[Risk-Adjustment of Return to Work After Medical Rehabilitation: Methodical Advancements in Quality Assurance of the German Pension Insurance]. / Adjustierung des sozialmedizinischen Verlaufs nach medizinischer Rehabilitation: methodische Weiterentwicklung der Reha-Qualitätssicherung der Deutschen Rentenversicherung.

PURPOSE: Besides the quality of life, patients' return to work is one of the most important treatment results of medical rehabilitation paid by the German Pension Insurance. In order to be able to use the return to work as a quality indicator for medical rehabilitation, a risk adjustment strategy for pre-existing characteristics of patients, rehabilitation departments and labour markets had to be developed. METHODS: Multiple regression analyses and cross validation were used to develop a risk adjustment strategy, which mathematically compensates the influence of confounders and thus allows for appropriate comparisons between rehabilitation departments regarding patients' return to work after medical rehabilitation. Under the inclusion of experts, the number of employment days in the first and second year after medical rehabilitation were chosen as an appropriate operationalization of return to work. Methodological challenges in the development of the risk adjustment strategy were the identification of a suitable regression method for the distribution of the dependent variable, modelling the multilevel structure of the data appropriately and selecting relevant confounders for return to work. A user-friendly way of communicating the results was developed. RESULTS: The fractional logit regression was chosen as an appropriate regression method to model the U-shaped distribution of the employment days. Low intraclass correlations indicate that the multilevel structure of the data (cross-classified labour market regions and rehabilitation departments) is statistically negligible. Potential confounding factors were theoretically preselected (medical experts were involved for medical parameters) and tested for their prognostic relevance in each indication area using backwards selection. Cross validations proved the risk adjustment strategy to be stable. Adjustment results were displayed in a user-friendly report, including the users' perspective (focus groups and interviews). CONCLUSIONS: The developed risk adjustment strategy allows for adequate comparisons between rehabilitation departments and thus enables a quality assessment of treatment results. Methodological challenges, decisions and limitations are discussed in details throughout this paper.

Return to work after medical rehabilitation in Germany: influence of individual factors and regional labour market based on administrative data.

Background: The influence of both individual factors and, in particular, the regional labour market on the return to work after medical rehabilitation is to be analyzed based on comprehensive administrative data from the German Pension Insurance and Employment Agencies. Method: For rehabilitation in 2016, pre- and post-rehabilitation employment was determined from German Pension Insurance data for 305,980 patients in 589 orthopaedic rehabilitation departments and 117,386 patients in 202 psychosomatic rehabilitation departments. Labour market data was linked to the district of residence and categorized into 257 labour market regions. RTW was operationalized as the number of employment days in the calendar year after medical rehabilitation. Predictors are individual data (socio-demographics, rehabilitation biography, employment biography) and contextual data (regional unemployment rate, rehabilitation department level: percentage of patients employed before). The estimation method used was fractional logit regression in a cross-classified multilevel model. Results: The effect of the regional unemployment rate on RTW is significant yet small. It is even smaller (orthopaedics) or not significant (psychosomatics) when individual employment biographies (i.e., pre-rehabilitation employment status) are inserted into the model as the most important predictors. The interaction with pre-rehabilitation employment status is not substantial. Conclusions: Database and methods are of high quality, however due to the nonexperimental design, omitted variables could lead to bias and limit causal interpretation. The influence of the labour market on RTW is small and proxied to a large extent by individual employment biographies. However, if no (valid) employment biographies are available, the labour market should be included in RTW analyses. Supplementary Information: The online version contains supplementary material available at 10.1186/s12651-023-00330-1.

First onset of treatment of patients with eating disorders and treatment course: Results of data from a German health insurance company.

OBJECTIVE: This study examines, inpatient treatment costs, and typical treatment courses of patients with an eating disorder using secondary data. METHOD: The data were provided by a German health insurance company (data from 4.2 million members from 2004 to 2010; corresponds to a market share of 6% of all statutorily insured persons in Germany). An age and gender matched control group without an eating disorder diagnosis was assessed for comparisons from the same dataset. RESULTS: Two thousand seven hundred and thirty four cases with an eating disorder diagnosis (anorexia nervosa [AN], bulimia nervosa [BN] or combination [ANBN]) were identified. The inpatient costs of treatment were €5471.15 for BN, €9080.26 for AN, €10,809.16 for ANBN and €339.37 for the control group. Interestingly, there are numerous mild episodes of eating disorders that could be successfully treated solely on an outpatient basis with a short treatment duration. CONCLUSION: Our findings suggest that course and severity of eating disorders can vary from mild to very severe. Data from health insurance companies depict rather different disease and treatment courses than studies on primary data derived from treatment institutions.

[Predictors of the Use of Different Occupational Rehabilitation Measures: A Comparison of Integration Measures, Partial Qualifications and Full Training]. / Prädiktoren für die Inanspruchnahme unterschiedlicher Leistungen zur Teilhabe am Arbeitsleben: Ein Vergleich von Integrationsmaßnahmen, Teilqualifizierungen und Vollausbildungen.

PURPOSE: Occupational rehabilitation is an essential part of supporting return to work by the statutory pension insurance institutes. It is useful if health-related restrictions threaten the ability to work. There are various forms of occupational rehabilitation which differ considerably in terms of content, structure, duration, intensity of care and costs. The aim of the study was to identify personal characteristics that can influence the use of three different occupational rehabilitation measures. METHODS: All rehabilitants who underwent an occupational rehabilitation in the cooperating occupational rehabilitation centre (Berufsförderungswerk) from 2009 to 2014 under the funding of the German Federal Pension Fund were included in the analysis. A multinomial logistic regression was calculated in order to obtain information on the predictors of utilization of three occupational rehabilitation measures (integration measure, partial qualification, full training). As potential influencing factors, various sociodemographic characteristics as well as various parameters that reflect the employment status of rehabilitants in the previous year were included in the model. RESULTS: The analyses included a total of 934 rehabilitants who had completed an integration measure (n=443), partial qualification (n=315) or full training (n=176). In the final logistic regression model, gender (p<0.0001), age (p<0.0001), education level (p=0.0033), driving license (p<0.0001), willingness to move (p=0.0012), recognized disability (p=0.0404) and the employment status in the third month before the start of the measure (p=0.0020) proved to be significant predictors of utilization. CONCLUSION: The utilization of the different occupational rehabilitation measures is determined by various influencing factors. In particular, the more extensive and cost-intensive full training are more likely to be taken up by younger, male and more highly qualified rehabilitants.

[Effect of Rehabilitation on the Delayed Entry into the Retirement due to Reduced Earning Capacity]. / Effekt der Rehabilitation auf den verzögerten Eintritt in die Berentung aufgrund von Erwerbsminderung.

BACKGROUND: Early retirements make up a large portion of indirect costs of illness caused by chronic back pain. METHODS: Claims data from statutory health insurance and German Pension Fund provide the basis for analysis. Cox-Regression was performed for duration to early retirement, whereby beside sociodemographic and treatment characteristics, the effect of rehabilitation was considered. RESULTS: Early retirement started on average 7.1 month later through rehabilitation. Therefore, rehabilitants made € 8,432.60 higher payments to statutory health insurance and German Pension Fund per rehabilitant. Based on the total number of 21,262 early retirees with orthopedic indications, this can save € 180.7 million. The timing of the early retirement was also affected by age and sickness benefits in the previous month. Savings by avoiding entry into early retirement have not yet been taken into account in this model. CONCLUSION: Rehabilitants receive later pensions due to reduced ability, which allow for more contributions to statutory health insurance and German Pension Fund. This indicates that medical rehabilitation is an economic and effective treatment.

[Cluster-Randomized Trials: Methodical and Practical Implications]. / Cluster-randomisierte Studien: Methodische und praktische Aspekte.

Quite often critics demand more randomized studies in rehabilitation science to gather methodological evidence of high quality. However, it is also recognized that the design of double-blind, placebo-controlled, randomized studies often cannot simply be transferred into rehabilitation science. Validity concerning the health care is here in the focus. Thus, treatment as-usual is mostly used as placebo treatment and double-blinding is partly not definable. Additionally, it is often difficult to offer 2 similar forms of treatment in one rehabilitation hospital due to lack of capacity. Additionally, contamination effects are to be expected when patients of different study arms communicate. Here cluster-randomized studies may be helpful. However, in comparison to individual randomized studies they need often higher sample sizes, a more complex methodology of sample size calculation as well as extensive methods of statistical analysis.Within this article advantages and disadvantages as well as the characteristics of cluster randomization are described and information is given how they can be implemented into the field of rehabilitation science.

[Utilization of Rehabilitation After Orthopedic Operation - Does Severity of Case Influence the Setting of Rehabilitation (Out- Vs. Inpatient)?] / Inanspruchnahme einer Anschlussrehabilitation nach orthopädischer Operation ­ Beeinflusst die Fallschwere das Rehabilitationssetting (ambulant vs. stationär)?

OBJECTIVE: The aim of this study was to examine which factors predict rehabilitation setting (inpatient vs. outpatient) after hospitalization in order to indicate the meaning of severity for access to a certain kind of rehabilitation. METHODS: All patients with surgery for hip or knee (joint) endoprosthesis or disc surgery between 2005 and 2010 were selected for analysis from anonymized data from statutory health insurance (AOK Baden-Württemberg) and German Pension Fund (Bund as well as Baden-Württemberg). Logistic regression was performed for outpatient vs. inpatient rehabilitation. RESULTS: Patients from all surgery groups utilize more often inpatient rehabilitation, if they started treatment immediately after hospitalization than patients that start treatment after a period at home. With increasing age as well as comorbidities patients use more inpatient rehabilitation. The probability for inpatient rehabilitation decreased between 2005 and 2009. CONCLUSION: Beneath severity also context factors seem to be issues for the choice of inpatient or outpatient rehabilitation. For a demand-orientated access to a certain kind of rehabilitation, environmental conditions like support by family or accessibility to therapeutic, nursing or medical assistance and medical parameters like severity should be weighed against each other.

[Health Economic Effects of Rehabilitation for Chronic Back Pain - An Observational Study with Combined Secondary Data from Statutory Health Insurance and German Pension Fund]. / Gesundheitsökonomische Effekte der Rehabilitation bei chronischem Rückenschmerz ­ Eine Beobachtungsstudie mittels kombinierten Sekundärdaten einer gesetzlichen Krankenkasse und der Deutschen Rentenversicherung.

BACKGROUND: Chronic back pain is the most common indication in medical rehabilitation. Numerous studies hint on positive effects of rehabilitation on health state. However, there is no evidence about the effectiveness of rehabilitation due to the lack of a valid comparison group. METHODS: Based on combined secondary data from German Pension Fund and statutory health insurance, a comparison group of insured persons was identified by their typical patient career that did not apply for rehabilitation for unclear reasons. Effectiveness was measured by direct and indirect costs of back pain between rehabilitants and non-rehabilitants. RESULTS: Costs of rehabilitation split in 2.742 € direct costs and 2.597 € indirect costs. In the 2 years following rehabilitation, rehabilitants were hospitalized less frequent and caused less indirect costs due to disability. Therefore, the benefit of rehabilitation was 727 € in the first year after rehabilitation and additional 37 € in the subsequent year. CONCLUSION: Rehabilitation for chronic back pain contributes to maintain the ability to work. Moreover, rehabilitation reduces duration of disability and healthcare utilization, hence direct and indirect costs of illness are lowered compared to a treatment without rehabilitation. Effects of rehabilitation by avoidance and delay of retirement are not yet recorded.

[A Projection of the Need for Rehabilitation in Germany Till 2040 Based on Demographic Factors]. / Eine Fortschreibung des Rehabilitationsbedarfs in Deutschland bis 2040 anhand demografischer Faktoren.

The demographic changes in Germany leads to a significant shift in the composition of the population and the workforce, this affecting the future need for medical rehabilitation. This paper estimates the future change in rehabilitation demand based on a forecast for demographic changes till 2040. First, the sensitivity of the rehabilitation demand with respect to demographic factors is estimated. Second, the demographic factors are projected by stochastic methods, resulting in forecasts for the future need for medical rehabilitation. The projections show that the short-term demand is likely to rise. Theoretically, yearly wage increases of about 2.2% are needed for covering the increasing medical rehabilitation costs from 2010 till 2017. For the mid-term demand, the model predicts a slight decline in rehabilitation cases. Considering all these facts, the budget for rehabilitation will probably not cover the future costs for rehabilitation. However, the long-term forecast is subject to considerable uncertainty.

[Return to Work after Disk Surgery - Influenced by Rehabilitation?] / Erwerbsstatus nach einer Bandscheibenoperation: Was bewirkt eine Anschlussrehabilitation?

OBJECTIVE: The aim of this study was a comparison of treatment results in the year after disk surgery between the following treatment groups: rehabilitation immediately after discharge from hospital, rehabilitation with a transition time (at home) up to twenty days after rehabilitation or no rehabilitation. METHODS: On basis of claims data from a statutory health insurance and the German Federal Pension Fund the comparison of treatment results was performed. Therefore, duration of disability, return to work and early retirement are considered as treatment results and are analyzed using general linear models (GLM). Furthermore utilization of occupational rehabilitation was compared between the treatment groups with logistic regression. RESULTS: Rehabilitants showed a lower risk of unemployment. Moreover, rehabilitants utilize more often occupational rehabilitation. Both rehabilitation treatment groups had a higher duration of disability (including duration of rehabilitation) in the first quarter after surgery. Afterwards the duration of disability decreased faster. Risk of early retirement was higher in patients that started rehabilitation immediately. CONCLUSION: Rehabilitants tend to have better treatment results in the year following disc surgery.

Experiences, attitudes and possibilities for improvement concerning the cooperation between occupational physicians, rehabilitation physicians and general practitioners in Germany from the perspectives of the medical groups and rehabilitation patients - a protocol for a qualitative study.

INTRODUCTION: Rehabilitation measures for patients in the working age primarily aim at maintaining employability, restoring fitness for work or timely return to work (RTW). To facilitate RTW after long sick leave in Germany, both rehabilitation physicians' knowledge about the patients' workplace and communication between the rehabilitation physician and the occupational physician need to be improved. This research will record the experiences and attitudes of occupational physicians, rehabilitation physicians and general practitioners, as well as of rehabilitation patients, to indicate barriers and possibilities for improvement concerning the intersection between workplace and rehabilitation institution. As a previous literature review has shown, insufficient data on the experiences and attitudes of the stakeholders are available. Therefore, an exploratory qualitative approach was chosen. METHODS AND ANALYSIS: 8 focus group discussions will be conducted with occupational physicians, rehabilitation physicians, general practitioners and rehabilitation patients (2 focus groups with 6-8 interviewees per category). Qualitative content analysis will be used to evaluate the data, thus describing positive and negative experiences and attitudes, barriers and possibilities for improvement at the intersection of general and occupational medicine and rehabilitation with regard to the workplace. The data from the focus groups will be used to develop a standardised quantitative questionnaire for a survey of the medical groups and rehabilitation patients in a follow-up project. ETHICS AND DISSEMINATION: The research will be undertaken with the approval of the Ethics Committee of the Medical Faculty and University Hospital of Tuebingen. The study participants' consent will be documented in written form. The names of all study participants and all other confidential information data fall under medical confidentiality. The results will be published in a peer-reviewed medical journal independent of the nature of the results.

[Utilization of Rehabilitation after Disk Surgery - A Cross-Sectoral Analysis of Claims Data from Statutory Health Insurance and German Federal Pension Fund]. / Inanspruchnahme der Anschlussrehabilitation nach einer Bandscheibenoperation.

The aim of this study was to identify relevant factors that influence utilization and interim period between hospitalization and postoperative rehabilitation after disk surgery. Logistic regression was performed for utilization of an early postoperative rehabilitation and for an interim period, when patients were going to a rehabilitation facility (directly after hospitalization or after a period at home) on claims data from statutory pension insurance and statutory health insurance. Increased utilization of postoperative rehabilitation was found in older and German patients. Moreover, adiposity and additional physiotherapy in hospital increased the utilization of postoperative rehabilitation, while blood transfusion during hospitalization was an inhibiting factor.Female gender, older age and additional physiotherapy in hospital decreased the probability for an interim period between hospitalization and postoperative rehabilitation. However, the probability for an interim period increased from 2005 to 2010. Utilization and interim period between hospitalization and postoperative rehabilitation meet patient's needs and seem adequate. Nevertheless, there are indications for under-utilization of certain patient groups (foreign citizens, unemployed persons, male patients).

A prospective randomized controlled trial comparing occupational therapy with home-based exercises in conservative treatment of rotator cuff tears.

BACKGROUND: This pilot study evaluates the outcome after occupational therapy, compared to home-based exercises in the conservative treatment of patients with full thickness rotator cuff tears. METHODS: Forty-three adult subjects (range, 18-75 years), who had a full thickness rupture of the rotator cuff which was verified by magnetic imaging tomography, with clinical signs of a chronic rotator cuff impingement, and who were available for follow-up, were randomized to occupational therapy or to independent home-based exercises using a booklet. After drop-out, 38 patients were available for full examination at follow-up. Before therapy and after 2 months of conservative treatment, pain intensity, the Constant-Murley score, isokinetic strength testing in abduction and external rotation, functional limitation, clinical shoulder tests and health-related quality of life (EQ-5D) were evaluated. RESULTS: Two-thirds of the patients improved in clinical shoulder tests, regardless of the therapy group. There were no significant differences between the groups with reference to pain, range of motion, maximum peak force (abduction, external rotation), the Constant-Murley score, and the EQ-5D index. The only significant difference observed was the improvement in the self-assessed health- related quality of life (EQ-5D VAS) favoring home-based exercises. CONCLUSION: Home-based exercise, on the basis of an illustrated booklet with exercises twice a day, supplies comparable results to formal occupational therapy in the conservative treatment of rotator cuff tears. The results of this pilot study suggest some potential advantages related to psychological benefits using home-based treatment.

Short-term goal attainment of in-patient rehabilitation in Germany and long-term risk of early retirement in patients with musculoskeletal diseases: results from a prospective 5-year follow-up study.

PURPOSE: Occupational consequences of musculoskeletal disorders (MSDs) are consistently found in epidemiological studies. The aim of this study was to evaluate the prognostic value of various short-term rehabilitation outcome parameters on early retirement in Germany. METHOD: In a prospective multi-centre cohort study of self-rated patient status, physician chosen therapy goals and attainment were measured by means of standardized questionnaires at the beginning and end of medical rehabilitation. Information with regard to disability was collected by self-report over a 5-year follow-up period. RESULTS: We included 1268 MSD patients aged 45-57 who underwent a 3-week, multidisciplinary, in-patient rehabilitation programme in 10 rehabilitation centres in Southern Germany between January and December 2001. During follow-up (mean duration: 3.9 years) 117 (9%) patients received a disability pension. After adjustment for sex, age and patient outcomes, risk for early retirement was significantly increased for patients with only partial success with respect for the therapy goals pain reduction (HR 1.95), improvement in spine motility (HR 1.6) and improvement of muscle strength (HR 2.3). Patients who did not have the therapy goal were at the same risk as patients with full goal achievement. CONCLUSIONS: Clinicians' rating of short-term therapy outcome might be of prognostic relevance of MSD patients' long-term employment status.

[Can routine data on in-patient rehabilitation of musculoskeletal diseases replace the physicians' judgement in quality management? --an investigation on 12,014 observations]. / Ist das arztliche Urteil in der Qualitätssicherung stationärer Rehabilitation bei Patienten mit Erkran- kungen des Bewegungs- apparates durch Routine- parameter zu ersetzen? Eine Untersuchung an 12 014 Beobachtungen.

The acceptance of quality management is strongly influenced by the additional work-load necessary to obtain data. "Quality management questionnaire? Do we really need it? In rehabilitation, we must deliver a long and detailed discharge report anyway...". This frequent comment from the physician side has prompted us to investigate whether compilation of quality-management questionnaires really provides new information, or if a prediction model (for example similar to that predicting early retirement based on routine data in a discharge report) could be used to replace the physician judgement. If the prediction accuracy of the model is sufficiently high, the compilation of quality-management questionnaires might become obsolete, sparing the paperwork load of the physician. A central issue in the quality-management system of the LVA Baden-Wuerttemberg (a regional pension insurance institute) is the mutual agreement on a certain rehabilitation goal by patient and physician at the beginning of therapy. At the end of the rehabilitation program, the achievement of the goal is discussed with the patient in a discharge interview. In addition, patient and physician fill out a structured questionnaire with specification on three rehabilitation dimensions (WHO standard ICF: Body function and structure, activity, and participation). However, the results of multivariate modelling of 10 routinely observed parameters on more than 12,000 observations in patients with musculoskeletal diseases demonstrate that the agreement between the prediction model and the physician judgement of rehabilitation success is far away from optimal values. Thus, in this case the physician judgement can not be replaced by a forecast model solely based on routine data. Accordingly, the evaluation of rehabilitation success within the framework of a quality-management system based on currently valid standards must directly rely on the physician judgement.