["Scores of Independence for Neurologic and Geriatric Rehabilitation (SINGER)" - development and validation of a new assessment instrument]. / "Selbständigkeits-Index für die Neurologische und Geriatrische Rehabilitation (SINGER)" - Entwicklung und Validierung eines neuen Assessment-Instruments.

In the context of developing and testing a procedure for "Outcome-oriented payment for rehabilitation after stroke", we found that the instruments commonly used to measure the outcomes of rehabilitation after stroke (e. g., Barthel-Index or FIM) were not meeting the special requirements of the new payment system. Therefore the "Scores of Independence for Neurologic and Geriatric Rehabilitation" (SINGER) was developed as a new assessment instrument. This instrument is based on the ICF and measures 20 aspects of "independence in activities of daily living". The characteristic feature of the SINGER is, above all, the way all items are graded in 6 steps: the gradation does not refer to the degree of disability but to the kind and amount of help required for the respective activity, i. e.: 0 = totally dependent on professional help; 1 = professional contact help needed; 2 = contact help by (instructed) lay persons sufficient; 3 = preparation or supervision by lay persons still needed; 4 = independent with assistive device or still slow; 5 = independent without assistive device. For experienced personnel in neurologic rehabilitation, these gradations are "intuitively plausible". A manual moreover describes each grade in detail for each item so that the instrument can be used in rehabilitation facilities without extensive training. The SINGER has been tested and validated in a pilot study (n = 100) and in 2 subsequent studies with large case numbers in neurologic rehabilitation (n = 1058 and n = 700 patients after stroke in all categories of severity). Factor analyses showed that the instrument contains 2 dimensions which can be interpreted as "physical activities" and "activities of communication and cognition". Each of these 2 dimensions can be split into 2 sub-dimensions that can be assigned to the tasks of therapeutical professions in care/Occupational Therapy, physiotherapy, logopedics, and neuro- psychology. The test criteria of reliability, sensitivity, convergent validity, floor and ceiling effects as well as sensitivity to change show good to very good results. Particular emphasis can be given to the high degree of interrater reliability and the wide range of possible applications in clinical practice as well as in research. A limitation of the instrument to be taken into account is the fact that the SINGER has not yet been tested and validated in geriatric rehabilitation facilities.

[Pay for performance in rehabilitation after stroke - results of a pilot project 2001-2008]. / Ergebnisorientierte Vergütung der Rehabilitation nach Schlaganfall - Entwicklungsschritte eines Modellprojekts 2001-2008.

The project aimed at developing and testing a new payment system which provides financial incentives for rehabilitation centers to achieve the best outcomes possible for their patients but does not create additional costs for the insurance funds. The system is conceived as a "quality competition" organized by the centers among themselves with a scientific institute acting as a "referee". Centers with outcomes above average receive a bonus financed by a corresponding malus from the centers below average. In a stepwise process which started in 2001 and was continually accompanied by a scientific institute, we developed the methodological and organizational prerequisites for the new payment system and tested them in two multicentric studies with large case numbers (n=1,058 and n=700, respectively). As a first step, a new assessment instrument (SINGER) was developed and validated in order to measure the outcomes in a reliable, valid, and change-sensitive way. In the second phase, we developed a regression analytic model which predicted the central outcome variable with >84% variance explained. With this model, the different case-mix in the participating centers can be controlled, so that comparisons of outcomes across centers can take place under fair conditions. In the recently completed third phase, we introduced an internet-based programme SINGER-online into which the centers can enter all relevant data. This programme ensures a high quality of all data and makes comparisons of outcomes across all centers possible at any chosen time. The programme contains a special module accessible to the medical services of the health insurance only, which allows sample checks of the data entered by the clinics and helps to ensure that all centers keep to the principles of a fair competition for better quality for their patients. After successful testing of these elements, a functioning model of pay-for-performance in rehabilitation after stroke is now available.

[Initial status of patients and effects of rehabilitation after stroke--analysis of a patients' and a physicians' questionnaire in three neurological rehabilitation centres with a follow-up after 6 months]. / Eingangsbelastung der Patient(inn)en und Ergebnisqualität der Rehabilitation nach Schlaganfall--Resultate einer arztseitigen und patientenseitigen Untersuchung in drei neurologischen Kliniken mit Follow-up nach 6 Monaten.

Rehabilitation after stroke has to face specific problems when treating patients with more or less severe disabilities in cognition and communication. Correspondingly, stroke rehabilitation takes a special position within the larger field of rehabilitation, and relatively little is known outside the neurological scientific community about the status of patients at admission, the case mix in the centres and the short- and medium-term effects of rehabilitation. The present study describes in some detail the initial status in unselected samples of consecutive patients (n = 768) from three neurological rehabilitation centres. The description shows a very inconsistent picture in all centres, ranging from patients with no neurological deficits to patients needing intensive care. Across the centres, we found remarkable differences in case mix. In order to measure the effects of rehabilitation after stroke, an instrument was developed that combines a physicians' questionnaire aiming at an assessment of the severely disabled cases with a patients' questionnaire for the less severe cases for which the physicians' questionnaire would show "ceiling effects" so that improvements could no longer be depicted. The application of the instrument showed that about 50 % of the sample were not capable of answering the patients' questionnaire. For the patients with neurological deficits, the functional parameters of the physicians' questionnaire showed significant improvements at discharge that can be interpreted as "strong" effects (effect sizes 1.0-1.3). For the patients with less severe deficits (and usually in later stages of the rehabilitation process), the patients' questionnaire showed "strong" improvements on the somatic and psychosocial scales both at discharge and 6 months later. On the functional scales, however, only small improvements were found. Finally, predictors could be identified that explain a large amount of the variance for length of stay (R(2) =.42) as well as for the effects of rehabilitation (R(2) =.74). When comparing effects across rehabilitation units with differences of case mix, these predictors should be statistically controlled in order to assure fair comparisons.

[Complications of ventral fusion operations in degenerative intervertebral disk diseases]. / Komplikationen ventraler Fusionsoperationen bei degenerativen Bandscheibenerkrankungen.

1112 anterior cervical fusion operations were performed on 951 patients according to the method described for the first time by Grote in 1970. The neurogenic, mechanical and inflammatory complications arising with this method are described. The typical complications are demonstrated by means of case reports and their possible causes are discussed. The incidence rate of the individual complications is compared with that reported in the literature for a total of 8366 fusions performed on 6384 patients.

[Complications in lumbar intervertebral disk operations]. / Komplikationen bei lumbalen Bandscheibenoperationen.

During the period from 1980 to 1985 we performed 1957 lumbar disc operations. In 1720 (87.9%) first operations and 237 patients (12.1%) with reoperation we found 127 complications (6.5%). General complications occurred in 1.6%, infection in 2.8%, mechanical complications in 1.6% and neurological complications in 0.5%. The rate was, except for general complications much higher in reoperation (16%) than in first operation (5.2%). We found 1.1% postoperative irreversible neurological complications. Further operative treatment because of complications was necessary in 2.3%. The types and causes of complications are discussed and compared with the results in the literature.