[Job insecurity as risk for adverse health effects amongst german workers: a cohort study]. / Arbeitsplatzunsicherheit als Risiko für gesundheitliche Beeinträchtigungen bei deutschen Erwerbstätigen: eine Kohortenstudie.

OBJECTIVE: This study investigates the relation of perceived job insecurity and self-rated health amongst German workers. METHODOLOGY: The database of the investigation was created from survey data of the Socio-economic Panel (SOEP). The analysis considered data from the surveys in 2003, 2004 and 2006. Included were all employed persons aged 30-60 years in 2003 (n=9 272). In order to analyse the impact of perceived job insecurity measured in 2003 on the self-rated health in 2004 (n=8 709) and 2006 (n=7 773) an ordinal logit-model was used. RESULTS: Persons with high job insecurity had--after adjustment for age, gender, education and occupational status--a higher risk of adverse self-rated health both after one year (OR=1.18; 95% CI: 1.06-1.31) and three years (OR=1.18; 95% CI: 1.05-1.32). The analysis could also identify an interaction between occupational status and job insecurity. High job insecurity proved to be a health risk, particularly for persons with lower occupational status (2004: OR=1.37; 95% CI: 1.15-1.62; 2006: OR=1.31; 95% CI: 1.09-1.57). CONCLUSION: The study supports the proposal that, for a cohort of German workers, perceived job insecurity increases the risk of adverse health effects amongst workers with lower occupational status.

[Efficacy of intensified inpatient rehabilitation in musculoskeletal disorders: systematic review and meta-analysis]. / Wirksamkeit einer intensivierten stationären Rehabilitation bei muskuloskelettalen Erkrankungen: systematischer Review und Meta-Analyse.

BACKGROUND: Previous reviews concerning inpatient orthopaedic rehabilitation in Germany stated no convincing evidence of its effectiveness. However, work-related and behavioural-medicine concepts of rehabilitation have for several years been established in order to intensify and broaden conventional rehabilitation. But so far none of the previous studies had compared intensified and conventional rehabilitation within the framework of a systematic review of randomized controlled trials and used a meta-analytic approach. OBJECTIVE: To assess the effectiveness of intensified inpatient orthopaedic rehabilitation on clinically relevant outcomes in patients with musculoskeletal disorders. METHODS: We searched the following databases as of 26 November 2007: MEDLINE from 1966, EMBASE from 1989, PSYNDEX from 1977, PsycINFO from 1980. We included randomized controlled trials (RCTs) that had studied adults with musculoskeletal disorders, who had participated in intensified inpatient orthopaedic rehabilitation in Germany. Outcome measures were self-rated state of health, pain intensity, functioning, and days of sick leave. Standardised mean difference and associated 95% confidence interval were calculated. Cochran's Q statistic was used to assess the heterogeneity of the results, and the I (2) statistic was used to determine any inconsistency between the studies. RESULTS: Five relevant trials were identified in 15 publications. Four of them were considered to be high-quality RCTs. The trials identified reported 18 randomized comparisons of intensified orthopaedic rehabilitation and conventional orthopaedic rehabilitation. There is strong evidence that intensified rehabilitation improves self-rated state of health when compared with conventional rehabilitation at mid-term and long-term follow-up. There is moderate evidence that intensified rehabilitation with a psychological group intervention reduces pain intensity when compared with conventional rehabilitation at long-term follow-up. There is no evidence of reduced days of sick leave and improved functioning. CONCLUSIONS: The relevant studies provide evidence that intensified rehabilitation improves self-rated state of health and reduces pain intensity in rehabilitants with musculoskeletal disorders.

[Perspectives in rehabilitation. General position paper on future trends and challenges in rehabilitation by the Health Advisory Board of the German Federal Association for Rehabilitation]. / Perspektiven der Rehabilitation. Ein Positionspapier des Arztlichen Sachverständigenrates der Bundesarbeitsgemeinschaft f ü r Rehabilitation (BAR) zur Weiterentwicklung der Rehabilitation.

The Health Advisory Board of the German Federal Association for Rehabilitation (BAR) describes future trends and challenges in rehabilitation as deriving from the socio-demographic development in Germany and the structural characteristics of its Social and Health Care Insurance System. The focus is on elder employees to sustain and regenerate their capacity for employment, on people which are no longer employed to activate their autonomy and ability for self-support, and on rehabilitation as a holistic and integrative process extending through the social security and health insurances. There is an urgent need and a real chance to benefit from already existing scientific findings more frequently and to integrate them effectively into adequate further education and training programmes for professionals. Finally the conclusion summarises 8 theses to facilitate rehabilitation as an integral and essential part of the German social security and health sector. This paper was fully accredited by the members of the BAR Managing Board.

[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.

[Effects of work-related medical rehabilitation in patients with musculoskeletal disorders]. / Effekte berufsbezogener Behandlungselemente in der orthopädischen Rehabilitation der Rentenversicherung. Ergebnisse einer randomisierten Verlaufsstudie.

A work-related orientation within medical rehabilitation represents concepts with a stronger focus on the patient's individual vocational requirements and is based on different vocationally-orientated strategies of treatment. "Medical Occupational Orientation" ("Medizinisch-berufliche Orientierung", MBO), the model of Klinik Niedersachsen in Bad Nenndorf, places Functional Capacity Evaluation according to Susan Isernhagen (EFL) at the centre of rehabilitation diagnostics and therapy. This study investigates the effects of the MBO model relative to activities and vocational participation of patients with musculoskeletal disorders faced with vocational problems and on management at the interface between medical and vocational rehabilitation. Presented are findings of a randomized follow-up study aimed at evaluating the MBO model. A total of 494 patients of LVA Westfalen, a regional insurance agency, took part. A need for MBO was diagnosed for 222 patients. These patients were randomly assigned either to the MBO model of treatment (experimental group --> U[+]) or to the conventional medical treatment (control group --> K[+]). Patients without a need for MBO (U[-], K[-]) were treated likewise. The written questionings took place at the beginning (t (1)) and end of rehabilitation (t (2)), as well as six (t (3)) and twelve months (t (4)) after the patients' discharge. Currently, the results are based on the 6-month follow-up. Concerning the activities, an MBO-related effect in the experimental group (U[+]) has been found for the Pain Disability Index (PDI), effect sizes being d (u+) = 0.82; d (k+) = 0.17. The risk of unemployment six months after rehabilitation is decreased for MBO(+) patients who participated in the MBO model. In addition, the clinic can make effective prognosis concerning subsequent participation in vocational rehabilitation for both experimental groups (U[+], U[-]). Established for the first time in a randomized controlled trial, the findings presented show that patients with musculoskeletal disorders who are faced with particular vocational problems will achieve significantly better results concerning activities and vocational reintegration if their medical rehabilitation had been based upon an EFL-centred MBO approach.

[Rehabilitation as a subject of health services research]. / Rehabilitation als Gegenstand der Versorgungsforschung.

Since the mid-1990s, the lack of proper development in health services research in the healthcare system of the Federal Republic of Germany has been repeatedly criticised by healthcare policy-makers and experts alike, whilst also being the subject of a number of reform initiatives. Rehabilitation sciences, which were established in Germany as an autonomous scientific discipline in the early 1990s, could benefit in terms of conception, methodology and organisation from these activities and the new interest bestowed on healthcare sector research. At the same time, the converse also holds true since from the very beginning health services research has played a particular role in the development of rehabilitation sciences-unlike the role it has played in the overall healthcare system. The complex nature of the areas of research covered by rehabilitation, together with the theoretical plurality and methodological diversity associated with it, may be ascribed to the fact that (up to the present) this sector has lacked a broader framework connecting together health research concerns and issues. This article presents a comprehensive overview of current concerns and issues as evidenced in publications of the past 15 years that make an explicit contribution to health services research. It highlights the rehabilitation system research undertaken in the past decade as a central plank of health services research. Furthermore, it also investigates the backdrop to health services research in rehabilitation in terms of its development, its research concerns, its methodology, its organisation and its infrastructural embeddedness.

[Occupational orientation in medical rehabilitation and measures for participation in the professional life]. / Berufliche Orientierung in der medizinischen Rehabilitation und Leistungen zur Teilhabe am Arbeitsleben.

Return-to-work and protection of work-related participation is stated as a primary objective of rehabilitation by the statutory pension insurance institutes. A general continuous management of work-related participation in rehabilitation is a prerequisite for optimal results in view of stay in work and return to work. This means an extended vocational orientation in medical rehabilitation, individualized occupational rehabilitation according to need and capacity in connection with closer linkages between medical and occupational rehabilitation. In the course of the "Rehabilitation Sciences" research funding programme and beyond it, quite a few research projects and scientific activities aimed at development, testing and evaluation of -new screenings and diagnostic instruments with better findings of vocational related needs in medical and occupational rehabilitation, -specific methods of therapy and models for treatment settings with immediate reference to the work related restriction and capacity, as well as -models of the organization and forms of cooperation between medical and occupational rehabilitation. This paper reviews the projects and findings in these research fields in relation to the requirements for an increase of general continuous vocational orientation in rehabilitation.

[Outpatient cardiological rehabilitation--acceptance and conditions related to choice of setting]. / Teilstationäre kardiologische Rehabilitation - Akzeptanz und Bedingungskonfigurationen für die Settingentscheidung*

In view of the increasing demands for more co-operation and integration among health care providers and "uninterrupted" care delivery processes increasing attention is being paid to establishing the determinants of a more flexible form of rehabilitation setting. Interest is focused particularly on determining at what stages and under what conditions specific choices of rehabilitation setting are made. In 1838 patients admitted consecutively to a cardiological rehabilitation clinic, the study investigated how many patients opted for outpatient rehabilitation and what factors influenced the patients' choice of rehabilitation setting. A total of 165 (9 %) of the 1838 patients chose outpatient rehabilitation. Patients who prefer outpatient rehabilitation are mainly male, belong to a higher social class and are younger. Patients who choose inpatient treatment feel more restricted by their illness. This is also revealed in the difference in coping strategies employed. Patients who prefer the inpatient setting show a greater tendency towards rumination than outpatients. It is thus comprehensible that these patients hope to gain a greater distance from their day-to-day problems. The results indicate that patients' willingness to take advantage of outpatient forms of rehabilitation is moderated both by sociodemographic, psychosocial and disease-related variables as well as by context variables. It is embedded in the complex biopsychosocial conditions governing rehabilitation. One consequence for managing the introduction of more flexible modes of rehabilitation could be to avoid dirigistic and unidimensional control parameters. The results indicate that more flexible disease management cannot follow fixed rules, but rather that the planning of individual requirements should be taken into account.

[Economic limits in rehabilitation]. / Wirtschaftliche Grenzen der Rehabilitationsmedizin.

At the end of the 90s, the German government imposed strict budget restrictions--to an extent previously unknown--on German rehabilitation medicine, arguing that this was necessary for economic reasons. In particular, these restrictions have led to considerable and permanent cuts in the area for which the pension insurance system is responsible. The consequence of this has been that in 1998--for the first time in the history of the rehabilitation system--expenditure on medical rehabilitation was distributed approximately equally between the pension and health insurance systems. A factor which contradicts the restrictions imposed by law is that an increase in the need for rehabilitation among those in gainful employment--due to demographic factors--can also be observed at the macro-economic level. This increase will peak in 2015 as will the increased demand for rehabilitation due to a change in the curative paradigm--for example due to sharp rates of growth in surgery which is performed. An internal contradiction to a restrictive health policy in rehabilitation medicine arises from the increasing number of evidence-based instances of proof of the effectiveness of rehabilitation, which also indicate economic benefits.

[Demographic and curative factors of need for rehabilitation--possibilities and limits of simple time series models]. / Demographische und kurative Bedingungsfaktoren des Reha-Bedarfs--Möglichkeiten und Grenzen von einfachen Zeitreihenmodellen.

Regarding rehabilitation demands, macro-analytical time-series models outline a method for the estimation of effective rehabilitation needs and for explaining the magnitude of the requirements. Their range is limited, in so far as they are unable to clarify the rehabilitation requirement regarding individual micro-level behavioural aspects. For the moment the rehabilitation requirements are hidden units in the models. Differing macro-dimensions have been gradually included in the analysis. The demographic parameters of the potential patients in need of rehabilitation are the fundamental starting point. Rehabilitation requirements are increasingly modelled by the magnitude of the curative requirements. These are characterised in the rehabilitation as "preliminary or follow up". Two examples of simple time-series models in rehabilitation--for the development of rehabilitation demand--illustrate empirically, which possibilities and boundaries are set in view of demographic and curative requirements by the interpretative range of the macro-concepts. What is methodically interesting with it, is how the analytical borders of such time-series models can experience a recognisable theoretical broadening, through a projection in real logistical facts--here in the interaction between prognosis and retrospection.

[Concept and measurement of need for rehabilitation--framework for a multidimensional investigational approach]. / Zum Begriff und zur Messbarkeit der Rehabilitationsbedürftigkeit--Ein Rahmenkonzept für einen mehrdimensionalen Untersuchungsansatz.

As before the concept and content regarding the need for rehabilitation have still not been sufficiently clarified. In particular, an operationalization of the underlying parameters, as the basis for their measurement is absent. Some exemplary research concepts have been introduced and their methodological implications have been put out. Resulting from this, up till now, in the most developed model, determining the need for rehabilitation has been developed as a latent multi-dimensional variable. A framework, as a starting point for a multi-dimensional investigation regarding the need for rehabilitation has been introduced. According to this, the need for rehabilitation is a multidimensional, qualitative construct, that can not be directly observed and measured. The empirical investigation, which is based on this, limits the description of the need for rehabilitation to the various patterns of determinants, (description by a set of requirement factors and arranged factors) which result in different effects. Therefore different samples regarding the qualitative aspect do not mean the lesser or greater need for rehabilitation based on a continuum of measurement, but different qualitative forms which are visible in different effects.

[The quality assurance program of mandatory social security in the realm of medical rehabilitation. Concept, status of implementation and prospects]. / Das Qualitätssicherungsprogramm der gesetzlichen Rentenversicherung für den Bereich der medizinischen Rehabilitation. Konzept, Stand der Umsetzung und Perspektiven.

The quality improvement programme aims at the comparison of clinics in charge of the statutory pension insurance. The programme has been implemented successively in 1994, supported by researchers and teams of experts on specific subjects. Instruments and procedures have been developed to all programme items including a clinic comparing and information system, thus permitting routine use in practice. Performing regular clinic-comparisons analysing structural quality (equipment, staff, clinical concept, management), procedural quality (recording of rehabilitation process), and outcome quality (success of the rehabilitation estimated by physician and patient) of rehabilitation facilities shall initiate quality competition and stimulate a constant improvement of quality. significant basis, therefore, is a clinic-comparing information and reporting system. The developed instruments and procedures are available for all institutes providing rehabilitation.

[Rehabilitation management categories. A new approach to case mix in medical rehabilitation]. / Rehabilitanden-Management-Kategorien (RMKs). Ein neuer Ansatz zur Fallgruppenbildung in der medizinischen Rehabilitation.

Creating typical treatment case groups in medical rehabilitation, in short: Rehabilitee Management Categories (RMKs, Rehabilitanden-Management-Kategorien), is a key issue for quality assurance within the frame of modern concepts of Total Quality Management (TQM), not least utilizing current organization and management concepts (Managed Care). So far, the problem of creating highly homogeneous case groups has remained unsolved on the basis of the present methodological framework. Critical prerequisites for any further scientific work on this problem are being established in the field of medical rehabilitation with the help of the Classification of Therapeutic Services (CTS) as well as development of instruments documenting therapy plans for typical rehabilitation case groups, process-relevant quality features and definitions of therapy goals as a basis for quality screening under the Pension Insurance quality assurance programme in medical rehabilitation. These developments have clearly contributed to expanding the theoretical foundations as well as the prerequisites for empirical grounding of Rehabilitee Management Categories in medical rehabilitation under the Pension Insurance scheme. A project for determination of rehabilitation case groups which is based on these developments, is due to start at the Humboldt University and Technical University, Berlin in the near future within a rehab promotion initiative of the German Pension Insurance system in cooperation with the Federal Ministry of Research and Technology. Conceptually, the determination of Rehabilitee Management Categories by far exceeds all previous approaches as (1) it will be generated by an iterative process of empirical service descriptions and theoretical consensus building among experts, (2) not only static parameters but also process-related details will be recorded, and (3) quality requirements will be defined for the rehabilitation process and outcome. As a result, rehabilitation-relevant case groups are to be created, which will include a definition of process- and outcome-oriented quality standards. Unlike previous case group concepts, the new approach encompasses quality management issues as an integral part of its development. Since this concept for determination of Rehabilitee Management Categories incorporates the definition of quality standards, i.e., guidelines, prerequisites will be created for integrating these standards into quality management concepts, as well as service management across the interfaces of the German service delivery system (Managed Care).

[Berlin-Brandenburg-Saxony Rehabilitation Research Group]. / Reha-Forschungsverbund Berlin-Brandenburg-Sachsen (BBS).

The principal subject of the Rehabilitation Research Network of Berlin, Brandenburg and Saxony (BBS) is "the theoretical and practical bases of the organisation and economics of rehabilitation". What is involved is a nation-wide analysis of the rehabilitation system, i.e. obtaining empirical information on the question as to what organisational forms are currently used to carry out rehabilitation and what results are achieved. This empirical stocktaking also includes economic aspects as far as possible. This study is to serve as a basis for developing, testing and implementing steps to rationalise steering mechanisms in the rehabilitation system. The first aspect to be studied is "national steering problems in institutionalised forms of rehabilitation". The focus is on projects on information management and performance and quality management in rehabilitation sciences as well as on the actual work of a number of bodies paying for rehabilitation (Bundesversicherungsanstalt für Angestellte, Landesversicherungsanstalten) as well as rehabilitation facilities (clinics etc.). The two other focuses of the study will examine "rehabilitative adjustment to remedies and technical aids/prostheses" and problems facing "family members in the context of rehabilitation". In studying these two areas, we are particularly interested in examining the interaction between institutionalised aspect of rehabilitation and informal factors both inside and outside the system. The BBS approach is supported by close co-operation with the regional pension insurance institutes (BfA, LVAs) with regard to both the data model and steps being taken. The principal instrument of co-operation is the "Gesellschaft für Rehabilitationswissenschaften e.V." (Society for Rehabilitation Sciences). In Berlin the BBS co-operates with Free University, the Technical University and the Robert Koch Institute and in Saxony with the universities in Dresden and Leipzig. Responsibility for scientific questions in the BBS lies with the Institute for Rehabilitation Sciences of Berlin's Humboldt University.

[Assessment of long-term needs and expenditures development for rehabilitation services of the BfA with reference to the growth and occupational rehabilitation regulation (WFG)]. / Abschätzung der langfristigen Bedarfs- und Ausgabenentwicklung für die Rehabilitationsleistungen der BfA unter Berücksichtigung des Wachstums- und Beschäftigungsförderungsgesetzes (WFG).

Based on a Prognos Model projection (1998 to 2040), the number of medical and occupational rehabilitation service treatments required will increase by about 70,000 between 1998 and 2015, reaching 500,000. Thereafter, the situation improves and the number drops to between 370,000 and 430,000. The WFG law provides a 2.7 billion DM budget for the entire time period which results in a growing deficit, reaching 1.7 billion DM by 2015, and enabling the provision of only 50% of the treatments required in the western states, if it is assumed that a reduction of treatment in the eastern states is precluded. This service deficit makes an increase in early retirements probable, thereby, generating costs on balance which exceed any potential savings in the areas of rehabilitation. It is, therefore, necessary to adapt the WFG law to the demands of real needs so that the BfA may continue to fulfill its legal obligation, "rehabilitation before retirement" to the accustomed and necessary extent.

[Cost-benefit evaluation of medical rehabilitation by social security pensions and effects of the growth and occupational rehabilitation regulation (WFG)]. / Kosten-Nutzen-Bewertung der medizinischen Rehabilitation der Rentenversicherung (RV) und die Auswirkungen des Wachstums- und Beschäftigungsförderungsgesetzes (WFG).

The retirement insurers, within the scope of their responsibility for health care, have already adopted the standard that calls for quality control, cost-efficiency, and outcome-focusing. For a start, the BfA (Federal Insurance Agency for Salaried Employees) has compiled a pilot evaluation presented here, based solely on its own costs and returns on costs. This evaluation demonstrates that rehabilitation "pays off". With regard to the WFG, this means that cost-saving in rehabilitation generates significant cost increases through loss of premium payments and necessary early-retirement outlays. The analysis presented shows that future investment in rehabilitation is required to ensure positive returns for the RV.