Effectiveness of behavioural medical rehabilitation under real-life conditions in Germany: A propensity-score matched analysis.

OBJECTIVES: In Germany, behavioural medical rehabilitation programmes have been implemented for patients with musculoskeletal disorders and additional mental health comorbidity. The aim of this cohort study is to assess the relative effectiveness of behavioural medical rehabilitation under real-life conditions. DESIGN: Participants received either a common or behavioural medical rehabilitation programme. Propensity score matching was used to provide balanced samples of both groups (German Clinical Trials Register: DRKS00016404). PARTICIPANTS: A total of 360 patients treated in behavioural medical rehabilitation were compared with 360 matched controls. The mean age of study participants was approximately 53.5 years (standard deviation (SD)=7.0 years) and 74.0% were women. RESULTS: No significant and clinical meaningful differences were found in return to work, applications for disability pension, and the number of patients receiving social security benefits in the year after rehabilitation. However, participants in behavioural medical rehabilitation reported better self-rated work ability, physical functioning and self-management skills, and decreased pain disability and fear-avoidance beliefs 10 months after rehabilitation. Standardized effect sizes were between 0.13 and 0.22. CONCLUSION: Behavioural medical rehabilitation had no clinical meaningful effect on maintaining and restoring work ability. However, behavioural medical rehabilitation affected pain and disease management skills 10 months after completing the rehabilitation programme.

Work-related medical rehabilitation in patients with mental disorders: the protocol of a randomized controlled trial (WMR-P, DRKS00023175).

BACKGROUND: Various rehabilitation services and return-to-work programs have been developed in order to reduce sickness absence and increase sustainable return-to-work. To ensure that people with a high risk of not returning to work can participate in working life, the model of work-related medical rehabilitation was developed in Germany. The efficacy of these programs in patients with mental disorders has been tested in only a few trials with very specific intervention approaches. To date, there is no clear evidence of the effectiveness of work-related medical rehabilitation implemented in real-care practice. METHODS/DESIGN: Our randomized controlled trial will be conducted in six rehabilitation centers across Germany. Within 15 months, 1800 patients with mental disorders (300 per rehabilitation center) will be recruited and assigned one-to-one either to a work-related medical rehabilitation program or to a conventional psychosomatic rehabilitation program. Participants will be aged 18-60 years. The control group will receive a conventional psychosomatic rehabilitation program without additional work-related components. The intervention group will receive a work-related medical rehabilitation program that contains at least 11 h of work-related treatment modules. Follow-up data will be assessed at the end of the rehabilitation and 3 and 12 months after completing the rehabilitation program. The primary outcome is a stable return to work. Secondary outcomes cover several dimensions of health, functioning and coping strategies. Focus groups and individual interviews supplement our study with qualitative data. DISCUSSION: This study will determine the relative effectiveness of a complex and newly implemented work-related rehabilitation strategy for patients with mental disorders. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00023175 , September 29 2020).

Effects of nationwide implementation of work-related medical rehabilitation in Germany: propensity score matched analysis.

OBJECTIVES: Since 2014, the Federal German Pension Insurance has approved several departments to implement work-related medical rehabilitation programmes across Germany. Our cohort study was launched to assess the effects of work-related medical rehabilitation under real-life conditions. METHODS: Participants received either a common or a work-related medical rehabilitation programme. Propensity score matching was used to identify controls that were comparable to work-related medical rehabilitation patients. The effects were assessed by patient-reported outcome measures 10 months after completing the rehabilitation programme. RESULTS: We compared 641 patients who were treated in work-related medical rehabilitation with 641 matched controls. Only half of the treated patients had high initial work disability risk scores and were intended to be reached by the new programmes. The dose of work-related components was on average in accordance with the guideline; however, the heterogeneity was high. Work-related medical rehabilitation increased the proportion of patients returning to work by 5.8 percentage points (95% CI 0.005 to 0.110), decreased the median time to return to work by 9.46 days (95% CI -18.14 to -0.79), and improved self-rated work ability by 0.38 points (95% CI 0.05 to 0.72) compared with common medical rehabilitation. A per-protocol analysis revealed that work-related medical rehabilitation was more effective if patients were assigned according to the guideline and the minimal mandatory treatment dose was actually delivered. CONCLUSIONS: The implementation of work-related medical rehabilitation in German rehabilitation centres affected work participation outcomes. Improving guideline fidelity (reach and dose delivered) will probably improve the outcomes in real-world care. TRIAL REGISTRATION NUMBER: DRKS00009780.

Implementing the German Model of Work-Related Medical Rehabilitation: Did the Delivered Dose of Work-Related Treatment Components Increase?

OBJECTIVES: Work-related components are an essential part of rehabilitation programs to support return to work of patients with musculoskeletal disorders. In Germany, a guideline for work-related medical rehabilitation was developed to increase work-related treatment components. In addition, new departments were approved to implement work-related medical rehabilitation programs. The aim of our study was to explore the state of implementation of the guideline's recommendations by describing the change in the delivered dose of work-related treatments. DESIGN: Nonrandomized controlled trial (cohort study). SETTING: Fifty-nine German rehabilitation centers. PARTICIPANTS: Patients (N=9046) with musculoskeletal disorders were treated in work-related medical rehabilitation or common medical rehabilitation. Patients were matched one-to-one by propensity scores. INTERVENTIONS: Work-related medical rehabilitation in 2014 and medical rehabilitation in 2011. MAIN OUTCOME MEASURES: Treatment dose of work-related therapies. RESULTS: The mean dose of work-related therapies increased from 2.2 hours (95% confidence interval [CI], 1.6-2.8) to 8.9 hours (95% CI, 7.7-10.1). The mean dose of social counseling increased from 51 to 84 minutes, the mean dose of psychosocial work-related groups from 39 to 216 minutes, and the mean dose of functional capacity training from 39 to 234 minutes. The intraclass correlation of 0.67 (95% CI, 0.58-0.75) for the total dose of work-related therapies indicated that the variance explained by centers was high. CONCLUSIONS: The delivered dose of work-related components was increased. However, there were discrepancies between the guideline's recommendations and the actual dose delivered in at least half of the centers. It is very likely that this will affect the effectiveness of work-related medical rehabilitation in practice.

Work-related medical rehabilitation in patients with musculoskeletal disorders: the protocol of a propensity score matched effectiveness study (EVA-WMR, DRKS00009780).

BACKGROUND: Musculoskeletal disorders are one of the most important causes of work disability. Various rehabilitation services and return-to-work programs have been developed in order to reduce sickness absence and increase sustainable return-to-work. As the effects of conventional medical rehabilitation programs on sickness absence duration were shown to be slight, work-related medical rehabilitation programs have been developed and tested. While such studies proved the efficacy of work-related medical rehabilitation compared with conventional medical rehabilitation in well-conducted randomized controlled trials, its effectiveness under real-life conditions has yet to be proved. METHODS/DESIGN: The cohort study will be performed under real-life conditions with two parallel groups. Participants will receive either a conventional or a work-related medical rehabilitation program. Propensity score matching will be used to identify controls that are comparable to treated work-related medical rehabilitation patients. Over a period of three months, about 18,000 insured patients with permission to undergo a musculoskeletal rehabilitation program will be contacted. Of these, 15,000 will receive a conventional and 3,000 a work-related medical rehabilitation. We expect a participation rate of 40 % at baseline. Patients will be aged 18 to 65 years and have chronic musculoskeletal disorders, usually back pain. The control group will receive a conventional medical rehabilitation program without any explicit focus on work, work ability and return to work in diagnostics and therapy. The intervention group will receive a work-related medical rehabilitation program that in addition to common rehabilitation treatments contains 11 to 25 h of work-related treatment modules. Follow-up data will be assessed three and ten months after patients' discharge from the rehabilitation center. Additionally, department characteristics will be assessed and administrative data records used. The primary outcomes are sick leave duration, stable return to work and subjective work ability. Secondary outcomes cover several dimensions of health, functioning and coping strategies. DISCUSSION: This study will determine the relative effectiveness of a complex, newly implemented work-related rehabilitation strategy for patients with musculoskeletal disorders. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00009780 , February 10, 2016).