Predictors of early retirement and rehabilitation for use in a screening to detect workers in need of rehabilitation.

In the German pension insurance sector a screening is being suggested to ensure the participation in rehabilitation measures of workers at risk of health-related early retirement. Screening presupposes empirical indicators of rehabilitation needs. A study is presented that determined predictors of early retirement and rehabilitation from longitudinal data for use in a screening for the selection of workers likely to be in need of rehabilitation. We gathered longitudinal data by conducting a second survey with a cohort for which the first survey had delivered clinical findings, lab. values, medical diagnoses and self reports regarding morbidity, medication, health-related behavior, family- and occupational-related strains, and sociodemographic information (first survey T0: 1975/76, n = 3.968; second survey T1: 1992/93, n = 28.463). The survey of T1 also comprised inquiries of the pension insurance institutions concerning the retirement and rehabilitation status for pension-insured study subjects (n = 1.794). Based on these subjects, using multi- and bivariate regression analysis, we determined those T0 variables which were significantly related to the events of early retirement (98 cases/357 controls), rehabilitation (127 cases/200 controls) and early retirement or rehabilitation (185 cases/270 controls) in the period T0-T1. The significant T0 variables were subsequently used for the definition of a selection index which measured rehabilitation need by a simple sum score (number of significant T0 variables present). We tested the discriminative power of this index for a subsample of the cohort (cases who retired early or underwent rehabilitation and controls). The index classified 68% of the cases correctly. The sensitivity reached 57% and the specificity 76%. In connection with this result, the long prognostic time interval (up to 17 years) has to be considered. In the case of screening the preselection of workers via the index would occur at the same time as the medical assessment of the actual need for rehabilitation. An earlier study showed that this would raise sensitivity and specificity of an index based on predictors of early retirement substantially.

["Index for rehabilitation eligibility" for screening social insurance workers]. / Ein "Index der Rehabilitationsbedürftigkeit" für ein Screening rentenversicherter Arbeitnehmer.

The principle "priority of rehabilitation over early retirement" might be realised by a screening by which employees in need of rehabilitation are detected in time and rehabilitation measures are purposively started. With the "Index of Rehabilitation Need" we continued our efforts to develop an applicable screening tool on an epidemiological basis. To this end (1) longitudinal data were established by repeating an epidemiological survey of a population sample in the Nordenham/Brake region (T0 = 1975/76, T1 = 1992/93); (2) T0-variables were identified which correlated significantly with the events of early retirement and/or rehabilitation in the period of T0 to T1 (98 cases of early retirement/357 controls; 127 cases of rehabilitation/200 controls; 185 cases of early retirement of rehabilitation/270 controls) using bivariate and multivariate regression analysis; (3) significant T0-variables were used to construct a questionnaire index (based on self assessment of symptoms/complaints, consumption of medicaments, smoking, and work load--16 items), a medical examination index (based on clinical/laboratory findings and medical diagnoses--10 items), and an overall index (sum of both indices--26 items); (4) the index values were calculated for cases of early retirement of rehabilitation and controls of the cohort (185/270), for each index significant differences between cases and controls tested, and the screening characteristics of the overall index analysed; (5) possible reasons for incorrect classifications were examined using a subsample of cases and controls (n = 96/78), for which additional data on medical and work history, stressful life events, and attitudes towards rehabilitation had been collected. All indices showed significant differences between cases of early retirement or rehabilitation and controls. These differences proved to be stronger with the questionnaire and overall indices (p < .0000 each) than with the medical examination index (p < .0006). The overall index did not detect 18% of the cases in need of rehabilitation (false negatives). The proportion of the false positives was 14%; sensitivity and specificity amounted to 57% and 76%. The analysis of the subsample revealed only two possible and plausible reasons for incorrect classifications: the time span between the first survey and the year of early retirement as well as injuries. The index detected cases of early retirement or rehabilitation more easily where the time span between T0 and the year of early retirement was shorter. The index cannot detect cases of early retirement and rehabilitation caused by injuries between T0 and T1, since it is based on chronic disorders and stresses to be the reason for both events. With respect to the sensitivity and specificity of the index the relatively long prediction period needs to be taken into consideration--between T0 and the time of the events there could have been a period of up to 17 years. However, the objective of a screening is not to predict the long-term outcome but to preselect persons who are likely to need rehabilitation and should be invited to a socio-medical examination in order to clarify their rehabilitation need and to start appropriate rehabilitation measures. The chance to detect true positive candidates and to exclude false negative candidates is essentially higher when the measurement of the predictors and the examination are carried out at the same time as has been shown in a former study. With regard to further proceedings we suggest to apply the index in a screening and to investigate the cost effectiveness and other aspects of the screening in a demonstration project.

[Harmonization of the assessment of outcomes, predictors and costs as well as testing for gender-specific differences in rehabilitation research]. / Harmonisierung der Messung von Outcomes, Prädiktoren und Kosten sowie Prüfung geschlechtsspezifischer Unterschiede in der rehabilitationswissenschaftlichen Forschung.

The scientific program "Rehabilitation Research in Germany" includes as a priority topic the evaluation of the effectiveness of rehabilitation regarding return to work. Controlled intervention studies with randomized allocation to treatment and a minimum follow-up of six to twelve months after rehabilitation are of primary importance. It is also recommended that the studies should include economic aspects and consider gender differences. Another request is harmonization of studies with respect to methods, assessment tools, and implementation to improve the relevance of the studies and to allow for combining the results. The authors respond to this request. They make proposals for harmonizing the assessment of outcomes, predictors, and costs as well as for testing gender differences in intervention studies. The proposals address the rehabilitation research networks and aim to provide a basis of discussion and to initiate the necessary consensus finding between the networks. Proposals include (1) a taxonomy of outcomes and predictors for rehabilitation and recommendations for generic assessment tools which allow for data-pooling of studies; (2) a concept for the pre-post and follow-up measurement and recommendations concerning the time interval on which evaluation of the effectiveness and efficiency of rehabilitation or treatment modalities should be based; (3) descriptions of the content and interpretation of the self assessment instruments which are recommended for cross study comparisons; (4) a procedure to assess the direct and indirect costs, i.e. costs of treatments and costs of disease consequences, which considers especially the assessment of rehabilitative services and their monetary evaluation; (5) provisions for ensuring representativeness of women in intervention studies and procedures for testing differences in treatment outcomes between women and men; (6) a procedure to reach harmonization by establishing a coordination committee including representatives of the research networks, and by using well-established methods such as consensus conferences.

[Health status of spa visitors]. / Gesundheitszustand der Kurteilnehmer.

German compulsory health insurance grants outpatient and inpatient prevention and rehabilitation treatments at spa facilities to avoid early retirement and long term care. A survey including participants between the age of 55 and 75 (n = 721) was conducted to determine the extent to which the current granting of spa treatment complies with regulations ("Begutachtungsanleitung Kuren"). The analysis was based on the data provided in the treatment application form by the general practitioners and on the answers of participants to a questionnaire on health-related quality of life (IRES). It compared a) cases granted outpatient/inpatient treatment at spa facilities, b) cases granted prevention/rehabilitation treatments at spa facilities and c) participants in spa treatments and controls from the IRES standard sample. For musculoskeletal diseases and diseases of the connective tissue, outpatient treatment was more often granted than inpatient treatment. There were no differences in the diagnoses of participants in prevention and rehabilitation treatments. Patients complaining about severe impairments/disabilities were granted inpatient rather than outpatient treatment. There were only minor differences between cases granted prevention and rehabilitation treatments respectively. The participants in spa treatment felt more impaired/disabled than controls of the standard sample. Overall, the selection of participants in spa treatment and the referal to outpatient and inpatient and inpatient treatments for the most part follows a needs-based pattern; however, improved differentiation is required between outpatient and inpatient prevention and rehabilitation treatments.

Assessment methods for rehabilitation.

Diagnostics and evaluation in medical rehabilitation should be based on methods that are as objective as possible. In this context quantitative methods are an important precondition. We conducted for the German Pensions Insurance Institutions (which are in charge of the medical and vocational rehabilitation of workers and employees) a survey on assessment methods for rehabilitation which included an evaluation of American literature, with the aim to indicate procedures that can be considered for adaptation in Germany and to define further research requirements. The survey identified: (1) standardized procedures and instrumented tests for the assessment of musculoskeletal, cardiopulmonary and neurophysiological function; (2) personality, intelligence, achievement, neuropsychological and alcoholism screening tests for the assessment of mental or cognitive function; (3) rating scales and self-administered questionnaires for the assessment of Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL Scales); (4) generic profiles and indexes as well as disease-specific measures for the assessment of health-related quality of life and health status; and (5) rating scales for vocational assessment. German equivalents or German versions exist only for a part of the procedures identified. Translation and testing of Anglo-Saxon procedures should have priority over the development of new German methods. The following procedures will be taken into account: (a) instrumented tests for physical function, (b) IADL Scales, (c) generic indexes of health-related quality of life, (d) specific quality of life and health status measures for disorders of the circulatory system, metabolic system, digestive organs, respiratory tract and for cancer, and (e) vocational rating scales.

Screening process to discover insured persons in need of rehabilitation.

In order to prevent early retirements in Germany, medical rehabilitation measures are implemented among workmen and salaried employees whose fitness for work is jeopardized or diminished. Only around half of those retiring early take advantage of these measures in the last 5 years prior to retirement. To increase the numbers making use of rehabilitation measures, we developed a screening process whereby the pension insurance institutions responsible for the measures are able to identify insured persons in need of rehabilitation and urge them to take part. The screening process comprises two stages: written questioning to determine the probable risk cases by means of predictors of early retirement, and medical clarification of these cases by means of a standardized rehabilitation assessment. The screening process and devices were tested in an experimental trial involving 600 people aged between 45 and 54 insured with a pension insurance institution responsible for workers in the Stuttgart area. Main results were: (1) The screening process was accepted by the insured. Around 70% of the insured took part in the screening. (2) The questionnaire is suitable for pre-selection of the probable risk cases that require medical clarification. Given complete answers, 83% of the cases were correctly classified in comparison with the judgement of the pension insurer's physicians. (3) The screening was effective, i.e. it increased the participation of insured persons in need of rehabilitation in rehabilitation measures. Compared with a control random sample, in the experimental trial, 70% more rehabilitation measures were applied for and approved.

[Screening for determination of workers in need of rehabilitation]. / Screening zur Ermittlung Rehabilitationsbedürftiger Arbeiter.

Blue collar workers whose fitness is at risk may receive in-patient rehabilitation therapy in the Federal Republic of Germany, provided they apply for it to their annuity insurance company. Only 50% of the workers who retire early (before the age of 60) and are in need of medical rehabilitation make such an application within the five-year period before retirement. It is against this background that we are developing and testing a screening procedure which includes all insured workers and recommends a rehabilitation therapy to those at risk. The screening procedure involves two steps: a questionnaire which is then followed by a medical examination. In an experiment with 600 workers who are insured with the LVA Württemberg (the relevant insurer) we tested: whether the screening is accepted by the insured and their family doctors, to what extent the insurer's appointed doctors ratify the family doctor's report and give approval for rehabilitation therapy, whether the questionnaire is suitable for the preselection of insured at risk, and whether the screening detects insured at risk who do not apply for rehabilitation therapy. Participation at the screening was 68% and speaks well for the acceptance of the procedure. The family doctors recommended rehabilitation therapy in 43% of all cases whereas the insurer's appointed doctors recommended such a therapy only in 25%. This discrepancy arose in 2/3 of the cases due to the fact that the insurer's appointed doctors refused renewed rehabilitation therapy during the mandatory three-year waiting period or considered out-patient rehabilitative treatment sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)

[Predictors of early retirement and focused assignment to medical rehabilitation]. / Prädiktoren der Frühberentung und gezielte Zuweisung zur medizinischen Rehabilitation.

Previous work and results from the project "Identification of a high-risk profile for early retirement" were presented. The project is being supported by the LVA-Württemberg (pension insurance for blue collar workers). In this project, a two-step screening process to determine prospective early retirees and provide specific assignment for medical rehabilitation is being developed and tested, with the goal of adhering better to the basic principle of "rehabilitation before retirement". The foundations for the solution proposed in the two-step screening are predictors of early retirement, with which prospective retirees can be detected early on. On the basis of a cohort study on environmental effects and frequency of illness during the period 1974-85, we have identified predictors for early retirement and premature death. Early retirees complained of health problems even years before retirement. In particular, they complained of shortness of breath and respiratory tract ailments, general impairment of physical performance, and ailments of the skeletal and motor apparatus. Data for persons who died prematurely after 1974 were largely consistent with those for early retirees. Most prominent in this case were complaints indicating coronary risk or angina pectoris, chronic bronchitis, and peripheral circulation problems. We evaluated the significantly increased health problems in the risk groups from the 1974 inquiries as indicators or predictors for early retirement. We utilized them for a questionnaire which was designed to determine the predictive risk profile for early retirement, and may be therefore suitable as a screening instrument for identifying prospective early retirees among currently employed insured persons (screening stage 1).

[Early detection of breast cancer in relation to patient and physician characteristics]. / Probleme der Früherkennung des Brustkrebses auf seiten der Patientin und des Arztes.

Higher participation rates of women in regular examination for early cancer detection (Krebsfrüherkennungsuntersuchung, KFU) are expected to improve the effectiveness of breast cancer screening. In the Federal Republic of Germany the law guaranties yearly examination. The detection of early stages is also intended to make breast conserving therapy possible. In our project "Patient- and physician-related problems of early breast cancer detection" we believed that early detection of breast cancer depends not solely on the participation of women entitled to make use of regular examination. We assumed that it depends also on the diagnostic reliability of the examinating physicians. Therefore, we became interested in the factors that cause early or late diagnosis in patients with malignant and good breast lesions. In order to identify these factors, we asked patients and the examinating physicians for case reports. Our qualitative investigations included 50 patients in the area of Munich and Ulm. We found out that, though most patients participated regularly in the early cancer detection examination, participation had no influence on early or late detection of the disease. The majority of patients included in the study, belonged to the group of women with a high participation rate according to the statistics. In general, examination for early cancer detection failed to recognize breast cancer in symptomless women. Not until the patient presented symptoms breast cancer was diagnosed. Early and late diagnoses followed this pattern. Only the patient with early breast cancer and primary surgery by a gynaecologist retained her breast. The surgeons removed the breast. They did not even consider partial resection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Measurement methods for self-assessment of the state of health by rheumatism patients]. / Messinstrumente zur Selbsteinschätzung des Gesundheitszustands für Rheuma-Patienten.

In the course of the preparation of multicenter clinical trials involving patients suffering from rheumatic diseases, a self-administered questionnaire for the subjective assessment of health status was developed and tested; the pilot study included 186 patients at 14 hospitals. The questionnaire gathered data in the following areas: pain, complaints, psychological wellbeing, depression, anxiety, and functional status. Experts participating in our project thought these parameters to be relevant to the self-assessment of health status. Scales from the literature on psychometry and health indicators were chosen to assess the parameters. In the pilot study the usefulness and feasibility of the parameters and measurements were tested. A revised and shorter form of the original self-administered questionnaire was developed on the basis of the results of the pilot study, and this questionnaire was then recommended for use in clinical trials. The questionnaire is discussed in the light of the recent literature reporting on similar assessment methods for rheumatic patients.