Christian Gerlich

Prostate cancer patients’ quality of life assessments across the primary treatment trajectory: ‘True’ change or response shift?

Abstract Background Self-report questionnaires are widely used to assess changes in quality of life (QoL) during the course of cancer treatment. However, comparing baseline scores to follow-up scores is only justified if patients’ internal measurement standards have not changed over time, that is, no response shift occurred. We aimed to examine response shift in terms of reconceptualization, reprioritization and recalibration among prostate cancer patients. Material and methods We included 402 newly diagnosed patients (mean age 65 years) and assessed QoL at the beginning of cancer treatment and three months later. QoL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). We employed structural equation modeling testing measurement invariance between occasions to disentangle ‘true’ change and change in the measurement model (response shift). Results We found reprioritization effects for both the Physical Functioning and Role Functioning subscales of the EORTC QLQ-C30, indicating that both had gained importance for representing the latent construct of QoL at follow-up. These effects added to the worsening effect evident in the latent construct, thus rendering observed changes even more pronounced. In addition, we found recalibration effects for both the Emotional Functioning and Cognitive Functioning subscales indicating judgments becoming more lenient over time. These effects counteracted ‘true’ negative changes thus obscuring any substantial changes on the observed level. Conclusion Our results suggest that changes observed in some subscales of the EORTC QLQ-C30 should not be taken at face value as they may be affected by patients’ changed measurement standards.

[Vocational orientation in medical rehabilitation: development of a practice handbook and a homepage as user-oriented media for rehabilitative practice].

Vocational orientation in medical rehabilitation has become an important issue in rehabilitation science and practice in Germany. Although a variety of vocationally oriented interventions has been developed in recent years, there is still a lack of consensus with regard to the definition of specific types of interventions as well as relevant criteria (e. g., methods; instruments; duration/frequency; patient groups). Building on preliminary definitions, basic types of vocationally oriented measures/interventions were conceptually modified and refined in the context of a consensual process. 39 experts of various professions were contacted during a 2-stage Delphi survey to evaluate existing definitions of vocationally oriented interventions using key questions. Standardized descriptions of 5 vocationally oriented basic interventions were specified in cooperation with an interdisciplinary panel of experts. Descriptions were published in a workbook and a homepage for researchers and clinicians, which also contain information on the implementation of measures into rehabilitative care as well as good practice examples. The media developed in this project may contribute to the transfer of research results on vocationally oriented rehabilitation into health care practice.

Entwicklung von Verfahrensweisen und Instrumenten zur externen Qualitätssicherung in Einrichtungen der stationären Vorsorge und Rehabilitation für Mütter und Väter einschließlich Mutter-/Vater-Kind-Einrichtungen

OBJECTIVE There so far is no standardized program for external quality assurance in inpatient parent-child prevention and rehabilitation in Germany. Therefore, instruments and methods of external quality assurance were developed and evaluated on behalf of the federal-level health insurance institutions. METHODS On the level of structure quality, a modular questionnaire for assessing structural features of rehabilitation/prevention centers, basic and allocation criteria as well as a checklist for visitations were developed. Structural data were collected in a nationwide survey of parent-child prevention and rehabilitation centers. Process and outcome quality data were collected in n=38 centers. Process quality was assessed using multiple methods (process-related structural features, case-related routine documentation, and incident-related patient questionnaires). Outcome quality was measured via patient questionnaires (n=1 799 patients). We used a multi-level modelling approach by adjusting relevant confounders on institutional and patient levels. RESULTS The methods, instruments and analyzing procedures developed for measuring quality on the level of structure, processes and outcomes were adjusted in cooperation with all relevant stakeholders. Results are exemplarily presented for all quality assurance tools. For most of the risk-adjusted outcome parameters, we found no significant differences between institutions. CONCLUSIONS For the first time, a comprehensive, standardized and generally applicable set of methods and instruments for routine use in comparative quality measurement of inpatient parent-child prevention and rehabilitation is available. However, it should be considered that the very heterogeneous field of family-oriented measures can not be covered entirely by an external quality assurance program. Therefore, methods and instruments have to be adapted continuously to the specifics of this area of health care and to new developments.

Vocationally Oriented Interventions in German Medical Rehabilitation Centers: Influence of Shared Decision Making on Patientsʼ Motivation to Deal with Vocational Problems

RESULTS The screening of applicants succeeded at the beginning of the project: the well-being analysis attracted intended participants suffi ciently. The participant’s main expectations for the analysis were related to clarifi cation of one’s own well being, coping with stress and having problems in work ability. So far 100 people have gone through the well-being analysis (mean age 39, proportion of women 80%). Out of the 100, thirty people have gone through the TUULIintervention. The group interviews proved that the level of the participant’s experienced benefi t was relatively high. Even though no straightforward solutions were found to their particular problems, participants felt that the problems themselves became pinpointed and clearer to them after the intervention. More information will be received from the follow up questionnaires to be mailed six months after the intervention.

Development and evaluation of a standardized peer-training in the context of peer review for quality assurance in work capacity evaluation

BackgroundThe German quality assurance programme for evaluating work capacity is based on peer review that evaluates the quality of medical experts’ reports. Low reliability is thought to be due to systematic differences among peers. For this purpose, we developed a curriculum for a standardized peer-training (SPT). This study investigates, whether the SPT increases the inter-rater reliability of social medical physicians participating in a cross-institutional peer review.MethodsForty physicians from 16 regional German Pension Insurances were subjected to SPT. The three-day training course consist of nine educational objectives recorded in a training manual. The SPT is split into a basic module providing basic information about the peer review and an advanced module for small groups of up to 12 peers training peer review using medical reports. Feasibility was tested by assessing selection, comprehensibility and subjective use of contents delivered, the trainers’ delivery and design of training materials. The effectiveness of SPT was determined by evaluating peer concordance using three anonymised medical reports assessed by each peer. Percentage agreement and Fleiss’ kappa (κm) were calculated. Concordance was compared with review results from a previous unstructured, non-standardized peer-training programme (control condition) performed by 19 peers from 12 German Pension Insurances departments. The control condition focused exclusively on the application of peer review in small groups. No specifically training materials, methods and trainer instructions were used.ResultsPeer-training was shown to be feasible. The level of subjective confidence in handling the peer review instrument varied between 70 and 90%. Average percentage agreement for the main outcome criterion was 60.2%, resulting in a κm of 0.39. By comparison, the average percentage concordance was 40.2% and the κm was 0.12 for the control condition.ConclusionConcordance with the main criterion was relevant but not significant (p = 0.2) higher for SPT than for the control condition. Fleiss’ kappa coefficient showed that peer concordance was higher for SPT than randomly expected. Nevertheless, a score of 0.39 for the main criterion indicated only fair inter-rater reliability, considerably lower than the conventional standard of 0.7 for adequate reliability.

Contents Vol. 1, 2016

Associate Editors Silvio Danese – Catholic University School of Medicine, Rome, Italy Hans Herfarth – University of North Carolina, Chapel Hill, USA Pin-Jin Hu – Sun Yat Sen University, Guangzhou, China Beat Müllhaupt – University Hospital, Zurich, Switzerland Dario Sorrentino – Virginia Tech–Carilion School of Medicine, Roanoke, USA Stephan Vavricka – Triemli Hospital, Zurich, Switzerland Hsiu-Po Wang – National Taiwan University, Taipei, Taiwan Mamoru Watanabe – Tokyo Medical and Dental University, Tokyo, Japan Ming-Shiang Wu – National Taiwan University, Taipei, Taiwan Suk-Kyun Yang – University of Ulsan College of Medicine, Seoul, Korea

Externe Qualitätssicherung in Mutter-/Vater-Kind-Einrichtungen: Entwicklung von Instrumenten im Bereich Strukturqualität

AIM OF THE STUDY As required by German law, inpatient institutions offering prevention and rehabilitation measures for mothers, fathers and children are obliged to implement external quality assurance measures. In 2 pilot projects funded by the German federal association of health insurance funds, external quality assurance procedures for in-hospital prevention and rehabilitation of mothers and fathers were analyzed with the aim of developing a set of instruments for the description of structural characteristics in this area of health care and to evaluate its appropriateness. Concerning structure-related quality, the project included a) designing and evaluating a questionnaire, b) the definition of assessment criteria for subsequent comparative data analyses, and c) the description and documentation of the current state in the field of rehabilitation and prevention for mothers, fathers and children. METHOD To document structural quality comprehensively, a modular questionnaire was developed and tested in a survey of 115 inpatient prevention and rehabilitation institutions for mothers, fathers and children. Involving an expert panel, preliminary basic and selection criteria were defined in order to assure a conducive assessment with regard to structural attributes. RESULTS The majority of institutions had provider agreements for both prevention and rehabilitation. Measures for mothers/fathers with children were predominant; only 7 institutions exclusively treated mothers and fathers. Institution sizes varied strongly. Major indications included psychosomatics, dermatology, and pneumology. Overall, structural conditions of the institutions showed a high standard. Potential for development was found with regard to some aspects of the conceptual framework of institutional practice and the implementation of the International Classification of Functioning, Disability and Health (ICF) in diagnostics. In this article, the degrees of fulfillment with relation to the structural dimensions are presented, referring to the analysis of the preliminary basic criteria. CONCLUSIONS The developed modular questionnaire tapping structural features of inpatient mother/father-child institutions has proven to be a useful instrument to describe the structural quality in future routine practice of quality assurance. In addition, the data can be used for the definition of the final set of criteria.

Outcome Assessment in External Quality Assurance Programs for Family-Oriented Medical Rehabilitation in Germany

INTRODUCTION In-patient medical rehabilitation and prevention programs for mothers, fathers, and children (mother-/father-/child rehabilitation) are a distinctive feature of the German social security system. It aims at defi cits in functioning disability, and health problems associated with family life and family-related interaction. All providers of medical rehabilitation in Germany are legally obligated to participate in comparative quality assurance programs. For mother/father/child rehabilitation, such a program was developed, being commissioned and fi nanced by the head organizations of the German statutory health insurance funds.