[Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part II: Structural Requirements to Manage an Appropriate Rehabilitative Healthcare]. / Die Zukunft der medizinisch-rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil II: Strukturelle Voraussetzungen und Anforderungen an das rehabilitative Versorgungssystem.

BACKGROUND: Rehabilitative health care is paying increasing attention to multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance. METHODS: Terms, requirements, design, configuration, challenges and supply of sociomedical rehabilitation were described in part I. A project group of the Medical Advisory Board of the Federal Rehabilitation Council describes manifold fields of actions to be taken in the rehabilitation of persons with multimorbidity. RESULTS: The actions proposed range from reviewing existing forms of management to identifying rehabilitative needs and initiating accurately fitting interventions, sensitizing and enlarging competences of involved personnel, considering multimorbidity in guidelines and further research on questions still open.

[Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part I: Definition of Terms, Issues and Challenges]. / Die Zukunft der medizinisch­rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil I: Begriffsbestimmung, Versorgungsfragen und Herausforderungen.

BACKGROUND: Rehabilitative health care is increasingly focusing its attention on multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance. METHODS: After defining the term "multimorbidity" in the context of rehabilitative health care, an exploratory overview of the prevalence and clinical implication of this condition as reported in the literature was drafted. Based on a case history, special attention was paid to general as well as special challenges regarding design, configuration and supply of sociomedical rehabilitative care. Consensus was achieved with the Health Advisory Board of the German Federal Rehabilitation Council. RESULTS: The proposed actions necessary for the healthcare of persons with multimorbidity include specific function-oriented individual assessment of needs via the distinctive allocation, selection and performance of rehabilitative procedures as well as post-rehabilitative care until the patient's reintegration into his social environment.

[Correction: Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part I: Definition of Terms, Issues and Challenges]. / Errata: Die Zukunft der medizinisch­rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil I: Begriffsbestimmung, Versorgungsfragen und Herausforderungen.

W. SEGER, W. CIBIS, A. DEVENTER, S. GROTKAMP, N. LüBKE, P.-W. SCHöNLE, M. SCHUBERT. DIE ZUKUNFT DER MEDIZINISCH-REHABILITATIVEN VERSORGUNG IM KONTEXT DER MULTIMORBIDITäT - TEIL I: BEGRIFFSBESTIMMUNG, VERSORGUNGSFRAGEN UND HERAUSFORDERUNGEN KüNSTLERISCHE THERAPEUTEN IM GESUNDHEITSWESEN. GESUNDHEITSWESEN 2016;: Bei diesem Beitrag fehlte ein Autor und die zugehörige Institutsangabe. Nachfolgend die ergänzten Autoren und Institute: AUTOREN:: W. Seger1, W. Cibis2, A. Deventer3, S. Grotkamp4, N. Lübke5, P.-W. Schönle6, M. Schmidt-Ohlemann7, M. Schubert2 INSTITUTE:: 1 MDK Niedersachsen, Hannover 2 Bundesarbeitsgemeinschaft für Rehabilitation (BAR), Frankfurt 3 Praxis für Physikalische und Rehabilitative Medizin, Hamburg 4 MDK Niedersachsen, SEG 1, Hannover 5 Kompetenz-Centrum Geriatrie (KCG), Hamburg 6 Maternus Kliniken, Bad Oeynhausen 7 Diakonie Bad Kreuznach, Rehabilitationsklinik, Bad Kreuznach.

[False Medical Treatment Investigation in Otorhinolaryngology by the MDK in Lower Saxony and Bremen]. / Behandlungsfehlerbegutachtung in der HNO-Heilkunde bei den MDK Niedersachsen und im Lande Bremen.

Objective: In a retrospective study the cases of possibly false medical treatment investigated by the Health Advisory Boards (MDK) in Lower Saxony and Bremen, Germany, in the years from 2012 to 2015 were analyzed. Material and Methods: All relevant data - especially diagnoses and procedures - were recorded in accordance to a standardized data entry form and were evaluated. In addition, relevant case studies are presented. Results: Altogether 206 cases of possibly false medical treatment were recorded for the investigated period. Among them there were 24 cases (12%), in which a false medical treatment was detected. The relevant case studies showed on the one hand, that relevant false medical treatment does occur in the field of ENT-surgery and on the other hand that it is sometimes very difficult do get the right decision even on a high-skilled background. Conclusions: In the field of Otorhinolaryngology there is a constant number of cases for examination in possibly false medical treatment, although the number of detection of false medical treatment is rather lower than in other disciplines. Analysis of possible false medical treatment cases produces the chance of preventing false medical treatment in future.

[Development of a claim form for the initiation of post-treatment rehabilitation for nationwide use by all reimbursement agencies: a report and plea for reducing administrative barriers]. / Entwicklung eines bundeseinheitlichen und kostenträger- übergreifenden Antragsformulars für die Einleitung der Anschlussrehabilitation: Projektbericht und Plädoyer zum Abbau administrativer Hürden.

We describe the results of a survey of claim forms that are used when starting rehabilitation following inpatient treatment and of an evaluation of a claim form developed on the basis of the results. The survey of different existing forms shows a high overlapping in content, suggesting the possibility of unification to one claim form that can be accepted by all insurers. In analogy to the Delphi method criteria for evaluation were consented and applied by the author group to assess the relevance of the claim forms content items for the process of initiating rehabilitation. A group of further experts added their evaluations. We prioritised the results and extracted the essential contents to conceive a unified claim form eligible for all types of rehabilitation. The claim form was discussed in 3 focus groups, revised accordingly and tested in the Hannover Medical School. Test results show that all relevant information is asked for and that the form is well manageable. The users' request for an IT-based solution and further ideas for improvement were integrated into the revised and validated version of the claim form. It is now available for all stake holders, in particular for insurers, as a means to improve quality of care and efficiency by standardisation of rehabilitation claim forms.

[Clinical reasoning supportive to a medical service provider as a tool for complaint management: a case study for pragmatic reasoning]. / Beschwerdebearbeitung in einem medizinischen Dienstleistungsunternehmen als Clinical Reasoning Prozess: Reflexion eines Fallbeispiels an Hand des pragmatischen Reasoning.

The process of "clinical reasoning" is exemplified as supportive to the complaint management of the Statutory Medical Health Advisory Board in Lower Saxony, Germany, within the operational division for long-term care insurance. A model case from real life illustrates in detail the hypothetical-deductive approach by Beusheusen and Klemme/Siegmann. Because of the potential area of conflicts between human concern in the case of a long-term care burden and legal requirements, the process was analysed in terms of a pragmatic reasoning. Human resources of the claimant and persons in charge at customer's service were demonstrated as well as political, statutory and institutional determining factors. Concluding self-perception validates the process in the context of evidence-based practice.

[Relevance of personal contextual factors of the ICF for use in practical social medicine and rehabilitation]. / Bedeutung der personbezogenen Faktoren der ICF für die Nutzung in der praktischen Sozialmedizin und Rehabilitation.

Personal contextual factors play an essential part in the model of the International Classification of Functioning, Disability and Health (ICF). The WHO has not yet classified personal factors for global use although they impact on the functioning of persons positively or negatively. In 2010, the ICF working group of the German Society of Social Medicine and Prevention (DGSMP) presented a proposal for the classification of personal factors into 72 categories previously arranged in 6 chapters. Now a positioning paper has been added in order to stimulate a discussion about the fourth component of the ICF, to contribute towards a broader and common understanding about the nature of personal factors and to incite a dialogue among all those involved in health care as well as those people with or with-out health problems in order to gain a comprehensive perspective about a person's condition.

[Comparison of development and mortality under domestic or institutional care with and without medical rehabilitation : The Hannover morbidity and mortality long-term care study]. / Vergleich von Pflegeverlauf und Sterblichkeit von Pflegebedürftigen mit und ohne medizinische Rehabilitation : Hannover Morbiditäts- und Mortalitätspflegestudie.

BACKGROUND AND OBJECTIVE: Empirical data, representative of the total population, are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients who are covered by statutory health insurance with regard to age and distribution of care levels when in home or institutional care with a special focus on whether rehabilitative care was performed. METHODS: The data of 88,575 LTC patients were analyzed longitudinally for 10 years, using routine data analyses on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221,625 observation years). The numbers of LTC patients and their care levels while in home or institutional care were calculated, as were any changes to another care level or discontinuation of LTC benefits (as a result of the need for care falling below the eligibility criteria for care leveI or to death) during 1-10 years after the onset of LTC, always with respect to whether rehabilitative care had taken place or not. For the evaluation of care factors an indicator was developed. RESULTS: Total mortality was found to decline and reactivation to increase considerably for LTC patients after rehabilitation, basically irrespective of their age or care level and in home or institutional care settings as well. Ten years after the onset of care, 30.7 % of the patients with rehabilitation were still in nursing care, 9.8 % were reactivated and 59.5 % deceased. In contrast, only 9.2 % were still in nursing care, 3.7 % reactivated and 87.1 % deceased without rehabilitation. These results are irrespective of age distribution, care level, and residence in home or institutional care settings. The care status of patients, measured by the percentage in reactivation, care level I-III, and death, substantially depends on age at onset and care level and in addition on rehabilitative procedures. Hypotheses for further research are outlined. CONCLUSION: Rehabilitation has a clear-cut potential for life extension as well as reducing or detaining long-term care if applied to (LTC) patients. The group of rehabilitated LTC patients has a comparatively higher degree of reducing or resolving LTC up to a complete reactivation or prolonging of life in spite of care needed. A successful rehabilitative effect occurs over all age groups and all care levels during home care considerably as well as during institutional care to a lower extent. Differentiation between the age at onset of LTC, care level, and first year and follow-up mortalities is recommended as well as between rehabilitated and nonrehabilitated care patients when undertaking medico-actuarial calculations.

[Simplifying post-treatment rehabilitation claim forms]. / Ein Weg aus dem Dickicht des Formulardschungels bei der Einleitung von Anschlussrehabilitation bzw. Anschlussheilverfahren.

Many different claim forms are used when starting rehabilitation following inpatient treatment, resulting in high administrative overheads for hospital staff, financial institutions and government agencies as well as patient allocation inefficiencies. We describe the problems ensuing on multiple and incompatible claim forms. On the basis of a survey of extant forms, we describe the content of a unified claim form that can be accepted by all insurers and which is optimised for hospital use. A model procedure for the development of a nationwide unified claim form allows for the assessment of the task's complexity and duration. Nevertheless, quality of care and efficiency considerations support a recommendation of standardisation of rehabilitation claim forms. On this basis the authors appeal to all relevant health-care players to enter into the enterprise of standardisation and to pursue this goal consistently.

[Personal factors of the ICF]. / Personbezogene Faktoren der ICF.

PURPOSE: The presentation aims at illustrating the draft proposal of personal factors of the ICF for German-speaking regions which has been published in 2010 by the working group ICF of Faculty II "Social Medicine and Rehabilitation" of the German Society for Social Medicine and Prevention, DGSMP. For this reason, each personal factor is illustrated by two examples. Thus, the benefit is intended to be convincing. METHODS: Applying a qualitative approach, the working group ICF consisting of members of various professions and institutions including a patients' representative selected for each item one example the factor serving as a facilitator and a second the factor serving as a barrier. RESULTS: The components of the personal factors, as proposed, are presented, each factor is accompanied by two examples. CONCLUSION: The presentation demonstrates the various possibilities of applying personal factors and intends to prove that the selection of items chosen makes sense. The process of a comprehensive discussion about the possible format of the component of personal factors in the ICF should lead to a further optimization of the proposal and the preparation of a discussion at an international level.

[Risks and chances of prioritization]. / Allgemeine Risiken und Chancen der Priorisierung.

Priority setting in medicine is associated with potential risks which can be avoided. The most important positive and negative factors influencing the discussion in other countries are specified. A diligent, well-balanced, off-limited, open-ended, and straightforward discussion which is picked up in due time comprises great chances for a consensual debate to further develop health care settings to the benefit of all citizens. This debate may advance considerably using terms correctly, respecting legitimacy and social justice, ensuring ethical fundamentals as well as transparency towards the general public.

[Operationalization and feasibility of the early rehabilitation index ("lower-saxony early rehabilitation index")]. / Versuch einer Operationalisierung und praxisorientierten Erweiterung des Frühreha-Indexes ("niedersächsischer Frühreha-Index").

This paper suggests an operationalization of the items of the early rehabilitation Barthel-index (ERBI). In addition, it presents a modification of this instrument, called lower-saxony ERBI (lsERBI). In order to validate the lsERBI, it has been used in 273 neurological rehabilitants. Findings suggest that the lsERBI has a higher specificity but lower sensitivity than the conventional ERBI. Inter-rater-reliability was high (r=0.84). Further studies are welcome to validate the lsERBI.

[Comparison of survival under domestic or institutional care: the Hannover morbidity and mortality long-term care study]. / Vergleich der Sterblichkeit Ambulanter und Stationärer Pflegepatienten im Langzeitverlauf: Hannover Morbiditäts- und Mortalitäts-Pflegestudie.

BACKGROUND AND OBJECTIVE: Empirical data, representative of the total population are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients with regard to age, gender and distribution of care levels when in home or institutional care. METHODS: The data of 88.575 long-term care patients were analysed longitudinally for ten years, using routine data on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221.625 observation years). The numbers of LTC patients and their care levels while remaining in home or institutional care were calculated, as were any changes to another care level or discontinuation of long-term care benefits (as a result of the need for care falling below the eligibility criteria for care level I or to death) during 1 - 10 years after the onset of long-term care. RESULTS: Total mortality was found to increase with age and care level in homecare as well as in institutional settings for both sexes. It is greatly influenced by the first year mortality, which for both genders was lower for care level 1 in home care settings but higher for care level 2 and much higher for care level 3 than in institutional care settings. Follow-up mortality (second to tenth year after the start of LTC) was lower for care level 1 and 2 in home care settings than for institutional care. But for care level 3 the follow-up mortality was conversely higher in home care settings than in institutional care (for both genders). The number of patients returning to an active life after rehabilitation is much higher for home care patients than those who had been in institutional care. The transfer rate from homecare to institutional care increased during the first three years after onset of care, descending thereafter, and was much higher than conversely. CONCLUSION: The slogan "outpatient care before inpatient care" must be differentiated and considered carefully with regard to the character and constellation of diseases, age attained, length of time after onset of care, care level, potential for resuming an active life, as well as level of compensation and number and nature of activities of daily life together with being given the necessary help when choosing between homecare or institutional care. Differentiation between first year and follow-up mortalities is recommended when undertaking medico-actuarial calculations.

[Personal contextual factors of the ICF draft from the Working Group "ICF" of Specialty Group II of the Geman Society for Social Medicine and Prevention]. / Personbezogene Faktoren der ICF - Entwurf der AG "ICF" des Fachbereichs II der Deutschen Gesellschaft für Sozialmedizin und Prävention (DGSMP).

Personal contextual factors play an essential part in the ICF model in relation to patient-centred care. It is generally assumed that their classification must refer to the country-specific social and cultural setting and its particular linguistic terms. Therefore personal factors are not classified as yet by the WHO for general use. In Germany in 2006 a group of experts working on the medical advisory board of statutory health insurance published a proposal for a systematic classification of relevant personal factors to describe the background of an individual's life and living. This classification was now further analysed and thoroughly revised by a more comprehensive group of German specialists working in different health care insurances and institutions, authorised by the German Society for Social Medicine and Prevention (DGSMP), supported by German-speaking Swiss ICF specialists. This classification is published as work in progress intending to broaden and prepare the process of discussion for a consensus conference to be held in Germany in 2011.

[Perspectives in rehabilitation. General position paper on future trends and challenges in rehabilitation by the Health Advisory Board of the German Federal Association for Rehabilitation]. / Perspektiven der Rehabilitation. Ein Positionspapier des Arztlichen Sachverständigenrates der Bundesarbeitsgemeinschaft f ü r Rehabilitation (BAR) zur Weiterentwicklung der Rehabilitation.

The Health Advisory Board of the German Federal Association for Rehabilitation (BAR) describes future trends and challenges in rehabilitation as deriving from the socio-demographic development in Germany and the structural characteristics of its Social and Health Care Insurance System. The focus is on elder employees to sustain and regenerate their capacity for employment, on people which are no longer employed to activate their autonomy and ability for self-support, and on rehabilitation as a holistic and integrative process extending through the social security and health insurances. There is an urgent need and a real chance to benefit from already existing scientific findings more frequently and to integrate them effectively into adequate further education and training programmes for professionals. Finally the conclusion summarises 8 theses to facilitate rehabilitation as an integral and essential part of the German social security and health sector. This paper was fully accredited by the members of the BAR Managing Board.

[Personal contextual factors (short version), part II]. / Personbezogene Kontextfaktoren (Kurzversion), Teil II.

In this journal a group of medical experts recently compiled a proposal for a systemic classification of personal contextual factors into domains, categories and items with respect to the ethical guidelines of the ICF (part I). In a second step the main issues have been transferred into the preliminary draft for a short version which is presented in this paper to give support for practical daily use in health insurance matters (part II).

[Personal contextual factors, part I]. / Personbezogene Kontextfaktoren, Teil I.

The International Classification of Functioning, Disability and Health (ICF) does not yet classify personal contextual factors. To determine the interaction of these factors on activities and participation of a person as well as their influence on the probable outcome of interventions, they must be taken into account in individual sociomedical expertises. Therefore, a group of medical experts working for the social health insurance medical advisory boards in Germany compiled a proposal for a systematic classification of personal contextual factors into domains, categories and items with respect to the ethical guidelines of the ICF. In a second step the main issues were transferred into the preliminary draft for a short version which will be published later to give support for practical daily use in health insurance matters.

Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial.

BACKGROUND: Chronic low back pain (LBP) is a growing health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat this condition, but have not demonstrated efficacy beyond 2 weeks, and no studies have shown that NSAIDs produce durable improvements in disability. METHODS: To evaluate the efficacy and durability of effect of etoricoxib for chronic LBP, a randomized, double blind, placebo-controlled trial was conducted at 46 centres. Three hundred and twenty-five patients with chronic LBP requiring treatment with an NSAID or paracetamol were randomized 1:1:1 to etoricoxib 60 mg (n=109), 90 mg (n=106), or placebo (n=110), daily for 3 months. Pre-specified endpoints over 3 months included LBP intensity scale (visual analog scale 0-100 mm) time-weighted average change from baseline, the Roland-Morris Disability Questionnaire (RMDQ), the LBP bothersomeness scale, patient and investigator global assessments, and measures of quality of life. RESULTS: Both etoricoxib groups experienced significant reductions in LBP intensity at 4 weeks versus placebo [-15.15 mm and -13.03 mm for 60 and 90 mg, respectively, probability (p)<0.001 for each], which was maintained over 3 months. Treatment resulted in significant improvement from baseline compared to placebo in RMDQ scores (etoricoxib 60 mg, -2.82 and 90 mg, -2.38, p<0.001 for each) over 12 weeks and most other efficacy endpoints. There were no significant differences between treatments in incidence of adverse events (AEs) or discontinuations due to AEs. CONCLUSION: Etoricoxib provided significant relief of symptoms and disability associated with chronic LBP detected at 1 week, confirmed at 4 weeks, and maintained over 3 months. Reductions in chronic LBP severity corresponded to improvements in physical functioning and quality of life. All treatments were generally well tolerated.