[Does Return to Work after Vocational Retraining Depend on Labour Market?] / Hängt die berufliche Wiedereingliederung nach beruflichen Bildungsleistungen vom Arbeitsmarkt ab?

Background: Studies about the impact of the labour market on return to work (RTW) after vocational retraining are contradictory. We examined if (1) RTW after vocational retraining depends on regional labour markets and if (2) the regional labour markets variance affects the influence of personal characteristics on RTW. Methods: The data consisted of the scientific use file (completed rehabilitation in the course of health insurance 2002-2009) of the German Federal Pension Insurance (51 626 persons of 7 year cohorts) and regional economic data (412 districts). Multilevel logistic regression models were used. Results: At the context level the logarithmic unemployment rate was the most relevant predictor. The RTW rate decreased with increasing unemployment rate, saturating at an unemployment rate of around 15%. Significant differences between the intervention types (integration, 1-year and 2-year vocational retraining programs) were observed. The effects of individual predictors were clearer with higher unemployment, e. g. education, individual unemployment, income and further vocational interventions prior to vocational retraining. Conclusion: We demonstrate that the success of vocational retraining depends on the regional labour market. Furthermore individual predictors show stronger effects on success with the context of "poor" labour markets. In addition to the existing evidence the regional unemployment rate should be taken into consideration in effectiveness research studies and benchmarking processes in quality assurance.

[Psychometric Testing of a Generic Assessment Tool for the Identification of Biopsychosocial Impairments in Persons with an Approval for Medical Rehabilitation]. / Psychometrische Testung eines generischen Assessments zur Erfassung bio-psycho-sozialer Beeinträchtigungen bei Versicherten mit Bewilligung einer medizinischen Rehabilitation.

BACKGROUND: In Germany, different rehabilitation measures were developed for patients with problems due to their specific chronic disease. The aim of the study was to test a generic assessment tool for a valid identification of disability patterns. This tool can effectively display the demand of specific rehabilitation measures in the medical rehabilitation. METHODS: The generic assessment tool was tested in a representative sample of individuals who have been granted a medical rehabilitation by the German Federal Pension Insurance. With this sample, we performed a cross-sectional study. RESULTS: Full data were available for 2 530 persons. Our analyses showed good psychometric properties of the integrated instruments concerning missing rate, ceiling and floor effects, reliability and factorial validity. We could identify a 3-dimensional structure of the assessment tool according to the biopsychosocial model. CONCLUSION: The presented assessment tool is suitable for the identification of biopsychosocial impairments and resources. This can help to allocate patients with chronic diseases in appropriate rehabilitation facilities and therapeutic modules.

[Are Two-Year Vocational Retraining Programs Really Better than One-Year Programs? Findings of a Propensity Score Matched Analysis]. / Sind Vollqualifizierungen wirklich besser als Teilqualifizierungen? Ergebnisse einer Propensity Score gematchten Analyse.

AIM OF THE STUDY: To analyze if one- and 2-year vocational retraining programs achieve similar effects on employment. METHODS: Analyses were performed with longitudinal administrative data. We included persons aged 18-59 years, who started their retraining between January and June 2005. One- and 2-year program participants were matched by propensity scores. RESULTS: The matched groups were balanced regarding all baseline scores (one-year program: n=514; 2-year program: n=514). 4 and 5 years after start of the vocational retraining program, annual income, the duration of welfare benefits and the risk of a disability pension were comparable in both groups. However, the accumulative income between 2005 and 2009 was 9 294 Euro higher (95% CI: 3 656-14 932 Euro) in one-year retraining participants. Moreover, participants of one-year programs received less welfare benefits. CONCLUSION: The development of a vocational rehabilitation strategy needs to consider the accumulative advantage of one-year programs.

[Does the Success of Work-related Interventions in the Rehabilitation of Neurological Diseases Depend on the Return-to-Work Prognosis? A Re-analysis of 2 Randomised Controlled Trials]. / Hängt der Erfolg arbeitsbezogener Leistungen in der Rehabilitation neurologischer Erkrankungen von der Wiedereingliederungsprognose ab? Eine Re-Analyse von 2 kontrolliert randomisierten Studien.

OBJECTIVE: The paper examines whether patients with neurological diseases and a poor return to work (RTW) prognosis gain more from work-related medical rehabilitation (WMR). METHODS: Re-analysis of matched samples of 2 randomised controlled trials (N=442; questionnaire at admission of rehabilitation and 15-month follow-up). Linear regression models were used calculating the effect of the WMR dependent on the RTW prognosis. Primary outcome was time of sick leave in the follow-up and physical and mental health measured by the SF-36. As secondary outcomes, strategies of coping skills and work-related attitudes were defined. RESULTS: Only for patients with a high non-RTW risk could positive effects of WMR be demonstrated on mental health, coping skills and the scale "work as a resource". In the 15-month follow-up, there were no differences in effects on duration of sick leave and physical health. CONCLUSIONS: The results based on this analysis indicate that patients with neurological diseases derive benefit from WMR only if their empirical RTW prognosis is poor. However, this only applies for the mental health in the medium term. Our study confirms the previous findings that suggest different effectiveness of the WMR for patients with different RTW risk.

[Are Administrative Data Prognostically Relevant for Intended Disability Pension Claims and Indicators of Subjective Need for Rehabilitation?]. / Sind administrative Daten für Rentenantragsintentionen und Indikatoren subjektiven Rehabilitationsbedarfs prognostisch bedeutsam?

OBJECTIVES: The aim of the study was to examine the associations of the Risk Index Disability Pension (RI-DP), which was calculated from administrative data, with intended disability pension claims and other health- and work-related characteristics. MATERIAL AND METHODS: Insured persons of the Federal German Pension Insurance were surveyed by questionnaire in 2013. Questionnaire data were additionally linked to administrative data. The gross sample was restricted to persons, who received sick leave benefits in the previous year while not claiming or utilizing any rehabilitation services for the previous 4 years. RESULTS: 1,261 men and 1,495 women were included in the analyses. The odds of an intended disability pension claim were 4.8-times higher in men and 3.4-times higher in women if RI-DP scores were high. Furthermore, high RI-DP scores were also associated with frequent disability days, poor self-rated work ability and frequent visits to physicians. DISCUSSION: The associations of the RI-DP with the examined characteristics imply that administrative data could support early identification of rehabilitation needs.

[What determines the participation in stepwise occupational reintegration on behalf of the German pension insurance? Results of the "SOR cohort study"]. / Wonach richtet sich die Inanspruchnahme von stufenweiser Wiedereingliederung zu Lasten der gesetzlichen Rentenversicherung? Erste Ergebnisse der STW-Kohortenstudie.

OBJECTIVE: Stepwise Occupational Reintegration (SOR) measures are of growing importance for the German statutory pension insurance. There is moderate evidence that patients with a poor prognosis in terms of a successful return to work, profit most from SOR measures. However, it is not clear to what extend these information are utilized when recommending SOR to a patient. METHODS: A questionnaire was sent to 40406 persons (up to 59 years old, excluding rehabilitation after hospital stay) before admission to a medical rehabilitation service. The survey data were matched with data from the discharge report and information on the participation in a SOR measure. Initially, a single criterion was defined which describes the need of SOR measures. This criterion is based on 3 different items: patients with at least 12 weeks sickness absence, (a) a SIBAR score>7 and/or (b) a perceived need of SOR.The main aspect of our analyses was to describe the association between the SOR need-criterion and the participation in SOR measures as well as between the predictors of SOR participation when fulfilling the SOR need-criterion. The analyses were based on a multiple logistic regression model. RESULTS: For 16408 patients full data were available. The formal prerequisites for SOR were given for 33% of the sample, out of which 32% received a SOR after rehabilitation and 43% fulfilled the SOR needs criterion. A negative relationship between these 2 categories was observed (phi=-0.08, p<0.01). For patients that fulfilled the need-criterion the probability for participating in SOR decreased by 22% (RR=0.78). The probability of SOR participation increased with a decreasing SIBAR score (OR=0.56) and in patients who showed more confidence in being able be return to work. DISCUSSION: Participation in SOR measures cannot be predicted by the empirically defined SOR need-criterion: the probability even decreased when fulfilling the criterion. Furthermore, the results of a multivariate analysis show a positive selection of the patients who participate in SOR measures. Our results point strongly to the need of an indication guideline for physicians in rehabilitation centres. Further research addressing the success of SOR measures have to show whether the information used in this case can serve as a base for such a guideline.

[How many work-related therapeutic services do patients with severe restrictions of work ability receive? Analysis of a representative rehabilitation sample across indications]. / Wie viele arbeitsbezogene Leistungen bekommen Patientenmit besonderen berufl ichen Problemlagen? Analyse einerrepräsentativen indikationsübergreifenden Stichprobe von Rehabilitanden.

OBJECTIVE: The aim of the study was to analyze how many work-related interventions were realized during medical rehabilitation on behalf of the German Federal Pension Insurance, whether persons with severe restrictions of work ability (SRWA) received more work-related treatments and if the requirements of the Implementation Guideline for work-related rehabilitation were met. METHODS: A representative sample of working age persons insured in the German Federal Pension Insurance stratified by main diagnosis groups fulfilled a postal questionnaire before admission to their rehabilitation centre. Work-related interventions were measured by the Classification of Therapeutic Services (KTL), a German classification of treatments during medical rehabilitation. RESULTS: The sample consisted of 2232 persons with full data. Persons with SRWA received work-related interventions by an average of 6.1 h. The standardized mean differences for the treatment dose of persons with and without SRWA were between 0.12 and 0.34 for different work-related modules. In none of the modules the required minimum level was met. There were no considerable differences in persons with and without SRWA receiving the required minimum level. CONCLUSIONS: The analysis clearly stated the insufficient frequency and intensity of work-related treatments in medical rehabilitation. Especially the missing link between SRWA and work-related treatments indicates the strong need to further disseminate recently published guideline recommendations on the provision of work-related treatments.

[A systematic review of the predictors of return to work following vocational retraining]. / Eine systematische Übersichtsarbeit zu den Einflussfaktoren auf die berufliche Wiedereingliederung nach beruflichen Bildungsleistungen.

BACKGROUND: Vocational Rehabilitation (VR) is an essential element of interventions aimed at re-integrating people with work disability into work. In this context, vocational retraining is of special importance. However, the success of vocational retraining, represented by subsequent returning to work (RTW), is only to a limited extent attributable to intervention quality. Apart from methodical influences participant-related as well as context-related attributes are discussed as influencing factors. To know these RTW predictors is a necessary condition for a valid comparative evaluation of intervention quality. METHODS: A structured literature search was conducted. All studies meeting the following criteria were included: publication between 2006 and 2011; context: German rehabilitation system and vocational retraining; multivariate analysis of RTW predictors. The evidence for or against the influence of a predictor was rated as strong if more than 75% of the models, and moderate if more than 50% of the models reported or excluded a significant relationship between predictor and RTW. All predictors included in more than 2 studies were considered in this review. RESULTS: 15 publications from 6 studies were included in the analysis. Due to differentiation of the models between different types of retraining the evidence was based on 9 prediction models. Strong evidence of an effect on RTW can be assumed for income before admission, subjective health rating and regular completion of retraining. There is moderate evidence for an effect of age and target job. Strong evidence against an effect on RTW is found for employment and occupational status before admission. There is moderate evidence against an RTW effect of sex, education and locus of control. Ambiguous evidence is obtained for the local job market, the type of retraining, social support and mobility. CONCLUSIONS: For the first time the review provides findings on the relevant influence factors of RTW following vocational retraining. These findings on the one hand could lead to an advance of intervention quality due to consideration of special personal and/or environmental factors. On the other hand there still remains an undeniable lack of information in this field. There is a special need for studies capable of confirming previous findings or of clarifying known uncertainties in the available evidence.

[A meta-analysis of the impact of sample, kind of outcome measurement and time of follow up on occupational re-integration after vocational retraining]. / Eine Meta-Analyse zum Einfluss von Stichprobe, Messmethode und Messzeitpunkt auf die berufliche Wiedereingliederung nach beruflichen Bildungsleistungen.

OBJECTIVES: Vocational Rehabilitation (VR) is an essential element of intervention to rehabilitate people with work disability due to chronic diseases. The activities are heterogeneous; of particular importance in the rehabilitation process is vocational retraining. These interventions are cost-intensive, take very long and have a decisive impact on the main goal, the return to work (RTW). However, vocational retraining is conducted under different settings: The question is to what extent this leads to specific methodical implications of RTW measurement that have an impact on the level of RTW. METHODS: The analysis was concentrated on the main outcome RTW after vocational retraining. A structured review was conducted of all German-language publications from 2005 to 2010 which report an RTW quota after vocational retraining. The main methodical conditions were: kind of RTW measurement (point in time rate vs. cumulative course rate), time of follow-up in years, and sample definition (all participants vs. participants with regular completion of retraining, RC). The impact of these conditions on the level of RTW was predicted by using a meta-regression model. The time of follow-up was standardized on the mean (1 year). RESULTS: 20 publications from 10 studies were included in the analysis. In all, 23 RTW quota were observed, from which 22 were included in the regression model. A positive impact on the level of RTW was identified for reduction of the sample to participants with RC (b=10.04; p=0.001), the time of follow-up (b=5.47; p=0.052) and, by trend, the interaction of the kind of RTW measurement and time of follow-up (b=6.32; p=0.090). There was no significance given for the main effect of kind of RTW measurement (p=0.787). The model fit was calculated with an adjusted R2=75.17%. CONCLUSIONS: The level of RTW given in the publications is very heterogeneous, but a major part of the variance was explained by the 3 methodical conditions we examined. Based on this, a classification system for RTW measurement after VR is presented, which could be a model for designing future studies as well as inter-actor communication of success after VR.

[Comorbidity from the patient perspective - does it work? Validity of a questionnaire on self-estimation of comorbidity (SCQ-D)]. / Komorbidität im Patientenurteil - geht das? Validität eines Instruments zur Selbsteinschätzung der Komorbidität (SCQ-D).

To minimize the medical effort for the measurement of comorbidity, which is a relevant factor for various outcome measures, the Self-Administered Comorbidity Questionnaire (SCQ) for patient self-evaluation has been developed. After successfully testing the psychometric characteristics and content of the original English version a validation of the German translation (SCQ-D) has so far been lacking. A total of 218 patients with gonarthrosis and coxarthrosis (average age 71.5 years) were included in the survey. A questionnaire for doctors as well as patients was used to collect data at five different measurement times (postoperative, beginning and end of rehabilitation as well as 4 months and 1 year postoperatively). To evaluate the matching of comorbidities according to the SCQ-D and the Charlson Comorbidity Index (CCI), aggregate indices for "problems" and "treatment" as well as correlation and kappa coefficients were calculated. The assessment of predictive validity in terms of treatment outcome was operationalized using the WOMAC and the postoperative 1 year hospitalization by applying multilevel models. The patient self-assessment using the SCQ-D correlated well with the physician assessment using CCI in terms of aggregate indices of 13 given disease groups with r = 0.49 (problems) and r = 0.48 (treatment). However, the results showed significant differences for certain diseases in the conclusions. The comorbidity measured by the SCQ-D proved to be a valid predictor of the hospitalization and the treatment outcome. Concerning the need for resource efficient data collection especially in large sample studies, the SCQ-D is a useful patient self-administered instrument to assess the type and extent of comorbidities.

[Risk Index Disability Pension (RI-DP). A register-based case-control study with 8,500 men and 8,405 women]. / Risikoindex Erwerbsminderungsrente (RI-EMR). Eine prozessdatenbasierte Fall-Kontroll-Studie mit 8500 Männern und 8405 Frauen.

The aim of our study was to identify variables of prognostic relevance for disability pensions (DP) in the register data of the German Pension Fund (GPF) and to use the identified variables to construct a risk index. The study was designed as a case-control study of insurants of the GPF Bund using disability pensioners from 2004-2008 as cases and active insurants as controls. Independent variables were selected from the accumulated register data from 2001-2003. Data of 8,500 men and 8,405 women were analyzed. The strongest predictor of future DP were days of sickness benefits. Men with short-term benefits had 6.1 times higher odds of receiving a DP, while men receiving long-term benefits had even 66.3 times higher odds of receiving a DP. For women, the odds were increased 3.8 and 38.4 times, respectively. The risk index score was calculated by transforming the linear combination of parameter estimators and personal characteristics to values ranging from 0-100. ROC analyses and survival analyses confirmed the prognostic relevance of the index score. Independent samples were used to validate our models. Our results show that the GPF has information which could enable an active strategy to enhance the provision of medical rehabilitation.

[A profile of requirements for the performance of work related medical rehabilitation from the perspective of the statutory pension insurance]. / Ein Anforderungsprofil zur Durchführung der medizinisch-beruflich orientierten Rehabilitation aus der Perspektive der gesetzlichen Rentenversicherung.

OBJECTIVES: Work-related medical rehabilitation (Work MR) is a specific part of medical rehabilitation, which is well-established and broadly investigated. In almost all indications there is evidence of benefit of Work MR in patients with distinctive work-related problems due to chronic disease or disability. Nevertheless, there is a lack of implementation in clinical practice. This is due to a variety of reasons, mainly a missing definition of the appropriate Work MR interventions. The development of a Profile of Requirements (PoR) for defining contents and patterns of Work MR on behalf of the Statutory Pension Insurance (SPI) therefore is a fundamental step towards evidence-based, needs-focused rehabilitation management. The article introduces such a PoR - for the present focused on somatic indications. METHODS: The PoR was developed by an SPI expert group and revised in an extensive discourse within the SPI. A strategy involved in this context was the dissemination of work-related therapeutical concepts in medical rehabilitation. RESULTS: In the PoR, Work MR is defined as a concrete work-related designing of therapeutical interventions as well as an integrated "philosophy" in thinking and practicing of the actors involved. Work MR is differentiated in 3 intervention levels: While work-related basic interventions (Level A) are provided in all facilities for all patients, core interventions (Level B) as well as specific interventions (Level C) are explicitly concentrated on patient subgroups with distinct work-related problems. In the PoR the relevant diagnostic and therapeutic work-related interventions are attributed to the different intervention levels and described concerning the concrete arrangement. The 3 central core interventions "Work-related psychological group interventions", "Work-related internal load test" and "Work conditioning" are presented. CONCLUSIONS: The decisive benefit of the PoR is to substantiate the requirements of Work MR on behalf of the SPI often worded in a rather unspecific manner in the past. In the current pilot study called "Work MR Management" the feasibility of Work MR in clinical practice based on the PoR is tested. The resultant recommendations will provide the basis for disseminating Work MR throughout Germany independent of setting and indication.

[Who benefits from stepwise occupational reintegration provided under the statutory pension insurance scheme?]. / Wer profitiert von Stufenweiser Wiedereingliederung in Trägerschaft der gesetzlichen Rentenversicherung?

BACKGROUND: Stepwise occupational reintegration (SOR) - since law amendments in April 2004 also provided under the German pension insurance scheme (Deutsche Rentenversicherung, DRV) - is an instrument intended to support insurants on sick-leave in reintegrating into work step by step after long-term illness. In 2008, the effectiveness of SOR regarding return to work was affirmed for the first time in a comprehensive study. However, in view of the growing amount of SOR, the question of differential effects of SOR in special subgroups is raised. METHODS: This paper presents a re-analysis of data collected in the 2008 study. A total of 696 patients after medical rehabilitation were included in the analyses, 348 with SOR provided by the DRV, and a control group of 348 patients without SOR matched on a multitude of different variables using the Propensity Scores. Successful outcome was measured using a combined criterion "Return to work in good health", that is, patients returning to gainful activity and with sick leave of under 6 weeks and no intention to retire within a one-year follow-period after medical rehabilitation. Differentiating criteria are age gender, rehab indication, periods of sick leave in the year before medical rehabilitation, kind of and access to medical rehabilitation. RESULTS: The data indicate especially good results of SOR for patients with mental disorders (OR=2.49), patients who were requested to participate in medical rehabilitation by a health insurance fund because of long-term sick leave (OR=2.71), and patients with longer periods of sick leave before medical rehabilitation (3 to <6 months: OR=2.41, 6 months and more: OR=2.23). In contrast, there are only minimal effects (statistically not significant) of SOR in patients with medical rehabilitation directly after a hospital stay ("Anschlussheilbehandlung"), patients with cardiac or oncological diseases, and in younger (age 19-34) and older patients (age 55-60). In-depth analyses show that SOR success is more marked in patients with poorer return to work prospects. DISCUSSION: The findings indicate differential effects of SOR after medical rehabilitation for subgroups, effects associated in particular with return to work problems, kind of disease, and age. There is evidence for greater benefits of SOR in groups of patients with a high risk of non-successful reintegration. Hence, SOR opens up new options after medical rehabilitation in patients with especially severe impairments.

[Improved outcome quality following total knee and hip arthroplasty in an integrated care setting: results of a controlled study]. / Verbesserte Behandlungsqualität durch integrierte Versorgung bei Knie- und Hüftgelenkersatz: Ergebnisse einer kontrollierten Studie.

OBJECTIVE: In Germany, the introduction of the Law on integrated care (IC) (§ 140 a-d SGB V) opened up the possibility of cross-sectional health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. Patients awaiting a hip or knee arthroplasty expect a higher benefit from such an intensified cooperation of operating hospital and rehabilitation centre. However, to date there is no study that investigated the anticipated effects on functional outcomes. Therefore, the aim of our study was the efficacy evaluation of an arthroplastic IC model in comparison with usual care. METHODS: The controlled multicentre trial included pensioners who received an arthroplasty following gonarthrosis or coxarthrosis. Implantation of the arthroplasty was accomplished in 11 hospitals. Participants of the intervention group (IG; 3 hospitals) were treated within an IC model, participants of the control group (CG; 8 hospitals) were treated within conventional care. Primary outcome were the functional complaints measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: 481 patients attended the study (IG: n = 249; KG: n = 232). Response at end of treatment was 85.9% (n = 413), response after 4 months was 89.4% (n = 430) and after 1 year 85.9% (n = 413). Multivariate analyses confirmed a reduction of treatment time by 4 days (b = -3.964; 95% CI: -5.833 to -2.094; p < 0.001) and improved functional outcomes on the WOMAC (4 months: b = -7.219; 95% CI: -11.184 to -3.254; p < 0.001; 12 months: b = -8.070; 95% CI: -12.101 to -4.039; p < 0.001). Patients of the IG rated the process better (e. g. cooperation between hospital and rehabilitation centre: b = 0.672; 95% CI: 0.401 to 0.943; p < 0.001); reported a better self-rated health after 1 year (b = 4.418; 95% CI: 0.050 to 8.786; p = 0.047), and were physically more active (b = 1.603; 95% CI: 0.655 to 2.551; p = 0.001). CONCLUSION: The IC setting improved coordination and communication at the interface between hospital and rehabilitation centre (internal patient orientation). Higher patient satisfaction and better outcome quality (external patient orientation) are not only achievable by improved medical devices but also by innovative communicative and organisational structures bringing along an improved process quality.

[Illness perceptions and functioning following total knee and hip arthroplasty]. / Subjektive Krankheitstheorien und funktionaler Verlauf nach Knie- und Hüftgelenkersatz.

OBJECTIVE: In spite of the cumulating evidence for the prognostic relevance of illness perceptions regarding the course of disease and recovery of hip and knee joint patients, there are still no studies that examine the effects of these perceptions on postoperative functioning as assessed by clinical ratings. The aim of this inception cohort study was to describe the course of functioning following a hip or knee joint replacement over a period of one year and to analyse moderator-type effects of illness perceptions in order to develop strategies for preoperative counselling and postoperative rehabilitation. METHODS: The course of functioning following a hip joint replacement was assessed by the Harris hip score (HHS), the course of functioning following a knee joint replacement by the American Knee Society score (AKSS). Illness perceptions were assessed by the brief illness perception questionnaire. Due to the non-linear relationship of time and functional outcome, time was transformed using a log transformation. Moderator-type effects were analysed by interaction terms of log time and illness perceptions. RESULTS: For 135 patients the course of the HHS was analysed, for 127 patients the course of the AKSS. Results after one year confirmed a successful treatment for 82.3 % of the hip patients and 70.6 % of the knee patients. Hip patients expecting an enduring illness had lower scores on the HHS after one year (p = 0.026). The expectation that the treatment will be helpful was associated with a better outcome (p = 0.002). The outcome of knee patients was moderated by the degree how concerned they were about their illness (p = 0.016). CONCLUSION: The results confirmed the prognostic relevance of illness perceptions for the functional outcome and indicate the importance of preoperative counselling and the potential benefit of patient-oriented education that is aimed at modifying illness perceptions.

[Factors of successful integrated care settings for total knee and hip arthroplasty: findings of a qualitative process analysis]. / Erfolgsfaktoren integrierter Versorgungsprozesse in der Endoprothetik: Ergebnisse einer qualitativen Prozessanalyse.

AIMS: In Germany, introduction of the law on Integrated Health Care (IC) (section sign 140a-d SGB V) opened up the possibility of cross-sectoral health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. However, cross-institutional and interdisciplinary work contexts demand new organizational structures in order to assure the coordination of different competences, resources and interests. This study aims at identifying factors of successful integrated care settings for total hip and knee arthroplasty. Using the example of an integrated care setting between an orthopaedic hospital and a rehabilitation clinic it will be examined which factors lead to successful implementation of the services and measures designed. METHOD: A qualitative research design was developed comprising different methods of data assessment (participant observation, guided expert interviews, document analyses) enabling a comprehensive exploration. Overall, data were derived from six consultations with patients, two integrated care information sessions and various documents (17 patient files, information material, patient lists, etc.). RESULTS: First of all, the different phases of development and implementation of integrated care settings were described. In this context, clearly defined aims, structures and appropriate measures seem to be crucial for an ideal long-term cooperation. Furthermore, the staff perspective on the effects of the IC programme on their daily routines proved an essential basis for process reconstruction. The staff members pointed out four main aspects regarding IC settings, i. e., improved image, increased knowledge, intensity of relationship, and less and more work effort. Against this background, factors of successful IC settings could be generated such as the need for central coordination, a regular staff information systems as well as accompanying process monitoring. CONCLUSION: Several key factors of successful integrated care settings in arthroplasty could be generated which provide important clues for shaping future interdisciplinary and cross-sectoral cooperation settings in health care services in general.

[Validity and reliability of a screening instrument for the identification of extensive work-related problems in patients with chronic diseases (SIMBO-C)]. / Validität und Reliabilität eines Screening-Instruments zur Erkennung besonderer beruflicher Problemlagen bei chronischen Krankheiten (SIMBO-C).

BACKGROUND: Work-related interventions have become an integral part of medical rehabilitation programmes on behalf of the German Pension Fund. Studies showed concordantly that work-related medical rehabilitation measures should focus on patients with extensive work-related problems. Therefore the identification of such problems has to be an integral part of effective work-related interventions in medical rehabilitation. Adequate screening instruments do exist, but publications regarding their psychometric quality across indications are still missing. AIM: Based on the SIMBO-MSK, which is a screening instrument for identification of work-related medical rehabilitation needs in patients with musculoskeletal disorders (MSD), a generic screening instrument for chronic diseases, SIMBO-C, was developed and tested for reliability and validity. METHODS: For testing psychometric attributes a German Pension Fund sample consisting of rehabilitation patients with MSD (MSD, n=182), psychosomatic disorders (PSY, n=173) and internal diseases (INN, n=71) were recruited. They filled-in a questionnaire at admission and at the three-months follow-up. The test-retest reliability was examined by means of Intra-class Correlation Coefficient (ICC) und Percentage of Agreement (PA) in a subsample (n=91) of patients who had been assessed additionally two weeks before starting their rehabilitation programme. Spearman correlation coefficients were calculated to observe the relationship between SIMBO-C on the one hand and Physical and Emotional Role Function (MOS-36), health status (EQ5-D) and subjective prognosis of work ability (SPE) on the other hand. Predictive validity was tested in three data sources: information about work ability in the medical report upon discharge, self-report on work ability from the Work Ability Index (WAI) as well as socio-medical situation at follow-up. In this context multiple linear and logistic regression models adjusting for age, gender, form of rehabilitation, indication and work status at admission were used. RESULTS: SIMBO-C was composed of the weighted sum of seven single items (range: 0-100). Extensive work-related problems were presented at a cut-off of > 30. Prevalence of extensive work-related problems was between 29% (MSK) and 43% (INN). With ICCs of 0.83 (PSY) up to 0.91 (INN) as well as PAs of 78% (INN) up to 90% (MSK), a high test-retest reliability across indications was found. Construct validity were moderate. Particularly, high effect sizes between patients with and without extensive work-related problems were found across indications. The prediction of future events was predominantly high. Statistically significant associations for self-reported work ability and cost-relevant events (claim for occupational rehabilitation, claim for early retirement, gradual reintegration, absence from work for more than six weeks at a stretch, unemployment after rehabilitation) could be accounted for, which partly demonstrated a "dose-response relationship". CONCLUSIONS: SIMBO-C can be characterised as a valid and reliable instrument for identification of patients with extensive work-related problems. This study in particular outlines the ability of the SIMBO-C to make predictions about problematic developments, which qualifies it as an instrument to be implemented at an early point of time in the rehabilitation process.

[Economic evaluation of medically occupationally orientated rehabilitation in patients with musculoskeletal disorders--a cost-benefit analysis from the perspective of the German statutory pension insurance scheme]. / Okonomische Evaluation einer medizinisch-beruflich orientierten Massnahme bei Patienten mit muskuloskeletalen Erkrankungen - Eine Kosten-Nutzen-Analyse aus Rentenversicherungsperspektive.

BACKGROUND: Musculoskeletal disorders are the most common health problem in Germany and the most frequent cause for medical rehabilitation under the German statutory pension insurance scheme. There is evidence of a strong association between musculoskeletal disorders and work-related problems. Recent research has shown that work-related interventions are adequate and effective as a treatment for patients with strong work-related problems. AIM: This evaluation compares the "work-related" (German: MBO, medizinisch-beruflich orientiert) rehabilitation to the standard medical rehabilitation provided in a clinical setting. From the perspective of a regional German statutory pension insurance agency, DRV Westfalen, it measures the efficiency of both treatments in patients with a diagnosed MBO demand 18 months after completion of the treatment. METHOD: The effect of both treatments on pension insurance revenues and costs up to 18 months after treatment was determined. Rehabilitation balance sheets of both treatments were compared in a cost-benefit analysis. From the difference obtained, conclusions could be drawn relative to the efficiency of the respective treatments. RESULTS: The descriptive analysis indicated additional receipts as a result of the MBO rehabilitation. Considering total costs, an effect amounting to 1 245 euro concerning the total revenue of DRV Westfalen is found if a patient had completed the MBO rehabilitation instead of the standard medical rehabilitation programme. CONCLUSION: Compared to standard medical rehabilitation, "work-related" rehabilitation hardly causes higher follow-up costs within 18 months, while generating higher receipts. Consequently, a more favourable monetary development is realized within the balance total in contrast to the standard medical rehabilitation. Limitations and consequences of these results are discussed in detail.

[SIMBO: a Screening Instrument for Identification of Work-Related Disabilities--analyses of construct and prognostic validity]. / SIMBO: Ein Screening-Instrument zur Feststellung des Bedarfs an Medizinisch-Beruflich Orientierten Massnahmen in der medizinischen Rehabilitation--Analysen zur Konstruktvalidität und Prognosegüte.

BACKGROUND: For a number of years, work-related interventions in medical rehabilitation (MBO) have been developed. Basically, these interventions concentrate on vocational problems of rehabilitees whose health disorders are strongly associated with contextual factors of the environment as well as personal factors. Previous studies showed a close relationship between the success of an intervention and identification of a specific demand. In fact there are several clinical concepts regarding specific demand. But there still is a lack of appropriate instruments for use in identification of occupational challenges. Therefore SIMBO (Screening Instrument for Identification of a Demand for Medical-Vocational Oriented Rehabilitation) has been developed recently. By using a scale for the intensity of work-related problems as well as a cut-off point, SIMBO is able to identify patients with and without a demand for work-related interventions. METHOD: Analyses relative to construct validity and predictive validity were carried out on two different samples--a multi-clinic sample (patients with musculoskeletal disorders) and a sample from the German statutory pension insurance agency DRV Westfalen (successful applications for medical rehabilitation). In this context the cut-off level discussion is very important. RESULTS: By means of the multi-clinic sample--irrespective of cut-off definition--the SIMBO-decision and the clinical identification of MBO-demand were found to agree in 74-78% of the cases. This corresponds to a maximum adjusted correlation of r=0.59 (phi coefficient). Compared to the external ratings of vocational problems given by DRV staff in handling the applications, however, only little agreement is found (64%, r=0.25). In fact, SIMBO had in 77% (r=0.50) of the cases been able to correctly predict work-related problems to be expected. So the result obtained using this instrument is far better than prediction of these problems in the external ratings by DRV staff (54%, r=0,21). Also, return to work (RTW) in good health after six months can be predicted correctly by SIMBO in 77% of the cases. This means that the probability of RTW in good health is reduced by 90% (Odds Ratio=0.1) if work-related problems had been identified by SIMBO. DISCUSSION AND CONCLUSION: Concerning its clinical as well as predictive quality, the validity of SIMBO-based ratings of work-related problems has been proven. Further, it has become obvious that SIMBO is suitable as an easy-to-handle tool for identification of a need for vocationally-focused interventions for use by the social insurance agencies which finance rehabilitation. Further interesting questions arise relative to application in different indications as well as potential uses as an outcome instrument.