Inequalities in therapeutic treatment during cardiac inpatient rehabilitation in Germany.

OBJECTIVE: Cardiac patients of low socio-economic status (SES) display low health status and increased need for rehabilitation. This study's objective was to examine whether and to what extent inequalities in the provision of rehabilitative health care occur in Germany. METHODS: We conducted an observational study with two points of measurement on 543 patients in cardiac inpatient rehabilitation. We used logistic regression and analysis of covariance to explore whether patients experience unequal therapeutic rehabilitative treatment. RESULTS: Patients of low SES were less frequently physically active, more likely to smoke and displayed a higher number of physical and psychological symptoms when entering rehabilitation. They were less likely to receive a number of therapies with differences being significant for core therapies of cardiovascular rehabilitation. Patients of higher SES received fewer hours of dietary counselling on average. CONCLUSIONS: While the latter difference might be in line with the needs of different socio-economic groups, most differences are unlikely to be tailored to patients' needs. Potential causes of inequalities in service provision like structural factors and aspects of the doctor-patient encounter should be further investigated.

Social epidemiology after the German reunification: East vs. West or poor vs. rich?

OBJECTIVE: Social epidemiology has consistently demonstrated an association between socio-economic disadvantage and ill health. Seventeen years after reunification, economic disparities persist between former "East" and "West" Germany. We examine whether there are according health disparities and how they developed over time. METHODS: Secondary analysis of socio-economic and health data for Germany. RESULTS: Health disparities, for example in life expectancy, are decreasing between East and West. Throughout Germany, however, differences in living conditions and demographic trends are widening at city and county level. This development is easily missed when only East and West are compared. CONCLUSION: Small-area analyses are required to disentangle the association between socio-economic inequalities and health in Germany. In such analyses, not only individual but also contextual (e.g. area level) characteristics need to be included. Contextual variables can be used to group smaller areas such as counties into clusters with similar properties. Thus, individual survey data can be linked with contextual characteristics while maintaining data protection and at the same time achieving sufficiently large case numbers. Concurrently, theoretical models explaining health inequalities need to be further developed so that they embrace contextual characteristics.

Predicting non-return to work in patients attending cardiac rehabilitation.

Return to work (RTW) is the primary goal in the rehabilitation of patients suffering from coronary heart diseases. However, in spite of expensive rehabilitative efforts, many patients do not resume work following cardiac rehabilitation. To increase cost-effectiveness, predictive tests for non-RTW are needed to identify patients who are at risk of applying for early retirement, for reasons other than medical ones, at the beginning of the rehabilitation process, so that the necessary intervention is incorporated into the rehabilitation programme. As part of a study aiming at developing an advisory programme which can be integrated into existing rehabilitation programmes, we developed a screening instrument for the identification of persons at risk of not returning to work at the onset of the rehabilitation process. More than 65% of the participants who had not returned to work 6 and 12 months following rehabilitation had been correctly identified as risk patients at the beginning of the rehabilitation process. Seventy-five percent had been correctly identified as not being at risk. Multiple regression analysis results showed that increased age, profession, positive expectations concerning RTW and level of depression were significant predictors of RTW. Gender and anxiety were not significant predictors.

Does age influence early recovery from ischemic stroke? A study from the Hessian Stroke Data Bank.

Age is the most important risk factor for developing a stroke. In addition, age may also influence stroke recovery. To allow structured discharge planning, it may be important to consider the influence of age on stroke recovery during the early phase. We studied the effect of patient age on early stroke recovery in a cohort of 2219 unselected stroke patients. Data on functional status (Barthel Index Score) were collected prospectively within 24h after admission, after one week and at discharge for 2219 acute stroke patients treated in 1999 and 2000 at 7 neurological departments in the county of Hesse, Germany. Multiple regression analyses were used to test for an association between age, relative recovery and speed of recovery of ADL after stroke. More than half of the patients (58 %) improved in functional status during hospitalization. 37 % had no change in Barthel Index score and only a small number of patients (5 %) deteriorated during this period. Relative improvement decreased with increasing age: patients younger than 55 years showed an improvement of 67 % of the maximum possible improvement compared whith only 50 % for patients above 55 years (adjusted R(2) = 0.120, beta(age) = -0.130, p < 0.001). Age only had a small effect on the speed of recovery. For younger patients functional recovery was slightly faster (adjusted R(2) = 0.256, beta(age) = -0.080, p < 0.001). Despite its strong influence on case fatality, age is a poor predictor of functional recovery during the very early phase after stroke. Resulting functional recovery depends much more on the extent of the initial disability. Advanced age should not be regarded as a limiting factor in the early rehabilitation of stroke patients.