[Development of a clinical guideline on medical rehabilitation of patients after lumbar disc surgery]. / Entwicklung einer Leitlinie zur medizinischen Rehabilitation von Patientinnen und Patienten nach lumbaler Bandscheibenoperation.

In cooperation with the Federation of German Pension Insurance Institutes (VDR) and with the VfR Norderney e. V., the university of Witten/Herdecke has developed a clinical guideline on medical rehabilitation for patients after lumbar disc surgery. Methodically, development of this guideline was based on the following three steps: (1) consideration of recent scientific literature, (2) analyses of structures and processes employed in rehab clinics, using consultations with clinic managers, with occupational groups involved in rehabilitation and analysis of patient files, as well as (3) the consensus process. One central result was the statement of substantial paucity of research on evidence for many therapeutic interventions used in orthopaedic rehabilitation of patients after lumbar disc surgery. Analyses and investigations in rehabilitation clinics showed a wide range of therapeutic interventions, used to very different extents. Development of the guideline therefore took place on the basis of consensus-based processes. Using formal consensus techniques according to recommendations of the Association of the scientific medical societies in Germany (AWMF), the guideline presented was developed in cooperation with the occupational groups involved in the rehabilitation process. Its structure focuses on the therapeutic targets, and it includes a clinical algorithm illustrating the orthopaedic rehabilitation process in a simple and understandable manner. The guideline presented is based on recent knowledge and corresponds to stage S2 of development. A further implementation project will evaluate practicability and acceptance of this guideline.

[Findings on the effectiveness of rehabilitation]. / Ergebnisse zur Wirksamkeit der Rehabilitation.

The German Federal Ministry of Education and Research (BMBF) and the German Pension Insurance scheme established a funding programme for research in rehabilitation. This review presents the findings of 38 available evaluation studies analyzing the effects of medical rehabilitation in Germany in different indications. With a total of 10 studies, the effectiveness of rehabilitation in chronic low back pain was evaluated most frequently. The other research projects analyzed the effects of rehabilitation in psychosomatic diseases (9 studies), cardiac diseases (9), cancer (4), neurological diseases (3), bowel diseases (1) and rehabilitation of children and juveniles (2). According to the results at hand, medical rehabilitation significantly improves the patients' state of health at the end of the rehab measure. Effectiveness is maintained in numerous patients also in the medium or fairly long-term. Hence, rehabilitation accomplishes a prerequisite for further gainful employment. Most of the patients treated have been suffering from chronic illness for many years and have developed psychological complaints besides their serious somatic symptoms and impairments. Here, rehabilitation takes on a fundamental assignment in the care of chronically ill patients. The projects carried out under the promotional focus highlight concrete perspectives for evidence based enhancement of medical rehabilitation. This, amongst others, also holds true for the positive experience with treatment modules within specific vocational training and with patient education. Some of the insights gained are already being realized. As a current task of development, the findings point to further improving the sustainability of rehabilitation's positive impact particularly in chronic low back pain. Pertinent conceptual approaches can be derived from the projects presented.

[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.

[Evaluation of outpatient rehabilitation: goals, conceptual framework and study design of a health and pension insurance joint research project]. / Die wissenschaftliche Begleitung im Rahmen der Empfehlungsvereinbarung von Kranken- und Rentenversicherung zur ambulanten Rehabilitation: Zielsetzungen, Rahmenbedingungen und Untersuchungsansatz.

In Germany the statutory health and pension insurance schemes are the main providers of medical rehabilitation, the majority of rehabilitation measures being given in an inpatient setting. Over the last few years, the health and pension insurance schemes have strengthened the extension of outpatient rehabilitation, and have funded a comprehensive evaluation study in this context. In this evaluation study outpatient rehabilitation in centres with different conceptual backgrounds is compared with inpatient rehabilitation in rehab clinics, indications considered being cardiology and orthopaedics. Overall, 14 rehab centres and more than 2000 patients were included in the project. The patients were interviewed and medically examined before and after the measure. A follow-up was done after six and twelve months. In addition to the rehabilitants themselves, the rehab centre physicians as well as the office-practice physicians were interviewed about the outcome of the rehab measure. One year after rehabilitation, data were collected from the relevant health and pension insurance funds concerning the benefits the patients had received. Due to the study's non-experimental design, validity of the results is confined to rehabilitants participating on an outpatient basis and who had been found medically suited for this type of rehabilitation, were capable of travelling to the rehab centre on their own within less than 45 minutes and had voluntarily opted for the outpatient setting. The findings of the study show that outpatient rehabilitants' motivation and expectations differ from those found in inpatient rehabilitation. The health economics analysis performed is restricted to the costs involved in the rehabilitation measure as such as well as the health-related benefits provided to the rehabilitants in the twelve-month study period. The issue of whether increasing outpatient rehab measures will lead to decreasing costs in the rehab system as a whole had not been considered in the framework of this project.

[Health economics analysis of prospective payment systems in medical rehabilitation]. / Gesundheitsökonomische Analyse der Vergütung mit Fallpauschalen in der medizinischen Rehabilitation.

The forthcoming introduction of the DRG-system as a new hospital funding system in Germany reinforced the discussion about a reform of the already existing funding system in medical rehabilitation. Experience and concepts from acute medicine, however, cannot be transferred directly to rehabilitation. The development of a patient classification system is a presupposition for prospective payment systems. Initial attempts in rehabilitation-specific patient classification systems already exist, even though a comprehensive approach is not yet noticeable. International patient classification systems scarcely seem to be transferable due to the specific German case-mix. The specific differences between acute medicine and medical rehabilitation relevant for the valuation of funding systems are analyzed. Particularly a reduction of the length of stay as a primary aim for the introduction of the DRG-system does not seem appropriate for medical rehabilitation. The existing funding system in medical rehabilitation is analyzed from an economic point of view. The cost management of the German pension insurance, being one of the rehabilitation providers in Germany, has achieved high quality standard of treatment as well as cost restriction. This funding system has been further developed during the last couple of years. Future developments are shown.

[Reconditioning in groups: an effective programme for the rehabilitation of patients with low back pain?]. / "Rekonditionierung in Gruppen" - Ein wirksames Rehabilitationsprogramm bei chronischen Rückenschmerzen?

The article reports on a study in which elements of a group-oriented reconditioning programme for patients with low back pain were incorporated into the routine of an in-patient orthopaedic rehabilitation clinic. The specific elements of the new programme consisted of stable group structures during the whole stay of 3 to 4 weeks, and of 3 to 7 hrs. walks in hilly ground three times a week. The effects of this programme were tested against a standard programme with a mix of passive and active elements using a controlled study design. 92 persons participated in an experimental group and 81 persons in a control group with no significant differences found between the two groups at admission. Effects were measured by means of a physicians' questionnaire and a multidimensional patients' questionnaire (IRES) answered at admission, at discharge, and at six- and twelve-month follow-up. The results of a two-factorial analysis of variance with repeated measures showed that the interaction between group and time on the summary score of the IRES was not significant, although the experimental group showed somewhat better effects at all times of measurement. The discussion focuses on the reasons for this result, among which the unexpectedly good effects in the control group are named, as well as certain difficulties with the implementation of a strongly activity-oriented programme into the course of a "normal" rehabilitation clinic.

Case control study of neuroblastoma in west-Germany after the Chernobyl accident.

BACKGROUND: To explore possible causes of a 1988 incidence peak of infant neuroblastoma in west German regions which were contaminated with more than 6000 Bq/m2 Cs137 from the Chernobyl accident. The primary working hypothesis was that parents of the diseased children had been contaminated by an excessive intake of locally produced food, especially mushrooms or deer. DESIGN: Case control study with 1:2 (cases:controls) matching. Data were collected from the children's parents by questionnaires and telephone interviews. SETTING: Nation-wide study (former FRG) based on the German Childhood Cancer Registry. SUBJECTS: Cases born in 1988 and reported with a neuroblastoma to the registry until March 1992. Population-based healthy controls, matched for age, sex and residence at time of diagnosis. RESULTS: The working hypothesis could not be confirmed by the study, because the parents of cases tended to eat less locally grown food than the parents of controls (RR = 0.63, 95% CI:0.20-1.97). Possible influence factors which previously have been described to be associated with neuroblastoma incidence could not be confirmed by the study. Parental exposure to herbicides and pesticides was associated with the occurrence of neuroblastoma (RR = 4.2, 95% CI:1.4-12.9). Neuroblastoma stage distribution in the contaminated regions was shifted towards lower stages as compared to the less contaminated regions and previous age cohorts. CONCLUSIONS: The study does not show additional evidence that the observed increase in neuroblastoma incidence might have been caused by exposure to fallout from the Chernobyl accident. The observed shift towards lower clinical stages may rather indicate increased diagnostic awareness. The association between neuroblastoma and parental exposure with herbicides and pesticides resulted from an extensive exploratory data analysis and needs to be confirmed in further studies.

Sero-epidemiological analysis of the risk of virus infections for childhood leukaemia.

Virus infections have been thought to be involved in the development of childhood leukaemia. In order to address this issue we determined, in a case-control study, the prevalence of antibodies to viruses infecting blood or bone-marrow cells [Epstein-Barr virsus (EBV), human herpes virus type 6 (HHV-6), parvovirus B19] as well as to the human virus known for its tumour-suppressive properties, the adeno-associated virus type 2 (AAV-2), in the sera of 121 children with leukaemia in Germany, and in 197 control individuals, hospitalized for other reasons, and matched for age and gender to the cases. In addition, we developed a questionnaire to be answered by the children's parents, in order to gain information on previous infections of the children as well as to calculate for factors which may influence serological findings. Comparative determination of the prevalence of antibodies against AAV-2, B-19 or HHV-6 revealed no significant differences in cases and controls. However, antibodies to EBV were more frequently found in children with leukaemia younger than 6 years of age (age at the time of diagnosis of leukaemia) than in controls. Apparently, infection with AAV-2 has no protective effect in childhood leukaemia, in contrast to results observed for other malignancies. Similarly, and in accordance with results on leukaemia in adults, we found no indication of a protective effect of infection with the parvovirus B-19. The data suggest that EBV, which is known to be involved in various lymphomas, may play a role in the development of childhood leukaemia in young children.

[Attitude to death and control behavior of medical students--a cross sectional study]. / Todesbezogene Einstellungen und Kontrollüberzeugungen von Medizinstudenten--Eine Querschnittstudie.

Within the scope of a cross-section study the Fear of Death Questionnaire (Hensle 1977), the Semantic Differential of the term Death (Potthoff 1980) and the IPC questionnaire (Krampen 1981) were submitted to n = 186 first- and second-year medical students and to n = 151 third- and fourth-year medical students. This was to trace the question how far the attitude toward death and the locus of control of medical students vary in the course of their education. In comparison with most of other respective publications our paper did not show any significant changes of their attitude toward death and their locuis of control neither. After more detailed analysis of the data discerning consideration of the fear of death questionnaire mentioned above is to be demanded prior to further use in medical fields. At least in view of medical students it's value regarding the construct validity is to be questioned. Concerning the Semantic Differential at least one adjective pair should be eliminated in future.