[Rehabilitation Goals of Patients with Coronary Artery Disease and Chronic Back Pain - An Analysis of Free Text Responses]. / Rehabilitationsziele von Patienten mit koronarer Herzerkrankung und chronischen Rückenschmerzen - Eine inhaltliche Analyse freitextlicher Zielnennungen.

BACKGROUND AND OBJECTIVE: Goal-setting is considered as an important step in medical rehabilitation. Regarding patient participation in the process, the possible inability of patients to develop personal goals is often discussed as a potential obstacle. This article examines whether patients have goals for medical rehabilitation and if so, which. METHODS: 189 patients with a diagnosis of coronary heart disease and 254 patients suffering from chronic back pain were surveyed in the run-up to their inpatient rehabilitation. Using a questionnaire, patients were asked to note their 3 most important rehabilitation goals. The free text data were then analyzed qualitatively and quantitatively. RESULTS: Most patients were able to express their personal rehabilitation goals before the beginning of their rehabilitation process.. Goals referring to coping with the disease were important to patients with both diagnoses. CONCLUSION: The rehabilitation goals expressed by the patients are suited for a participative goal-setting.

[Trends in rehabilitation of patients with rheumatic diseases in Germany]. / Leistungstrends der rehabilitativen rheumatologischen Versorgung in Deutschland.

Recent Deutsche Gesellschaft für Rheumatologie (DGRh, German Society of Rheumatology) guidelines emphasized the significance of coordinated multidisciplinary care and rehabilitation of patients with inflammatory rheumatic diseases. Nationwide data from the German pension insurance funds showed that inpatient rehabilitation due to rheumatoid arthritis (RA) varied by a factor of 2.6 between the different German states. From 2000 to 2012 rehabilitation measures were reduced by one third, most significantly in men with ankylosing spondylitis (AS). Rehabilitation measures because of RA or AS were provided up to 14 times more frequently by the German statutory pension insurance scheme compared with a large compulsory health insurance which is responsible for rehabilitation measures after retirement. In rehabilitation centers with high numbers of patients with inflammatory rheumatic diseases, higher structural and process quality were demonstrated. In 2011 a total of 40 % of RA patients in the national database of the collaborative arthritis centers showed medium or severe functional limitations. Among these disabled RA patients inpatient rehabilitation was reduced by about 50 % between 1995 and 2011. Out of all RA patients from outpatient rheumatology care with severe functional limitations 38 % had no functional restoration therapy within the previous 12 months with a high variation between rheumatologists. Experiences from other European countries may inspire German rheumatologists and other involved health professionals to initiate a wider range of rehabilitative interventions in the future.

[Work place health promotion programmes of the statutory German Pension Insurance]. / Betriebsnahe Präventionsprogramme der Deutschen Rentenversicherung.

BACKGROUND: In 2009, the amendment of § 31 Abs. 1 Nr. 2 SGB VI gave the German Pension Insurance the opportunity to provide outpatient medical treatments for insured people who have an occupation with particularly high risk of health. Ever since, the German Pension Insurance has developed various work place prevention programmes, which have been implemented as pilot projects. This article aims at systematically recording and comparatively analyzing these programmes in a synopsis which meets the current state of knowledge. METHODS: We developed an 8 page questionnaire focusing on work place prevention programmes by the German Pension Insurance. This questionnaire was sent to people in charge of all programmes known to us. RESULTS: All programmes have been drafted -across indications. They are aiming at insured people who already suffer from first health disorders but who are not in imminent need of rehabilitation. However, the concrete target groups at which the specific programmes are aimed differ (shift workers, nurses, elderly employees). Another difference between the various programmes is the setting (in- or outpatients) as well as the duration. CONCLUSION: All programmes are using existing structures offered by the German Pension Insurance. They provide measures in pension insurance owned rehabilitation centers. It would be desirable to link these performances with internal work place health promotion and offers of other social insurances.

[Consideration of Rehabilitation within High Class Quality Guidelines, Registered by the German Association of the Scientific Medical Professional Societies (AWMF)]. / Berücksichtigung der Rehabilitation in den S3-Leitlinien im Register der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF).

Clinical practice guidelines are systematically developed documents aiming at guiding decisions in specific areas of health care. Therefore, incorporating rehabilitation in guidelines adressing chronic diseases is of major importance. As information regarding consideration of rehabilitation in guidelines is lacking, the intention of our study was to analyse to what degree rehabilitation experts participated in guideline development and whether guidelines for chronic diseases include relevant information and recommendations concerning rehabilitation.In order to answer these questions we investigated 97 guidelines of high class quality, registered by the German Association of the Scientific Medical Professional Societies (AWMF). 36 out of these guidelines addressed chronic health conditions in which rehabilitation may be of relevance. Guidelines identified were analysed using a set of defined criteria.In 11 out of the 36 guidelines one or more medical rehabilitation societies participated in the development process, 17 include a chapter on rehabilitation issues, and 20 information concerning indication for rehabilitation processes. 24 guidelines consider rehabilitation in their recommendations.There is substantial variance concerning inclusion of rehabilitation in German guidelines on chronic diseases. Rehabilitation societies are encouraged to strive for stronger integration of rehabilitation into guidelines of other societies.

[Evaluation of a collaborative goal setting intervention in patients with chronic back pain]. / Evaluation einer Intervention zur partizipativen Vereinbarung von Rehabilitationszielen bei Patienten mit chronischen Rückenschmerzen.

BACKGROUND AND OBJECTIVE: Although setting rehabilitation goals is considered to be a core rehabilitation process, in actual rehabilitation practice there is a considerable need for improvement with respect to consistent goal orientation. The objective of the PARZIVAR project was therefore to develop an intervention for participative goal setting in medical rehabilitation. This article reports the results of the evaluation of the PARZIVAR intervention in patients with chronic back pain. METHODS: The PARZIVAR intervention was evaluated in a sequential control group design with 3 measurement points (before the start of rehabilitation, at the end of rehabilitation, and at 6-month follow-up). The proximal endpoints were defined as patient perception of participative goal setting, subjective awareness of goals, and satisfaction with goal setting. The distal endpoints were intensity of pain and generic and illness-specific functioning. RESULTS: Overall, the degree of achieving aspects of participative goal setting was higher in the intervention group. There were no differences regarding satisfaction with goal setting, however, and distal outcomes also remained unchanged after the intervention was implemented. DISCUSSION: Participation in the PARZIVAR intervention was partially reflected in the perception of the rehabilitation patients, but the effects regarding distal outcomes in the intervention group did not exceed those of usual care. There is a need for more research into how concepts of goal setting can be improved in the future to better address the diverse functions of goal setting.

[Female patients with fibromyalgia syndrome in somatic and psychosomatic rehabilitation center - an exploratory study on access routes and differences in patient characteristics]. / Fibromyalgiesyndrom-Patientinnen in psychosomatischen und somatischen Rehabilitationseinrichtungen - eine explorative Studie zu Zugangswegen und Unterschieden in Patientenmerkmalen.

STUDY OBJECTIVE: Fibromyalgia syndrome (FMS) is characterized by e. g. chronic, multilocular pain, and mental health problems. In Germany, patients with FMS are treated in somatic and psychosomatic rehabilitation centers - specialized for rheumatic diseases (somatic) or psychosomatic diseases. The aim of this study is to identify the status quo of FMS patients' access routes to the rehabilitation system, and to identify their predictors for being assigned to one or the other indication group. METHOD: Our cohort consists of 197 FMS patients from 3 psychosomatic (M=49.9 years) and 223 FMS patients (M=50.2 years) from 3 somatic rehabilitation centers. At the beginning of rehabilitation, patients filled out a questionnaire packet to identify their access routes to the rehabilitation centers and to record patients' disease-related, psychosocial and socio-demographic characteristics. To analyze the results we used descriptive calculations, calculated bivariate correlations, and conducted binary logistic regression analysis for the prediction of group membership. RESULTS: The access routes of FMS patients to a somatic or a psychosomatic rehabilitation center were often similar. Some items revealed significant group differences, i. e., a higher primary -rejection rate, longer waiting period between application for rehabilitation and its approval, and between the application itself and initiation of psychosomatic rehabilitation in comparison to somatic FMS patients. Prior experience of out-patient psychotherapy, and expectations ("psychological support") for the rehabilitation were predictive patient characteristics for the assignment into a psychosomatic rehabilitation center. Marriage, motivation, and expectations ("physical improvement" and "interaction with other patients") for the rehabilitation were predictive patient characteristics for the assignment in a somatic rehabilitation center. The predictors clarified 32% of the variance of group membership. CONCLUSION: Our results provide initial evidence of how FMS patients access the German rehabilitation system and which of their characteristics are responsible for being assigned to a particular rehabilitation setting.

[The state of quality management implementation in ambulatory care nursing and inpatient nursing]. / Der aktuelle Stand des Qualitätsmanagements in ambulanten und stationären Pflegeeinrichtungen.

AIMS: The demands being made on quality assurance and quality management in ambulatory care nursing and inpatient nursing facilities continue to grow. As opposed to health-care facilities such as hospitals and rehabilitation centres, we know of no other empirical studies addressing the current state of affairs in quality management in nursing institutions. The aim of this investigation was, by means of a questionnaire, to analyse the current (as of spring 2011) dissemination of quality management and certification in nursing facilities using a random sample as representative as possible of in- and outpatient institutions. METHOD: To obtain our sample we compiled 800 inpatient and 800 outpatient facilities as a stratified random sample. Federal state, holder and, for inpatient facilities, the number of beds were used as stratification variables. 24% of the questionnaires were returned, giving us information on 188 outpatient and 220 inpatient institutions. While the distribution in the sample of outpatient institutions is equivalent to the population distribution, we observed discrepancies in the inpatient facilities sample. As they do not seem to be related to any demonstrable bias, we assume that our data are sufficiently representative. RESULTS: 4 of 5 of the responding facilities claim to employ their own quality management system, however the degree to which the quality management mechanisms are actually in use is an estimated 75%. Almost 90% of all the facilities have a quality management representative who often possesses specific additional qualifications. Many relevant quality management instruments (i. e., nursing standards of care, questionnaires, quality circles) are used in 75% of the responding institutions. Various factors in our data give the impression that quality management and certification efforts have made more progress in the inpatient facilities. Although 80% of the outpatient institutions claim to have a quality management system, only 32.1% of them admit to having already been (or be in current preparation to be) certified, a figure that was 41.5% among the inpatient facilities. These percentages are smaller when one relies on information provided by the certifying institutions themselves rather on the nursing facilities. Most frequent is the certification according to the DIN EN ISO 9001 standard, since the care-specific certification procedures most widespread on the market enable facilities to combine a care-specific certificate with one according to DIN norms. CONCLUSION: Quality management has become very widespread in nursing facilities: every third institution claims to have been certified, and the trend to become certified has clearly intensified over the last few years. We observe overall very great acceptance of both internal quality management and external quality assurance. We suspect that the current use of quality management instruments in many nursing facilities will not fall behind such efforts in hospitals and rehabilitation centres.

[Restrictions in participation in women with fibromyalgia syndrome. An explorative pilot study]. / Beeinträchtigungen der Teilhabe bei Patientinnen mit Fibromyalgiesyndrom. Eine explorative Pilotstudie.

BACKGROUND: Patients with fibromyalgia syndrome are often severely restricted in their ability to participate in everyday activities and in social interaction. The aim of this study was to document female patients' subjectively-perceived limitations in participation and to develop material to generate items for a specific participation questionnaire. MATERIAL AND METHODS: We collected data from 8 groups of women with fibromyalgia syndrome (n=38), and developed a hierarchical system of categories using the patients' statements (ATLAS.ti; Qualitative Data Analysis). RESULTS: Our final group of categories contains 10 superordinate categories. Women with fibromyalgia syndrome often describe restrictions in their relationships with other people, and the impaired ability to engage in social and leisure activities. They speak of difficulties at the workplace, while doing housework, and complain about a lack of understanding and awareness on the part of the general public. CONCLUSION: Fibromyalgia syndrome patients admit to be extremely impaired in a variety of social roles. Their statements have enabled us to develop a questionnaire that reflects the range of factors restricting participation from the patient's perspective.

[Structures and practice of psychology departments in orthopaedic and cardiac rehabilitation: a comparison of outpatient and inpatient clinics in Germany]. / Strukturen und Praxis der Psychologischen Abteilungen in der orthopädischen und kardiologischen Rehabilitation: Vergleich zwischen ambulanten und stationären Einrichtungen in Deutschland.

We aimed at comparing the present structural quality and practice of psychological services in ambulatory (outpatient) and inpatient rehabilitation in Germany.A nationwide survey of psychological services in orthopaedic and cardiac outpatient rehab centres was carried out. Results were compared to those of an identical study of inpatient services that was conducted simultaneously.Data were obtained from 81 ambulatory centres (return rate: 44%). Structures and practice (e. g., diagnostic procedures, psychological interventions) in ambulatory and inpatient rehabilitation only differed marginally. Differences concern the staff/patient ratio which is slightly better in ambulatory centres and some aspects of working conditions (e. g., less assisting staff or supervision).From its beginning, ambulatory rehabilitation in Germany has followed the standards of the inpatient model as far as structural quality and processes are concerned. Psychological practice in the ambulatory setting reflects that too. It is discussed whether the uniformity of ambulatory and inpatient rehabilitation services really is appropriate, or whether a more flexible model (e. g., regarding treatment duration) is needed in the German rehabilitation system.

[Somatic rehabilitation as a field of work for psychologists: results of a nationwide survey of structures and practice in orthopaedic and cardiac inpatient medical rehabilitation]. / Die somatische Rehabilitation als Arbeitsfeld für Psychologen: Ergebnisse einer bundesweiten Befragung zu Strukturen und Praxis in der stationären orthopädischen und kardiologischen Rehabilitation.

OBJECTIVE: A detailed analysis of the present structural quality and practice of psychological services in inpatient medical rehabilitation facilities was conducted. The study was carried out for the indications chronic back pain and coronary heart disease. METHODS: A nationwide postal survey of psychological services in orthopaedic and cardiac inpatient rehabilitation facilities was carried out. RESULTS: Data from psychology departments of 169 orthopaedic and 75 cardiac inpatient rehabilitation facilities are available. In both indication areas an average of one psychologist is in charge of 100 patients. In the treatment of patients with chronic back pain and coronary heart disease, several methods of psychological assessment and a wide range of psychological interventions are being applied. On the whole, there are notable parallels between the psychological interventions provided to patients with chronic back pain and coronary heart disease. At the same time, however, there is considerable heterogeneity among rehabilitation facilities as to the psychological interventions carried out. DISCUSSION/CONCLUSION: The heterogeneity found reveals the low degree of standardization of psychological practice in medical rehabilitation of patients with chronic back pain or coronary heart disease. This emphasizes the need for developing and implementing recommendations or practice guidelines for psychological interventions.

[Acceptance and practicability of the rehab therapy standards for rehabilitation after total hip and knee arthroplasty - findings of a user survey of the pilot version]. / Akzeptanz und Praktikabilität der Reha-Therapiestandards für die Rehabilitation nach Hüft- und Kniegelenks-Totalendoprothese (TEP) - Ergebnisse einer Anwenderbefragung zur Pilotversion.

Implementation of the pilot version of the rehab therapy standards for rehabilitation following total hip or knee replacement was accompanied by a user survey. This survey allowed rehab centres to comment on the standards and suggest changes.Early 2010 a total of 160 rehab centres that had treated at least 50 German Pension Fund insurees following total hip or knee replacement in 2008 received a written survey together with an overview of performance data according to KTL (Classification of Therapeutic Procedures), data that reflect the degree to which the centres had complied with the requirements of the therapy standards.69% of the centres returned the questionnaire. The centres included predominantly agreed that the rehab standards fulfil the quality attributes "scientific foundation (evidence)", "relevance for day-to-day work", "up-to-dateness", and "inter- and multidisciplinary development". There were no statistically significant differences between centres with previously high or low compliance with the requirements of the standards relative to the ratings given for these global quality criteria. Almost all responders considered comprehensiveness and structure of the standards adequate. Between 55 and 94% found that therapeutic procedures were sufficiently represented by the treatment modules. Minimum percentages of patients requiring the respective treatment were considered adequate for 8 out of 13 modules. Responders suggested restricting continuous passive motion to knee replacement. Psychological interventions were considered less important. Among the main reasons for non-adherence to therapy standards in 2008 were: coding problems, too high demands, contraindications, and shortage of staff. Implementation of the standards was associated with both positive and negative expectations on the part of the rehab centres; an issue raised in addition was the effort involved in internal restructuring.The results of the user survey show that the concept of the rehab standards and its implementation basically are accepted. Criticism had mainly concerned continuous passive motion and the need for psychological interventions. Coding problems should not be overrated since the underlying performance data referred to a period of time before the standards were implemented. General appraisal of the rehab standards was independent of previous performance. This emphasizes the weight of user feedback. The rehab standards already have been revised in light of the results of the user survey.

[Predictors of participation in medical rehabilitation follow-up in working patients with chronic back pain]. / Prädiktoren der Teilnahme an einer Nachsorge nach ambulanter Rehabilitation bei erwerbstätigen Rehabilitanden mit chronischen Rückenschmerzen1.

BACKGROUND AND AIM: Outpatient follow-up programmes aim to increase the sustainability of rehabilitation. However, the factors influencing participation in follow-up programmes are still unclear. The aim of this study was to examine participation in the MERENA follow-up programme of the Rhineland-Palatinate German Pension Fund. METHOD: The study was conducted in 12 outpatient rehabilitation centres with 192 working patients who were being treated for chronic back pain at the time the survey was conducted. Both patients and physicians completed a written survey at the outset of rehabilitation, on completion, and again (if applicable) at the end of the follow-up programme. The data collected mainly concerned the patients' health and factors related to their occupational situation (e. g. functional capacity, working capacity) and reasons for refusing to participate in the MERENA follow-up programme. Predictors for participation in the follow-up programme were determined using binary logistic regression analysis. RESULTS: On completion of rehabilitation, nearly all patients were given the recommendation to participate in the follow-up programme. Half of these patients took advantage of the programme. The most frequently given reason for refusal to participate was that participation in the programme was not compatible with their duties at work. Low functional capacity and continued work disability increased the probability that a patient would take part in a follow-up programme after rehabilitation. In contrast, a longer commute to the centre was an obstacle to participation. Women were more likely to participate in the programme than men. CONCLUSIONS: The results indicate that participation in a follow-up programme is often not compatible with employment. We could not satisfactorily explain why women were more likely to participate in the programme. This result could have been related to women's more flexible time schedules. An improvement of the current situation could be achieved by having follow-up programmes closer to the home, by flexible follow-up offerings, alternative follow-up services (e. g. in certified physiotherapy centres and sport clubs) as well as by integrating companies in follow-up planning and implementation.

[Goal setting in inpatient medical rehabilitation: exploring the current practice]. / Reha-Zielvereinbarungen - gegenwärtige Praxis in der stationären medizinischen Rehabilitation.

OBJECTIVE: Goal setting is regarded as a key element in the rehabilitation process. Information about current goal setting practice is limited. However, there is potential for further improvement, e. g. as far as patient participation in the goal setting process is concerned. The study reports results of a survey on the current practice of goal setting in medical rehabilitation, focusing on development potential. The study examines acceptance and requirements for goal setting as well as patients' and professionals' experiences regarding goal setting during the rehabilitation process, with an emphasis on patient participation. METHODS: A total of n=40 rehabilitation professionals and n=210 inpatients with a diagnosis of chronic back pain, diabetes mellitus type 2 or coronary heart disease were surveyed at six rehabilitation centres using a questionnaire. Questionnaires contained predominantly closed-ended items regarding the current practice of goal setting. Several items were identical for both groups. In addition to the quantitative evaluation by means of frequency analyses free text data were evaluated. RESULTS: Rehabilitation professionals saw various benefits in goal setting with patients. Many professionals experienced patients to have personal goals for their rehabilitation, and most of them believed that patient participation in goal setting is possible. Also, barriers and requirements for goal setting were identified. A consistent concept for goal setting, involvement of and exchange between the different occupational groups and an elaborate handling of information in the context of goal setting seem to be realised at least partially. Professionals and patients reported similar frequencies of talks on goal setting at different times during the rehabilitation course. Patient participation seems to be realised to some extent but not comprehensively. The results show slight discrepancies between patients' and professionals' statements. DISCUSSION: Current practice of goal setting in inpatient rehabilitation of patients with the diagnoses named above is altogether on a relatively advanced level in the rehabilitation centres taking part in the study. The study identifies potential for development concerning a comprehensive implementation of goal setting, the realisation of patient participation, goal documentation and their integration into rehabilitation. Moreover, deeper involvement of the rehabilitation team and a stronger conceptual integration of the subject within the centres seem desirable. This can be taken up within the scope of interventions.

[Guidelines and guideline research. Overview and state of guideline implementation in medical rehabilitation]. / Leitlinien und Leitlinienforschung. Übersicht und Stand der Leitlinienimplementierung in der medizinischen Rehabilitation.

"Guideline research" is understood here to be the area of healthcare research that deals with the methodology and evaluation of processes for developing, implementing, assessing, and evaluating guidelines. For example, guideline research deals with the selection of adequate implementation strategies and the proof of the effectiveness and efficiency of the implementation of guidelines. The current data situation does not allow any reliable statements to be made about whether and to what extent the health-related outcome for patients is actually improved by implementing guidelines. For medical rehabilitation, there are a number of guidelines which appear to be just as good with respect to quality as the guidelines for acute medicine. However, there is a need for improvement in the quality criteria for methods. Rehab-related guidelines and therapy standards can be found in the AWMF guidelines, in the program for national healthcare guidelines, and in the rehabilitation quality assurance of the German Pension Fund. Guideline research in rehabilitation should concentrate on topics that arise from the specific situation of this area of healthcare, e.g., development of interdisciplinary guidelines, applicability of guidelines for multiple diseases, or possibility of evidence-based guidelines for complex interventions.

[The methodological quality of rehabilitation guidelines]. / Methodische Qualität von Leitlinien in der Rehabilitation.

INTRODUCTION: The concepts of clinical guidelines contribute to the decision-making and improvement in the quality of medical supply. This paper provides a literature research on rehabilitation guidelines and their evaluation by the "German Instrument for Methodological Guideline Appraisal (DELBI)". METHODS: The clinical guideline research was conducted with the help of an online database as well as expert surveys conducted between August and October 2007. The literature research was updated in October 2008. Only those guidelines that satisfied specific criteria were included in the evaluation. RESULTS: Although the research yielded 124 guidelines, only 28 were included in the evaluation after applying the criteria. In total, the evaluation was heterogeneous. With regard to each domain, the mean degree of fulfillment reached between 2.1% and 58.3%. DISCUSSION: Due to an extensive and detailed literature research and expert survey, all relevant clinical guidelines for rehabilitation, which are valid in Germany, could be gathered. A first examination of the guidelines seems to reveal several deficiencies. Possible reasons are discussed. CONCLUSION: This paper reveals a detailed survey of the clinical guidelines for rehabilitation. Compared to acute-care medicine, the number of available guidelines is distinctly smaller. With regard to the DELBI criteria, an enormous development in the quality of guidelines for rehabilitation is still necessary. Some of these might be due to inaccurate documentation, which will have to be considered in a further update.

[Quality assurance and quality management in medical rehabilitation]. / Qualitätssicherung und Qualitätsmanagement in der medizinischen Rehabilitation.

External quality assurance in medical rehabilitation is characterized by the programs of Germany's two largest providers of rehabilitation (the German pension insurance and the statutory health insurance). The programs were developed with considerable input from scientific institutes. Their strengths lie in measuring several relevant dimensions of quality, the comprehensive implementation for nearly all illnesses treated, integration of the patient perspective, and realization of prospective study designs with follow-up. Weaknesses include low relevance for patient allocation and compensation, the absence of systematic evaluations, and a lack of published patient information on the results of the quality measurements. Internal quality management in medical rehabilitation is regulated by sweeping legal guidelines. Since 2009, a statutory agreement has been in effect which includes a provision that all inpatient rehabilitation centers must be certified by October 2012. Areas for potential improvements in internal quality management processes include an improved theoretical basis, higher specificity for rehabilitation, and a more transparent, methodically improved structure of certification procedures.