Joern Moock

Health-related quality of life and IGF-1 in GH-deficient adult patients on GH replacement therapy: analysis of the German KIMS data and the Study of Health in Pomerania

OBJECTIVE To analyse 12-month response to GH treatment in a single-country cohort of hypopituitary adult patients with GH deficiency (GHD) in regards to health-related quality of life (HRQoL) and insulin-like growth factor-1 (IGF-1) compared with values from general population sample. Moreover, association between the response in HRQoL and the IGF-1 values in patients and in the background population was investigated. DESIGN HRQoL was assessed by quality of life assessment of GH deficiency in adults (QoL-AGHDA) in 651 patients retrieved from the German KIMS (Pfizer International Metabolic Database) before and after 12 months of GH replacement and in a sample drawn from a cross-sectional study in Germany (n=2734). IGF-1 was measured in KIMS patients and in the population-based study with the same assay technique. RESULTS In KIMS patients, mean QoL-AGHDA scores before GH replacement were 9.2+/-6.8 (8.7+/-6.8) in women (men) and in the general population sample 4.5+/-5.3 (4.3+/-5.0) in women (men). Mean differences in QoL-AGHDA scores were statistically significant for all age categories (P<0.05). The mean IGF-1 SDS of KIMS patients before GH replacement was -1.1+/-1.4 (-0.8+/-1.4) in women (men). After GH replacement, a significant increase of IGF-1 concentration and a significant decrease of QoL-AGHDA scores near to age- and gender-specific population-based values were observed. CONCLUSIONS This study confirms an improvement in HRQoL and an increase of IGF-1 SDS in GH-replaced adults, which approximated the values of general population. However, there was no association between IGF-1 values and HRQoL assessment as one of the important treatment outcomes.

Statistical implications of utility weighted and equally weighted HRQL measures: an empirical study

The utility-based approach to health measurement, exemplified by EQ-5D and Health Utilities Index (HUI), has been challenged on a theoretical basis, but the statistical implications of such an approach have received little attention. To empirically investigate this issue, psychometric properties and statistical efficiency of the EQ-5D and HUI Mark 3 (HUI3) classifiers were compared when scored using preference weighted (WPS) and equally weighted summary scores using two longitudinal datasets (n(stroke)=124; n(rehabilitation)=264). Test-retest reliability, construct validity, responsiveness, and relative efficiency (RE) ratios (with bootstrapped 95% confidence intervals) were examined. WPS had slightly lower test-retest reliability, particularly for EQ-5D (intraclass correlation coefficient=0.61 vs 0.72). For known-groups comparisons, WPS had greater inferential power for both EQ-5D and HUI3 (RE>1). No significant differences in sensitivity to change were observed for EQ-5D [0.71 (95% CI: 0.29,1.33) < or = RE < or = 0.96(95% CI: 0.69,1.32)] or HUI3 [0.97 (95% CI: 0.89,1.03) < or = RE < or = 1.23 (95% CI: 0.98,1.72)]. Implications of weighted scoring will depend on whether the weights are greater or less than equal weights where patients fall along the health state classifier continuum. Because utility weights can affect the statistical properties and significance of results, the summary score selected should be appropriate to the purpose of the study and population of interest.

Lebensqualitätsmessinstrumente in der Rehabilitation Unfallverletzter

ZusammenfassungPatientenberichtete Outcome-Parameter gewinnen in der medizinischen Forschung zunehmend an Bedeutung. Neben zahlreichen anderen Einsatzmöglichkeiten werden Instrumente zur Selbstauskunft auch zur Messung der gesundheitsbezogenen Lebensqualität verwendet. Die vorliegende Arbeit gibt einen Überblick über bei unfallverletzten Patienten zur Anwendung kommende patientennahe Assessmentinstrumente.AbstractPatient-reported outcome parameters are becoming more and more important in medical research. Besides numerous other applications for self-evaluation instruments, these are being used for measuring health-related quality of life. This article gives an overview of patient-related assessment instruments used for injured patients.

[Back pain and social status among the working population: what is the association? Results from a German general population survey].

BACKGROUND Little empirical evidence is available on differential associations between social status indicators and back pain in Germany. This study therefore systematically evaluated associations between different indicators of social status and back pain. METHODS In total 4,412 employed adults, aged 18 to 65 years participated in a postal survey in 5 regions of Germany. The point prevalence and 1-year prevalence of back pain were assessed as well as the level of disabling back pain. Educational level, professional category and household income served as measures of social status. Associations between social status and back pain have been assessed cross-sectionally using Poisson regression. RESULTS Educational level was the best predictor for back pain among the assessed social status indicators. Adults with a low educational level had almost a 4-fold risk of reporting disabling back pain compared to subjects with a high educational level. Associations were highest for disabling back pain and attenuated strongly over the point prevalence towards the 1-year prevalence. DISCUSSION Back pain cannot generally be regarded as a symptom of a low social status. However, social inequality is of major importance regarding the prediction of severe back problems. A better understanding of mediating factors is essential for the prevention and therapy.

Prediction of improvement in quality of life (QoL-AGHDA) in adults with growth hormone deficiency by normative reference limits: Data of the German KIMS cohort

OBJECTIVE The objective of the present study was to calculate sex- and age-specific normative values for health-related quality of life (HRQoL) in Germany using quantile regression. Furthermore, we investigate the estimates of these normative data to and to predict the improvement of QoL-AGHDA scores in the German KIMS cohort during growth hormone treatment. DESIGN Normative data of HRQoL was assessed by quality of life assessment of growth hormone deficiency (GHD) in adults (QoL-AGHDA) in a representative sample of the German population (n=4172). Corresponding data for 888 patients with GHD were retrieved from the German KIMS cohort (Pfizer International Metabolic Database). RESULTS The overall mean QoL-AGHDA score of the general population was 4.8±5.2. ANOVA indicated that variability in QoL-AGHDA scores did not differ significantly across gender (p=0.20), whereas age was a significant predictor (p<0.001). Given the QoL-AGHDA score distribution of the general population, we calculated reference values based on quantile regression. In KIMS patients we observed significantly higher QoL-AGHDA scores, 7.9±6.5 (p<0.001), before GH treatment. The optimal predictive QoL-AGHDA score was 6 (70th percentile) with a sensitivity of 0.57 and a specificity of 0.70 in ROC analysis. Furthermore, a baseline QoL-AGHDA score above the 70th percentile allowed predicting an improvement of QoL by GH treatment. CONCLUSIONS This study established normative reference values for the QoL-AGHDA in a representative sample of the German population. Based on these normative data a QoL-AGHDA cut-off value for prediction of improvement was investigated for the German population, which may facilitate clinical assessment of HRQoL response to GH replacement for patients with GHD.

Patient-reported outcomes in rehabilitation research: instruments and current developments in Germany

Monitoring the health status of patients has become a major activity in rehabilitation research in recent years. As a result, various self-assessment instruments have been developed, adapted or improved with the aim of measuring patient-reported outcomes and predictors. Among these are international instruments, such as the NHP or the SF-36, as well as those developed in Germany, such as the IRES, the FREM-17 or the SPE-scale. Some of the widely used international instruments, such as the NHP and SF-36, have been translated into German for application in Germany. All of these instruments have been thoroughly tested and validated in several studies. Current trends in statistical methods (e.g. responsiveness, Rasch scaling) as well as classical test-theoretical standards were taken into consideration in the development of these instruments. In this article, we provide a comprehensive review of five important assessment fields of rehabilitation research in Germany: health-related quality of life (generic, disease-specific, children and adolescents, preference-based), evaluation of specific therapy and education programs, motivation, screening for vocational problems and screening for comorbid disorders. The questionnaires are critically discussed, and perspectives for further research are specified. Although assessment instruments as the IRES or the SF-36 are well-established in rehabilitation research studies, there is still a need for further research to determine the best choice of instruments for a given purpose. The limitations of the questionnaires with respect to health care studies are also discussed.

Evaluation der Ergebnisqualität des besonderen Heilverfahrens der Gesetzlichen Unfallversicherung

ZusammenfassungDie Deutsche Gesetzliche Unfallversicherung (DGUV) fördert das Forschungsprojekt „Evaluation der Ergebnisqualität des Heilverfahrens der gesetzlichen Unfallversicherung“ mit dem Ziel, am Beispiel geeigneter Verletzungsarten die Grundlagen für eine ergebnisorientierte Evaluation des Heilverfahrens zu schaffen. In einem ersten Schritt erfolgte die Auswahl der einzubeziehenden Verletzungsarten. Hierzu wurde eine 2-stufige Delphi-Befragung durchgeführt. Aus einer Liste mit in Frage kommenden Verletzungsarten konnten 160 Befragte geeignete bzw. ungeeignete Verletzungsarten auswählen und weitere vorschlagen und bewerten. Die Teilnahmequote lag in beiden Runden bei etwa 60%. Als besonders geeignet eingeschätzt wurden distale Radiusfrakturen (75,9%), Sprunggelenkfrakturen (61,1%) und vordere Kreuzbandruptur (46,3%). Als am wenigsten geeignet beurteilt wurden Wirbelkörperfrakturen (9,3%), Handverletzungen (3,7%) und Beckenfrakturen (1,9%). Insgesamt erwies sich die Delphi-Befragung als geeignetes Instrument zur Verletzungsartenauswahl.AbstractThe German statutory accident insurance organization is supporting a research project to evaluate the outcome quality of medical treatment procedures associated with this insurance, with the aim of setting examples of particular kinds of injuries and injury patterns as the basis for a results-oriented evaluation of medical treatment measures. A first step was to select injury patterns that should be included. A two-step Delphi survey was carried out. A total number of 160 respondents could choose from a list of injury patterns, both suitable and unsuitable, to include. They could also suggest and evaluate further injury patterns. In both surveys, the number of participants was 60%. Injury patterns rated as particularly suitable included fractures of the distal radius (75.9%), ankle joint fractures (61.1%), and anterior cruciate ligament rupture (43.3%), whereas vertebral body fractures (9.3%), hand injuries (3.7%), and pelvic fractures (1.9%) were rated as less suitable. The Delphi survey proved to be a suitable instrument for the selection of injury patterns.

Bedeutung der postoperativen Übungsbehandlung für das Outcome der distalen Radiusfraktur

ZusammenfassungIn einer prospektiv randomisierten Studie wurde die Wertigkeit einer konsequenten und strukturierten Übungsbehandlung auf das Outcome der distalen Radiusfraktur untersucht. Von 380 konsekutiven Patienten konnten 198 in die Studie eingeschlossen und einer Interventions- (IG, gezieltes Management) oder Kontrollgruppe (KG, D-Arzt-Verfahren) randomisiert zugeteilt werden. In der IG erhielten die Behandler Empfehlungen zu Art, Umfang und Ausmaß der durchzuführenden Übungsbehandlung. Die Nachbehandlungsempfehlung wurde durch die VBG in ihrer Umsetzung begleitet. In der IG ergab sich ein geringeres Maß an verordneter Therapie. Diese wurde jedoch strukturierter und in kürzerer Zeit erbracht. Bezüglich des Outcomes, gemessen in der Minderung der Erwerbsfähigkeit (MdE), ergab sich, bei kürzerer Arbeitsunfähigkeitszeit, in der IG nur in 12,3% der Fälle eine MdE, in der KG, trotz scheinbar längerer Nachbehandlungsphase, dagegen in 27,4%. Das Outcome war somit in der IG signifikant besser, wobei keine höheren Therapiekosten zu beobachten waren. Die strukturierte Nachbehandlung im Sinne einer kombinierten Therapie wird in ihrer Bedeutung noch unterschätzt, daher scheint eine unterstützende Steuerung geboten. Sie sichert im Zusammenwirken aller Beteiligten einen größeren Behandlungserfolg.AbstractThe value of consequent and structured tutorial treatment on the outcome of distal radius fractures was examined within a prospective randomized study. Due to assessment criteria, 198 out of 380 consecutive distal fracture patients could be included in the study and randomly assigned to either an intervention group (focused management) or a control group (transition physician process). Recommendations about character, extent and degree of the exercise treatment conducted were given to therapists, in the intervention group post-treatment recommendations were carried out according to standard practice. In the interventions group there was a low degree of prescribed therapy, however, these therapies were carried out in a more structured way and within a shorter time frame. The outcome revealed that only 12.3% of cases treated within the intervention group, as measured by the reduction of earning capacity, showed a reduction despite apparently shorter periods of work incapacity. In contrast, a reduction of earning capacity was found in 27.4% of the cases treated within the control group despite apparently longer post-treatment periods. Working incapacity time periods and the outcome (reduction of earning capacity) were significantly shorter and better within the intervention group and higher therapy costs were not observed The relevance of structured post-treatment in terms of a combined therapy has therefore been underestimated and supportive control appears to be necessary. Combining both therapies assures higher treatment success in cooperation with all parties involved.

Rückenschmerz und Sozialschicht bei Berufstätigen@@@Back pain and social status among the working population: Ergebnisse einer deutschen Bevölkerungsstichprobe@@@What is the association? Results from a German general population survey

BACKGROUND Little empirical evidence is available on differential associations between social status indicators and back pain in Germany. This study therefore systematically evaluated associations between different indicators of social status and back pain. METHODS In total 4,412 employed adults, aged 18 to 65 years participated in a postal survey in 5 regions of Germany. The point prevalence and 1-year prevalence of back pain were assessed as well as the level of disabling back pain. Educational level, professional category and household income served as measures of social status. Associations between social status and back pain have been assessed cross-sectionally using Poisson regression. RESULTS Educational level was the best predictor for back pain among the assessed social status indicators. Adults with a low educational level had almost a 4-fold risk of reporting disabling back pain compared to subjects with a high educational level. Associations were highest for disabling back pain and attenuated strongly over the point prevalence towards the 1-year prevalence. DISCUSSION Back pain cannot generally be regarded as a symptom of a low social status. However, social inequality is of major importance regarding the prediction of severe back problems. A better understanding of mediating factors is essential for the prevention and therapy.

Assessmentinstrumente bei Verletzungen der oberen Extremität

ZusammenfassungAuch in den Heilverfahren der Gesetzlichen Unfallversicherung (GUV) rücken zunehmend Fragen von Effektivität und Effizienz und in neuerer Zeit auch der gesundheitsbezogenen Lebensqualität der Patienten in den Mittelpunkt. In zahlreichen Arbeiten aus dem Bereich der GUV wurde unterschiedlicher Optimierungsbedarf bei guten Ausgangsvoraussetzungen des berufsgenossenschaftlichen Heilverfahrens festgestellt. In vorliegender Studie wurde untersucht, ob in der täglichen Praxis einer GUV der Einsatz von Assessmentinstrumenten zur Messung der gesundheitsbezogenen Lebensqualität möglich ist und welche Schlussfolgerungen daraus gezogen werden können. Die Messparameter der eingesetzten Instrumente [SF-36 („short-form health survey with 36 questions“), DASH („disabilities of the arm, shoulder, and hand“) und EQ-5D (EuroQol-5D)] orientieren sich an der internationalen Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF: „international classification of functioning, disability and health“) und berücksichtigen insbesondere die Aspekte der Aktivitäten und Teilhabe an den unterschiedlichen Lebensbereichen. Nach Ansicht der Autoren kann mit ihnen gezeigt werden, dass die Ergebnisqualität der berufsgenossenschaftlichen Heilverfahren auch aus Patientensicht messbar ist.AbstractQuestions regarding efficiency and effectiveness, and more recently regarding patients’ health-related quality of life, have been raised regarding medical treatments even within the statutory accident insurance. In numerous studies regarding the statutory accident insurance authors have introduced different optimization needs in the case of good starting conditions of the statutory accident insurance medical treatments. The following study explores the possibility of applying assessment tools in the routine practice of the statutory accident insurance to measure health-related life quality. Measurement parameters of the applied tools [SF-36 (short-form health survey with 36 questions), DASH (disabilities of the arm, shoulder, and hand) and EQ-5D (EuroQol-5D)] are geared to the international classification of functional capability, disability and health (ICF), and take the aspects of activities and participation in different areas of life into particular consideration. From the authors’ point of view, results obtained with the instruments used in this study demonstrate that quality of care in the context of statutory accident insurance can be measured from a patient perspective.