Marco Streibelt

Effects of intensified work-related multidisciplinary rehabilitation on occupational participation: a randomized-controlled trial in patients with chronic musculoskeletal disorders.

This study examined the effects of work-related multidisciplinary rehabilitation (MR) on occupational participation in patients with chronic musculoskeletal disorders. A randomized-controlled trial was carried out. The sample included patients with chronic musculoskeletal disorders and severe restrictions of work ability (n=222). Participants in the intervention group received a work-related rehabilitation programme following a comprehensive functional capacity evaluation (FCE MR). Controls completed a conventional MR. The analysis was based on 1-year follow-up data. The primary outcome was stable occupational participation (SOP), defined as employment with at most 6 months of sick leave after rehabilitation. The secondary outcomes were the duration of sick leave, employment status and the Pain Disability Index. We included 102 patients in our analysis (intervention: n=55, control: n=47). Despite randomization there were group differences. Adjusting these differences, patients of the FCE MR had 3.5 times higher odds of SOP [95% confidence interval (CI): 1.2–9.8, P=0.018]. However, there was neither a significant difference in the duration of sick leave between both groups (b=−8.0 weeks, 95% CI: −17.4 to 1.4, P=0.095) nor higher odds of employment in favour of the FCE MR after 1 year (odds ratio=2.3, 95% CI: 0.9–5.8, P=0.088). Participants in the FCE MR reported less pain-related disabilities (b=−6.5, 95% CI: −12.6 to −0.4, P=0.038). The study had a limitation in terms of group balance. However, the findings indicate that the work-related FCE MR was more effective for SOP, but did not significantly affect employment rate and sick leave duration.

Value of Functional Capacity Evaluation Information in a Clinical Setting for Predicting Return to Work

OBJECTIVEnTo evaluate the quality of Functional Capacity Evaluation (FCE) information in predicting return to work (RTW).nnnDESIGNnProspective cohort study.nnnSETTINGnInpatient rehabilitation clinic.nnnPARTICIPANTSnPatients (N=220) with chronic musculoskeletal disorders (MSD) conducting a medical rehabilitation.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnPatients filled in questionnaires at admission and 1-year follow-up. An FCE was performed on admission. RTW was defined as a combination of employment at 1-year follow-up with a maximum of 6 weeks sick leave because of MSD in the postrehabilitation year. As predictive FCE information, the physical capacity (Dictionary of Occupational Titles categories 1-5), the number of test results not meeting work demands (0-25), and the testers recommendation of work ability in the actual job (> or =6h/d) were analyzed. Logistic regression models (crude and adjusted for the concurrent predictors employment, preadmission sick leave, and patients prognosis of RTW) were created to predict RTW.nnnRESULTSnComplete data were obtained for 145 patients. The sample showed a non-RTW at 1-year follow-up for 37.9%. All FCE information showed significant relations to RTW (r=.28-.43; P<.05). In the crude as well as in the adjusted regression models, all FCE information predicted RTW, but the models quality was low. The integration of FCE information led to an increase of 5%. The predictive efficiency was poor. The adjusted model for failed tests showed a substantial improvement compared with the reference model (concurrent predictors only).nnnCONCLUSIONSnThere was a significant relation between FCE information and RTW with and without concurrent predictors, but the predictive efficiency is poor. Primarily, the number of failed tests seemed to be of significance for patients with ambiguous RTW prognosis. A first proposal for a prediction rule was discussed.

Prospective Cohort Analysis of the Predictive Validity of a Screening Instrument for Severe Restrictions of Work Ability in Patients with Musculoskeletal Disorders.

ObjectiveThe aim of this study was to determine whether the Screening-Instrument zur Feststellung des Bedarfs an medizinisch-beruflich orientierter Rehabilitation (SIMBO) screening instrument can identify persons with a high work disability risk. DesignPatients with chronic musculoskeletal disorders and participation in a rehabilitation program were included in the analysis. Data were collected by questionnaires at admission and at the 6-mo follow-up. Failed return to work (RTW; i.e., unemployment or active employment with sick leave of >12 wks in the follow-up) was the primary outcome. Additional outcome data were obtained from the physician’s discharge form (e.g., assessment of work ability). Receiver operating characteristic analyses and logistic regression models were used to analyze the data. ResultsValid data were available for 1755 participants. Of these, 25% reported failed RTW. The area under the curve of the SIMBO score predicting failed RTW was 0.81 (0.79–0.83). The optimal cutoff to identify failed RTW was 23 points (of 100). The odds of failed RTW, unemployment, and sick leave of more than 12 wks were increased 12, 11, and 10 times for the persons with a SIMBO score of 23 points or greater compared with the persons with lower SIMBO scores. The odds of reduced work time capacity were increased 21 times. ConclusionsThe SIMBO predicts work disability in patients with chronic musculoskeletal disorders. Further research should focus on its predictive validity in patients with other disorders and within other rehabilitation systems.

Erfolgsfaktoren integrierter Versorgungsprozesse in der Endoprothetik: Ergebnisse einer qualitativen Prozessanalyse

AIMSnIn Germany, introduction of the law on Integrated Health Care (IC) (section sign 140a-d SGB V) opened up the possibility of cross-sectoral health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. However, cross-institutional and interdisciplinary work contexts demand new organizational structures in order to assure the coordination of different competences, resources and interests. This study aims at identifying factors of successful integrated care settings for total hip and knee arthroplasty. Using the example of an integrated care setting between an orthopaedic hospital and a rehabilitation clinic it will be examined which factors lead to successful implementation of the services and measures designed.nnnMETHODnA qualitative research design was developed comprising different methods of data assessment (participant observation, guided expert interviews, document analyses) enabling a comprehensive exploration. Overall, data were derived from six consultations with patients, two integrated care information sessions and various documents (17 patient files, information material, patient lists, etc.).nnnRESULTSnFirst of all, the different phases of development and implementation of integrated care settings were described. In this context, clearly defined aims, structures and appropriate measures seem to be crucial for an ideal long-term cooperation. Furthermore, the staff perspective on the effects of the IC programme on their daily routines proved an essential basis for process reconstruction. The staff members pointed out four main aspects regarding IC settings, i. e., improved image, increased knowledge, intensity of relationship, and less and more work effort. Against this background, factors of successful IC settings could be generated such as the need for central coordination, a regular staff information systems as well as accompanying process monitoring.nnnCONCLUSIONnSeveral key factors of successful integrated care settings in arthroplasty could be generated which provide important clues for shaping future interdisciplinary and cross-sectoral cooperation settings in health care services in general.

Predictive Validity of a Screening Instrument for the Risk of Non–Return to Work in Patients With Internal Diseases

OBJECTIVEnTo test the predictive validity of the SIMBO (Screening-Instrument zur Feststellung des Bedarfs an medizinisch-beruflich orientierten Maßnahmen in der medizinischen Rehabilitation [Screening Instrument for the Access to Work-Related Multimodal Rehabilitation]; total score ranges from 0 to 100 points) in patients with internal diseases in a rehabilitation setting.nnnDESIGNnProspective multicenter study.nnnSETTINGnInpatient rehabilitation centers.nnnPARTICIPANTSnPatients (N=1366) aged 18 to 65 years with internal diseases.nnnINTERVENTIONSnMultimodal rehabilitation programs.nnnMAIN OUTCOME MEASURESnThe primary outcome was occurrence of a critical return-to-work (RTW) event during the follow-up period. Receiver operating characteristic analyses were performed. Sensitivity, specificity, and positive predictive values were calculated for each disease group using the cutoff score of 27 points.nnnRESULTSnA total of 1366 patients with neoplasms (n=203); endocrine, nutritional, and metabolic diseases (n=355); and diseases of the circulatory (n=470), respiratory (n=255), and digestive (n=83) systems were included. Between 9.9% and 40.6% of the patients reported critical RTW events during the 3-month follow-up period. The area under the curve was between .849 (.754-.923) and .903 (.846-.959). Sensitivity and specificity ranged from 65.6% to 92.9% and from 80.4% to 89.9%, respectively. The positive predictive values were between 40.4% and 77.8%.nnnCONCLUSIONSnThe risk score SIMBO predicts short-term RTW problems after rehabilitation in patients with internal diseases. The cutoff of 27 points was confirmed as a reasonable threshold.

Sind administrative Daten für Rentenantragsintentionen und Indikatoren subjektiven Rehabilitationsbedarfs prognostisch bedeutsam

OBJECTIVESnThe aim of the study was to examine the associations of the Risk Index Disability Pension (RI-DP), which was calculated from administrative data, with intended disability pension claims and other health- and work-related characteristics.nnnMATERIAL AND METHODSnInsured persons of the Federal German Pension Insurance were surveyed by questionnaire in 2013. Questionnaire data were additionally linked to administrative data. The gross sample was restricted to persons, who received sick leave benefits in the previous year while not claiming or utilizing any rehabilitation services for the previous 4 years.nnnRESULTSn1,261 men and 1,495 women were included in the analyses. The odds of an intended disability pension claim were 4.8-times higher in men and 3.4-times higher in women if RI-DP scores were high. Furthermore, high RI-DP scores were also associated with frequent disability days, poor self-rated work ability and frequent visits to physicians.nnnDISCUSSIONnThe associations of the RI-DP with the examined characteristics imply that administrative data could support early identification of rehabilitation needs.

Verbesserte Behandlungsqualität durch integrierte Versorgung bei Knie- und Hüftgelenkersatz: Ergebnisse einer kontrollierten Studie

OBJECTIVEnIn Germany, the introduction of the Law on integrated care (IC) (§ 140 a-d SGB V) opened up the possibility of cross-sectional health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. Patients awaiting a hip or knee arthroplasty expect a higher benefit from such an intensified cooperation of operating hospital and rehabilitation centre. However, to date there is no study that investigated the anticipated effects on functional outcomes. Therefore, the aim of our study was the efficacy evaluation of an arthroplastic IC model in comparison with usual care.nnnMETHODSnThe controlled multicentre trial included pensioners who received an arthroplasty following gonarthrosis or coxarthrosis. Implantation of the arthroplasty was accomplished in 11 hospitals. Participants of the intervention group (IG; 3 hospitals) were treated within an IC model, participants of the control group (CG; 8 hospitals) were treated within conventional care. Primary outcome were the functional complaints measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).nnnRESULTSn481 patients attended the study (IG: n = 249; KG: n = 232). Response at end of treatment was 85.9% (n = 413), response after 4 months was 89.4% (n = 430) and after 1 year 85.9% (n = 413). Multivariate analyses confirmed a reduction of treatment time by 4 days (b = -3.964; 95% CI: -5.833 to -2.094; p < 0.001) and improved functional outcomes on the WOMAC (4 months: b = -7.219; 95% CI: -11.184 to -3.254; p < 0.001; 12 months: b = -8.070; 95% CI: -12.101 to -4.039; p < 0.001). Patients of the IG rated the process better (e. g. cooperation between hospital and rehabilitation centre: b = 0.672; 95% CI: 0.401 to 0.943; p < 0.001); reported a better self-rated health after 1 year (b = 4.418; 95% CI: 0.050 to 8.786; p = 0.047), and were physically more active (b = 1.603; 95% CI: 0.655 to 2.551; p = 0.001).nnnCONCLUSIONnThe IC setting improved coordination and communication at the interface between hospital and rehabilitation centre (internal patient orientation). Higher patient satisfaction and better outcome quality (external patient orientation) are not only achievable by improved medical devices but also by innovative communicative and organisational structures bringing along an improved process quality.

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

BACKGROUNDnMusculoskeletal 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.nnnAIMnThis 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.nnnMETHODnThe 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.nnnRESULTSnThe 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.nnnCONCLUSIONnCompared 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.

Effectiveness of Graded Return to Work After Multimodal Rehabilitation in Patients with Mental Disorders: A Propensity Score Analysis

Purpose Graded return to work (GRTW) is a strategy aimed at bringing people gradually back to coping with a full workload after an extended period of sick leave. This study aims to determine the effect of GRTW in addition to a multimodal rehabilitation on longer-term work participation in people with chronic mental disorders (CMDs). Methods Patients filled out questionnaires at the start of a multimodal rehabilitation and 15 months later. Balanced groups (GRTW, no GRTW) were formed by propensity score matching based on 27 covariates. The primary outcome measures were the return to work (RTW) status at follow-up and the number of days on sick leave during follow-up. Results From 1062 data sets (GRTW 508, no GRTW 554), 381 pairs were matched (age: 47.8 years; 78% female; 65% affective disorders, 28% neurotic or somatic disorders). At follow-up, 88% of the GRTW group had returned to work compared to only 73% of the controls (RRu2009=u20091.22, 1.13–1.31). The mean sick leave duration during the follow-up period was 7.0 weeks in the GRTW group compared to 13.4 weeks in the control group (pu2009<u20090.001). Additional explorative analyses showed that these effects were only observed in patients with an unsure or negative subjective RTW prognosis. Conclusions Based on this analysis, GRTW in addition to a multimodal rehabilitation is effective in enhancing successful work participation in people with CMDs. Earlier studies showing larger effects in people with a higher risk of a non-RTW were confirmed.

Meta-Synthesis of Qualitative Research on Facilitators and Barriers of Return to Work After Stroke

Purpose Despite existing rehabilitation services, return to work (RTW) rates among stroke survivors are quite low. An increased number of qualitative studies have been conducted to identify facilitators and barriers to RTW after stroke and to derive recommendations for future interventions. The aim of our study was to carry out a meta-synthesis of those studies and thus strengthen evidence in the field. Methods To identify relevant studies (qualitative studies focusing on RTW after stroke, published in English or German between 2000 and 2015), we conducted a systematic literature search in PubMed, OVID, and Web of Science. After assessing the quality of eligible studies, we synthesized their findings according to meta-ethnographic methodology. Results Fourteen out of 553 studies—three of very high, seven of high, three of medium, and one of low quality—met the inclusion criteria. After the extraction of all first-order concepts and their translation into 64xa0second-order interpretations, we synthesized the findings by developing a model of RTW factors after stroke. It contains factors related to the person (impairments, coping/adaptation, significance of work/RTW motivation), workplace (job demands/work adaptations, disability management, work climate/social support), and rehabilitation services (availability, accessibility, appropriateness), as well as relevant factors in the interaction of these three stakeholders (work capacity, performance and capability, and initial RTW experiences). Three basic principles—adaptiveness, purposefulness, and cooperativeness—complete the model and led us to its name: the APC model. Conclusions Successful RTW after stroke depends on diverse factors and stakeholders. Rehabilitation strategies have to consider this; otherwise they become RTW barriers themselves.