct a psychometric evaluation of the 'coping procedures'. METHODS: The item pool was generated in a multimodal way. Data were collected from 9 orthopedic rehabilitation centres, with longitudinal measurement at 3 points in time. The sample comprised N=214 rehabilitation patients. RESULTS: The questionnaire comprises CSM-based items with respect to coping procedures, their goals, and their appraisal. The coping procedures items loaded onto 2 scales, which reflected coping procedures with a focus on activity vs. biomedicine. A confirmatory analysis of a model with these 2 factors indicated an acceptable model fit. The distribution characteristics of the scales were in the range of normal distribution. Internal consistency was acceptable. The data show construct validity, sensitivity to change, comprehensibility and acceptance of the questionnaire. CONCLUSIONS: The psychometric results were satisfactory. The practical implications of our results are discussed.

[Rehabilitation Goals of Patients with Coronary Artery Disease and Chronic Back Pain - An Analysis of Free Text Responses]. / Rehabilitationsziele von Patienten mit koronarer Herzerkrankung und chronischen Rückenschmerzen - Eine inhaltliche Analyse freitextlicher Zielnennungen.

BACKGROUND AND OBJECTIVE: Goal-setting is considered as an important step in medical rehabilitation. Regarding patient participation in the process, the possible inability of patients to develop personal goals is often discussed as a potential obstacle. This article examines whether patients have goals for medical rehabilitation and if so, which. METHODS: 189 patients with a diagnosis of coronary heart disease and 254 patients suffering from chronic back pain were surveyed in the run-up to their inpatient rehabilitation. Using a questionnaire, patients were asked to note their 3 most important rehabilitation goals. The free text data were then analyzed qualitatively and quantitatively. RESULTS: Most patients were able to express their personal rehabilitation goals before the beginning of their rehabilitation process.. Goals referring to coping with the disease were important to patients with both diagnoses. CONCLUSION: The rehabilitation goals expressed by the patients are suited for a participative goal-setting.

[Collaborative Goal Setting in Rehabilitation (ParZivar II): Evaluation of an Intervention in Patients with Chronic Back Pain]. / Partizipative Zielvereinbarung in der Rehabilitation (ParZivar II): Evaluation einer Intervention bei Patienten mit chronischen Rückenschmerzen.

OBJECTIVE: The "ParZivar II" project had 2 aims: optimization of the "ParZivar I" intervention by individual coaching of physicians, and evaluation of the optimized intervention. METHODS: The intervention was evaluated in a sequential control group design in 4 rehabilitation facilities with 3 measurement points. A total of n=279 patients with chronic low back pain participated in the study. RESULTS: The optimized intervention shows the potential to statistically significantly improve proximal outcomes (e. g. goal-centric processes or patient-physician interaction). Regarding distal outcomes, no statistically significant differences were found. CONCLUSION: The "ParZivar" intervention is a suitable approach to increase participative goal setting. Due to the complexity of the intervention, problems of dissemination and the potential for improvement in study design, there is a need for further research.

Adolescent and parental perceptions about asthma and asthma management: a dyadic qualitative analysis.

BACKGROUND: Considering that asthma management is a family affair - with specific challenges in adolescence - a better understanding of both adolescent and parental perspectives on asthma and its treatment are needed as these constructs may substantially account for variation in illness-related behaviour and functioning. The present study aimed to (1) explore adolescents' and caregivers' perceptions about asthma and asthma management and (2) examine congruence and dissimilarities within the adolescent-caregiver dyads. METHODS: Data collection was conducted separately for adolescents and caregivers using a focus group approach for the adolescents and telephone interviews for parental data collection. In total, dyadic data from n = 15 adolescent patients with asthma (aged 11-17 years, M = 14.9) and their mothers (aged 37-55 years, M = 46.3) were considered in the study. The interviews were transcribed verbatim and analysed in a dyad-focused multistep qualitative content analysis procedure using the software. RESULTS: The results demonstrated high complexity in the perceptions among adolescents and mothers and reflected 113 specific themes that could be assigned to four main topics: asthma beliefs, representations of asthma treatment, perceptions about individual asthma management and perceptions about family asthma management. Dyadic analyses revealed congruence in the adolescent-caregiver dyads in most of the themes. However, we also found issues where divergent perceptions became evident including, for example, perceptions of asthma's general impact on adolescents' life or the question of who takes the main responsibility in asthma management. CONCLUSIONS: Adolescents' and caregivers' perceptions were found to reflect a great variety of beliefs regarding the adolescents' illness and illness-related behaviour on both the individual and the family level. The study adds to the illness perceptions literature by providing a systemic perspective that was rather rarely presented in prior research.

[Consideration of Rehabilitation within High Class Quality Guidelines, Registered by the German Association of the Scientific Medical Professional Societies (AWMF)]. / Berücksichtigung der Rehabilitation in den S3-Leitlinien im Register der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF).

Clinical practice guidelines are systematically developed documents aiming at guiding decisions in specific areas of health care. Therefore, incorporating rehabilitation in guidelines adressing chronic diseases is of major importance. As information regarding consideration of rehabilitation in guidelines is lacking, the intention of our study was to analyse to what degree rehabilitation experts participated in guideline development and whether guidelines for chronic diseases include relevant information and recommendations concerning rehabilitation.In order to answer these questions we investigated 97 guidelines of high class quality, registered by the German Association of the Scientific Medical Professional Societies (AWMF). 36 out of these guidelines addressed chronic health conditions in which rehabilitation may be of relevance. Guidelines identified were analysed using a set of defined criteria.In 11 out of the 36 guidelines one or more medical rehabilitation societies participated in the development process, 17 include a chapter on rehabilitation issues, and 20 information concerning indication for rehabilitation processes. 24 guidelines consider rehabilitation in their recommendations.There is substantial variance concerning inclusion of rehabilitation in German guidelines on chronic diseases. Rehabilitation societies are encouraged to strive for stronger integration of rehabilitation into guidelines of other societies.

[Evaluation of a collaborative goal setting intervention in patients with chronic back pain]. / Evaluation einer Intervention zur partizipativen Vereinbarung von Rehabilitationszielen bei Patienten mit chronischen Rückenschmerzen.

BACKGROUND AND OBJECTIVE: Although setting rehabilitation goals is considered to be a core rehabilitation process, in actual rehabilitation practice there is a considerable need for improvement with respect to consistent goal orientation. The objective of the PARZIVAR project was therefore to develop an intervention for participative goal setting in medical rehabilitation. This article reports the results of the evaluation of the PARZIVAR intervention in patients with chronic back pain. METHODS: The PARZIVAR intervention was evaluated in a sequential control group design with 3 measurement points (before the start of rehabilitation, at the end of rehabilitation, and at 6-month follow-up). The proximal endpoints were defined as patient perception of participative goal setting, subjective awareness of goals, and satisfaction with goal setting. The distal endpoints were intensity of pain and generic and illness-specific functioning. RESULTS: Overall, the degree of achieving aspects of participative goal setting was higher in the intervention group. There were no differences regarding satisfaction with goal setting, however, and distal outcomes also remained unchanged after the intervention was implemented. DISCUSSION: Participation in the PARZIVAR intervention was partially reflected in the perception of the rehabilitation patients, but the effects regarding distal outcomes in the intervention group did not exceed those of usual care. There is a need for more research into how concepts of goal setting can be improved in the future to better address the diverse functions of goal setting.

[Female patients with fibromyalgia syndrome in somatic and psychosomatic rehabilitation center - an exploratory study on access routes and differences in patient characteristics]. / Fibromyalgiesyndrom-Patientinnen in psychosomatischen und somatischen Rehabilitationseinrichtungen - eine explorative Studie zu Zugangswegen und Unterschieden in Patientenmerkmalen.

STUDY OBJECTIVE: Fibromyalgia syndrome (FMS) is characterized by e. g. chronic, multilocular pain, and mental health problems. In Germany, patients with FMS are treated in somatic and psychosomatic rehabilitation centers - specialized for rheumatic diseases (somatic) or psychosomatic diseases. The aim of this study is to identify the status quo of FMS patients' access routes to the rehabilitation system, and to identify their predictors for being assigned to one or the other indication group. METHOD: Our cohort consists of 197 FMS patients from 3 psychosomatic (M=49.9 years) and 223 FMS patients (M=50.2 years) from 3 somatic rehabilitation centers. At the beginning of rehabilitation, patients filled out a questionnaire packet to identify their access routes to the rehabilitation centers and to record patients' disease-related, psychosocial and socio-demographic characteristics. To analyze the results we used descriptive calculations, calculated bivariate correlations, and conducted binary logistic regression analysis for the prediction of group membership. RESULTS: The access routes of FMS patients to a somatic or a psychosomatic rehabilitation center were often similar. Some items revealed significant group differences, i. e., a higher primary -rejection rate, longer waiting period between application for rehabilitation and its approval, and between the application itself and initiation of psychosomatic rehabilitation in comparison to somatic FMS patients. Prior experience of out-patient psychotherapy, and expectations ("psychological support") for the rehabilitation were predictive patient characteristics for the assignment into a psychosomatic rehabilitation center. Marriage, motivation, and expectations ("physical improvement" and "interaction with other patients") for the rehabilitation were predictive patient characteristics for the assignment in a somatic rehabilitation center. The predictors clarified 32% of the variance of group membership. CONCLUSION: Our results provide initial evidence of how FMS patients access the German rehabilitation system and which of their characteristics are responsible for being assigned to a particular rehabilitation setting.

[Rehabilitation from the patient perspective--a qualitative analysis of the treatment beliefs of patients in inpatient orthopedic and psychosomatic rehabilitation]. / Rehabilitation aus Patientensicht--Eine qualitative Analyse der subjektiven Behandlungskonzepte von Patienten in der stationären orthopädischen und psychosomatischen Rehabilitation.

PURPOSE: As the common sense self-regulation model (CSM) was further developed in the late 1990s, its focus was, along with subjective illness perceptions, the treatment representations of patients, in particular medication-related perceptions. However until now, only few studies have dealt with subjective concepts regarding non-medication treatment. The objective of this study was to explore the core content areas of the treatment concept of rehabilitation patients as a basis for developing a questionnaire to survey rehabilitation-related treatment beliefs. METHODS: In 5 inpatient rehabilitation centres for psychosomatic and musculoskeletal diseases, guided focus groups were conducted with a total of n=25 rehabilitation patients. Some 56% of the participants were female; the average age was 52.8 years (SD=10.8). The interviews were transcribed and analyzed using the computer programme Atlas.ti based on the method recommended by Mayring in a multi-stage qualitative content analysis procedure. RESULTS: In the analysis of the discussion transcriptions, a total of 579 patient statements were categorized with 49 codes that were assigned to the areas (1) expectations and beliefs with respect to the rehabilitation process, (2) expectations of results, and (3) fears associated with rehabilitation. The process expectations were the most frequently discussed topic, constituting 58.2% of all patient statements. It was found that the patients associate not only numerous individual treatments with rehabilitation but also have concrete perceptions about the specific form rehabilitation should have, their own role in the rehabilitation process, and features of the overall rehabilitation concept. The outcome expectations are related to the areas activities of daily life and job, psyche, soma, and effectiveness of rehabilitation. Fears with respect to rehabilitation generally played only a subordinate role for those surveyed. The indication-specific analyses showed that the perceptions regarding the realization and form of rehabilitation differed among the various diagnosis groups, but the patients named similar categories for expectations of results and fears, with only some variation in importance. CONCLUSION: The focus groups allowed good insights into the patient perspectives of rehabilitation. Simultaneously, a good basis was created for generating contents of items for a questionnaire on the rehabilitative treatment concept, so that along with literature analyses, the qualitative method proved to be a suitable approach and good source for developing a questionnaire.

[Goal setting in inpatient medical rehabilitation: exploring the current practice]. / Reha-Zielvereinbarungen - gegenwärtige Praxis in der stationären medizinischen Rehabilitation.

OBJECTIVE: Goal setting is regarded as a key element in the rehabilitation process. Information about current goal setting practice is limited. However, there is potential for further improvement, e. g. as far as patient participation in the goal setting process is concerned. The study reports results of a survey on the current practice of goal setting in medical rehabilitation, focusing on development potential. The study examines acceptance and requirements for goal setting as well as patients' and professionals' experiences regarding goal setting during the rehabilitation process, with an emphasis on patient participation. METHODS: A total of n=40 rehabilitation professionals and n=210 inpatients with a diagnosis of chronic back pain, diabetes mellitus type 2 or coronary heart disease were surveyed at six rehabilitation centres using a questionnaire. Questionnaires contained predominantly closed-ended items regarding the current practice of goal setting. Several items were identical for both groups. In addition to the quantitative evaluation by means of frequency analyses free text data were evaluated. RESULTS: Rehabilitation professionals saw various benefits in goal setting with patients. Many professionals experienced patients to have personal goals for their rehabilitation, and most of them believed that patient participation in goal setting is possible. Also, barriers and requirements for goal setting were identified. A consistent concept for goal setting, involvement of and exchange between the different occupational groups and an elaborate handling of information in the context of goal setting seem to be realised at least partially. Professionals and patients reported similar frequencies of talks on goal setting at different times during the rehabilitation course. Patient participation seems to be realised to some extent but not comprehensively. The results show slight discrepancies between patients' and professionals' statements. DISCUSSION: Current practice of goal setting in inpatient rehabilitation of patients with the diagnoses named above is altogether on a relatively advanced level in the rehabilitation centres taking part in the study. The study identifies potential for development concerning a comprehensive implementation of goal setting, the realisation of patient participation, goal documentation and their integration into rehabilitation. Moreover, deeper involvement of the rehabilitation team and a stronger conceptual integration of the subject within the centres seem desirable. This can be taken up within the scope of interventions.

[Guidelines and guideline research. Overview and state of guideline implementation in medical rehabilitation]. / Leitlinien und Leitlinienforschung. Übersicht und Stand der Leitlinienimplementierung in der medizinischen Rehabilitation.

"Guideline research" is understood here to be the area of healthcare research that deals with the methodology and evaluation of processes for developing, implementing, assessing, and evaluating guidelines. For example, guideline research deals with the selection of adequate implementation strategies and the proof of the effectiveness and efficiency of the implementation of guidelines. The current data situation does not allow any reliable statements to be made about whether and to what extent the health-related outcome for patients is actually improved by implementing guidelines. For medical rehabilitation, there are a number of guidelines which appear to be just as good with respect to quality as the guidelines for acute medicine. However, there is a need for improvement in the quality criteria for methods. Rehab-related guidelines and therapy standards can be found in the AWMF guidelines, in the program for national healthcare guidelines, and in the rehabilitation quality assurance of the German Pension Fund. Guideline research in rehabilitation should concentrate on topics that arise from the specific situation of this area of healthcare, e.g., development of interdisciplinary guidelines, applicability of guidelines for multiple diseases, or possibility of evidence-based guidelines for complex interventions.

[The methodological quality of rehabilitation guidelines]. / Methodische Qualität von Leitlinien in der Rehabilitation.

INTRODUCTION: The concepts of clinical guidelines contribute to the decision-making and improvement in the quality of medical supply. This paper provides a literature research on rehabilitation guidelines and their evaluation by the "German Instrument for Methodological Guideline Appraisal (DELBI)". METHODS: The clinical guideline research was conducted with the help of an online database as well as expert surveys conducted between August and October 2007. The literature research was updated in October 2008. Only those guidelines that satisfied specific criteria were included in the evaluation. RESULTS: Although the research yielded 124 guidelines, only 28 were included in the evaluation after applying the criteria. In total, the evaluation was heterogeneous. With regard to each domain, the mean degree of fulfillment reached between 2.1% and 58.3%. DISCUSSION: Due to an extensive and detailed literature research and expert survey, all relevant clinical guidelines for rehabilitation, which are valid in Germany, could be gathered. A first examination of the guidelines seems to reveal several deficiencies. Possible reasons are discussed. CONCLUSION: This paper reveals a detailed survey of the clinical guidelines for rehabilitation. Compared to acute-care medicine, the number of available guidelines is distinctly smaller. With regard to the DELBI criteria, an enormous development in the quality of guidelines for rehabilitation is still necessary. Some of these might be due to inaccurate documentation, which will have to be considered in a further update.

[Development, implementation and use of an intervention procedure for providing needs-based patient information for rehabilitation patients]. / Entwicklung, Implementierung und Umsetzung einer Intervention zur bedarfsgerechten Patienteninformation für Rehabilitandinnen und Rehabilitanden.

PURPOSE: Patients have a great need for information that is often not satisfied by providing "standard" information. In order to reach the patients better, it is increasingly necessary to tailor patient information to the individual needs of patients and make stronger use of patients' "common sense" models. This article reports on the development and implementation of an intervention procedure for providing needs-based patient information as well as on initial results of its use. METHODS: Both the intervention concept and the operationalization of its contents are based on the common sense self-regulation model (CSM). The intervention aims to link the information given to patients to the existing illness beliefs and treatment beliefs of the rehabilitation patients. To do this, the illness and treatment representations held by the patients before rehabilitation are assessed, automatically analyzed using a computer programme, and aggregated in a "response questionnaire". This feedback is then passed on to the information-providing therapists well in advance of admission of the rehab patients. The contents and key organizational data of the intervention procedure were discussed with the treatment providers in a feasibility analysis before implementation. In addition, intervention training was also conducted before the start of the intervention. Since August 2009 the procedure has been implemented and evaluated in 9 cooperating rehab centres. Process documentation provides criteria relative to the feasibility of the intervention. RESULTS: The results on implementation of the intervention as well as on its feasibility have thus far been relatively encouraging. The treatment providers ascribe high relevance to the contents of the intervention and assess the major components to be generally feasible. From the treatment provider viewpoint, the rehabilitation patients benefit from the intervention, and it is also considered to be helpful for planning further treatment. CONCLUSION: The intervention procedure for needs-based patient information presents an option for making information available to patients as needed. It is based on theory and accepted by treatment providers. The strengths and weaknesses of the intervention are discussed.

Illness representations in women with fibromyalgia.

OBJECTIVE: In the US population, the prevalence of fibromyalgia is about 3.4% in women. For those who are affected, fibromyalgia is associated with significant limitations relating to quality of life, activity, and participation. Furthermore, fibromyalgia leads to serious socio-economic costs. The objective of the present paper is to describe the cognitive illness representations of women with fibromyalgia and to analyse their relationship to rehabilitation outcomes. METHODS: The outcome was measured using the SF-36 and fibromyalgia impact questionnaire. The illness perceptions were assessed using the Illness Perception Questionnaire - revised. The prediction of outcome was done using hierarchical multiple regression analyses. RESULTS: N=245 patients are included in the sample. The patients attribute a multitude of symptoms to fibromyalgia and name numerous triggering factors. Illness representations are correlated with the illness impact at the beginning of rehabilitation and predict the outcome after the end of rehabilitation. CONCLUSION: The fact that illness representations turn out to be predictors of outcome, even when the baseline health status is statistically controlled, highlights the relevance of the illness representations of patients with fibromyalgia. Therefore, effective and efficient methods should be developed for integrating patient's illness beliefs into the management of the illness as early as possible.

[Development of a questionnaire to assess treatment representations in rehabilitation patients]. / Entwicklung eines Fragebogens zur Erfassung des subjektiven Behandlungskonzepts von Rehabilitanden.

PURPOSE: The purpose of the study was to develop a generic questionnaire for assessing the patients' rehabilitation treatment representations on the theoretical basis of the Common Sense Model of self-regulation and analogous with established assessment instruments for illness representations and medication-related treatment representations. METHODS: Using theory-based and empirical patient and provider input, a pool of 115 items on the patients' rehabilitation treatment representations was generated. The items were first pre-tested on n=182 rehabilitation patients in nine rehabilitation centres for the indications musculoskeletal diseases and psychosomatic illnesses. The next step was the factor analytical reduction of the item pool. The resulting factors were analyzed for unidimensionality, and the remaining items were analyzed for distribution of values. Internal consistency and the "known groups validity" were used to determine reliability and validity, respectively. Finally, patient acceptance of the questionnaire was assessed. RESULTS: The item pool was considerably reduced by factor analysis and the remaining items were grouped under four factors. After eliminating other single items on the basis of modification indices and indicator reliability, the unidimensionality of these factors was assessed as good. The majority of the remaining 23 items showed an asymmetrical distribution, which was also reflected by low item difficulty. The contents of the scales can be interpreted as "somatic outcome expectation", "psychological outcome expectation", "process expectations", and "concerns". The internal consistency of the scales (Cronbach's alpha) lies between 0.80 and 0.84 for the entire sample. The treatment representations for psychosomatic patients differ in the anticipated direction from those of orthopaedic rehabilitation patients. Patient acceptance of the questionnaire was very positive. CONCLUSION: The questionnaire developed allows aspects of the patients' rehabilitation treatment representations to be measured, the features of which are highly relevant for providers as a basis for providing individualized patient information. However, the results of the pretest have to be tested confirmatory and also indicate that there is still potential for improving the instrument and making it more precise.

[Quality assurance and guidelines in rehabilitation for musculoskeletal diseases]. / Qualitätssicherung und Leitlinien in der Rehabilitation bei muskuloskelettalen Krankheiten.

Diseases of the musculoskeletal system are among the most common and most costly diseases in Germany. They are also associated with a considerable burden for those affected. As a result these disorders also dominate the utilization statistics with respect to medical rehabilitation measures paid for by the statutory pension insurance. In the last 10 years, quality assurance programs have been developed for rehabilitation--initiated and financed by the rehabilitation sponsors--that are characterized by a comprehensive, perspective, pronounced scientific basis, region-wide implementation, and strong patient orientation. The development of guidelines for rehabilitation began later than for acute medicine. In addition to the formulation of guidelines for rehabilitation by medical organizations and professional associations, the German pension insurance has developed so-called process guidelines containing framework requirements for the treatment of defined indication groups rather than support for decision-making in the rehabilitation of individual patients. By planned control of adherence to the process guidelines in the quality assurance programs of the pension insurers prompt implementation of the guidelines can be anticipated.

[Quality assurance in outpatient medical rehabilitation - concept and results of a pilot project to develop a quality assurance programme for musculoskeletal and cardiac diseases]. / Qualitätssicherung in der ambulanten medizinischen Rehabilitation: Konzeption und Ergebnisse eines Pilotprojekts zur Entwicklung eines Qualitätssicherungsprogramms für die Indikationsbereiche muskuloskeletale und kardiologische Erkrankungen.

PURPOSE: The concept and results of a pilot project to develop a quality assurance programme for outpatient medical rehabilitation in musculoskeletal and cardiac diseases are discussed. The processes developed and the results that were achieved using the instruments in 24 pilot institutions are described. METHODS: The quality of structure was assessed by defining and applying basic and detailed criteria; a version of peer review for outpatient treatment was developed to test the quality of process. The quality of results was determined by means of a prospective study with two or three measurement times and implementation of generic and disease-specific measurement instruments. The process was tested on n=1475 patients with musculoskeletal diseases and n=843 patients with cardiac diseases. RESULTS: The level of the quality of structure in the participating centres is quite high; 89-93% of the structure features required were fulfilled. The peer review indicated that the process had 25-40% serious shortcomings in cardiology and 15-20% for musculoskeletal diseases. The quality of results measurements show that the participating outpatient rehab centres achieved medium effects for the majority of the core rehab dimensions for the respective indications, but the findings also showed that at the time the follow-up reports were made there was often a reduction of positive effects and high effects were quite rare. While there were marked differences in quality of structure and process among the various institutions, there were only slight differences among the outpatient centres regarding quality of results. CONCLUSIONS: A scientifically sound quality assurance programme was developed that covers specific aspects of outpatient rehabilitation, to a great extent using the same structures that have been implemented in the quality assurance programmes for inpatient treatment. To implement the results presented here, the scientific findings will need to be evaluated in the respective committees of the cost-carriers. The tests of the programme in 24 pilot institutions showed an overall high level of quality, but also revealed potential for improvement in some areas.

[Evaluation of quality assurance--current data and consequences for research]. / Evaluation der Qualitätssicherung--aktuelle Datenlage und Konsequenzen für die Forschung.

The number of voluntary and compulsory quality assurance programs has been continuously increasing in all sectors of the healthcare system for many years, on both national and international levels. Based on a current, comprehensive analysis of the literature, however, the evidence of their efficacy and efficiency is limited at this time; even though positive impacts for quality management and quality assurance measures, especially on performance processes, are reported, the impact on outcomes has not been proven or has been insufficiently demonstrated up to now, and the data must be evaluated, overall, as "consistently inconsistent". Based on this evaluation, causes for the lack of evidence and the high variability of the results are first outlined, which are especially inherent in the complexity and heterogeneity of the analyzed interventions. Building on this, the implications for future evaluations of quality management and quality assurance measures are then inferred.

[Structure quality assurance in in-patient medical rehabilitation of children and adolescents]. / Sicherung der Strukturqualität in der stationären medizinischen Rehabilitation von Kindern und Jugendlichen.

BACKGROUND: So far, the routine programmes of the statutory pension and health insurance institutes for quality assurance in medical rehabilitation have not included facilities for children and adolescents. Thus, a conjoint project of the statutory pension and health insurance institutes to assess and to describe the structure quality of in-patient medical rehabilitation clinics for children and adolescents was initiated. The aim of the project was a survey and an analysis of the currently existing clinic structures and the development of criteria for an evaluation of the structure quality. The Institute of Medical Psychology, University of Hamburg and the Department of Quality Management and Social Medicine, University of Freiburg were engaged to conduct the project. METHOD: A questionnaire was developed in a multi-stage process with expert involvement which covers general information, characteristics of structure quality as well as structure affiliated process characteristics of clinics. The survey was planned as a cross-sectional study. Data collection was accomplished from 1.12.2004 - 15.3.2005. RESULTS: A total of n = 177 facility addresses were available. The return rate was 83.3 %. Eventually, n = 79 facilities were included in the analysis. In sum, the results underline the heterogeneity of services in the field of child and adolescent rehabilitation. CONCLUSIONS: The results allow an analysis of the current clinic structures as well as a first comparison of clinics on the basis of the assessed structure characteristics.