Matthias Bethge

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.

Erfolgsfaktoren integrierter Versorgungsprozesse in der Endoprothetik: Ergebnisse einer qualitativen Prozessanalyse

AIMS In 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. METHOD A 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.). RESULTS First 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. CONCLUSION Several 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

OBJECTIVE To 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. DESIGN Prospective multicenter study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Patients (N=1366) aged 18 to 65 years with internal diseases. INTERVENTIONS Multimodal rehabilitation programs. MAIN OUTCOME MEASURES The 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. RESULTS A 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%. CONCLUSIONS The 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

OBJECTIVES The 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. MATERIAL AND METHODS Insured 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. RESULTS 1,261 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. DISCUSSION The 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

OBJECTIVE In 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. METHODS The 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). RESULTS 481 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). CONCLUSION The 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.

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 (RR = 1.22, 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 (p < 0.001). 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.

Soziale Unterstützung als Ressource für Arbeitsfähigkeit

PURPOSE The study examined the association of social support with subjective work ability, subjective prognosis of gainful employment and general health perception. METHODS The analysis considered cross-sectional data from a sample of 2,983 employees (40-54 years) with sickness benefits in 2012. The postal survey was conducted in May 2013. RESULTS After adjustment for socio-demographic and work-related characteristics as well as personality factors low social support was significantly associated with lower work ability (b=- 2,7; 95% CI:-3,4 to 1,9), higher odds of poor employment prognosis (OR=2,0; 95% CI: 1,5 to 2,6) and poorer health perception (b=- 8,0; 95% CI:-10,1 to-5,9). CONCLUSIONS Low social support is potentially an independent predictor of lower work ability, employment prognosis and general health perception. To confirm causal relationships longitudinal data are needed, which will be assessed in 2015 and 2017.

Determinanten für intendierte Anträge auf medizinische Rehabilitation bei vorangegangenem Krankengeldbezug

OBJECTIVES The aim of the study was to identify determinants of intented applications for rehabilitation. MATERIAL AND METHODS We included persons paying pension contributions to the Federal German Pension Insurance who had received sickness benefits in the year before the first survey and had not applied or utilized rehabilitation services between 2009 and 2012. RESULTS 3,165 persons were considered for analysis. Intended applications were associated with low self-rated health, low self-rated work ability, frequent visits to physicians, professional and family support. These associations were relatively stable for different subgroups and were hardly moderated by sociodemographic characteristics. DISCUSSION The results emphasis the importance of professional and family support for the application for medical rehabilitation.

Direct and indirect effects of organizational justice on work ability

BACKGROUND Organizational justice (OJ), involving transparent workplace procedures and treating staff members with respect, has been of growing concern in recent epidemiological research as a determinant of health-related outcomes. AIMS To examine the factorial validity of the German version of Moormans Organizational Justice Questionnaire (OJQ), to investigate the direct cross-sectional effect of OJ on self-rated work ability and to analyse if there is an additional indirect effect of OJ on work ability mediated by effort-reward imbalance. METHODS An analysis of cross-sectional data from the Second German Sociomedical Panel of Employees, involving white-collar workers employed at least half time. We performed confirmatory factor analyses to test the factorial validity of the OJQ and analysed the direct and indirect associations of OJ and self-rated work ability by path model analysis. RESULTS Of the 1217 participants (47% female; mean age: 51) 36% had poor work ability. Factor analyses confirmed the two-factor structure of the German OJQ. Work ability was explained directly by OJ (β = 0.30) and effort-reward imbalance (β = -0.27). Additionally, we identified an indirect effect of OJ that was mediated by effort-reward imbalance (β = 0.14). The total effect of OJ on work ability was remarkably strong (β = 0.44). Associations remained unchanged after adjustment for socio-demographic parameters. CONCLUSIONS This study showed the importance of considering additional indirect pathways when examining the impact of OJ on the work ability of employees.

Ambulant vs. stationär durchgeführte Rehabilitationen: Ergebnisse einer Propensity Score gematchten Analyse

Objective Comparison of outpatient and inpatient rehabilitation concerning disability pensions and further work participation outcomes Methods We included 18-60 years old patients who completed an inpatient or outpatient rehabilitation program due to musculoskeletal disorders during the first half of 2007. Outpatient and inpatient patients were matched by propensity scores. Administrative data were analysed. Results Our primary analyses compared 4752 outpatient and 7435 inpatient patients. The absolute risks of a disability pension were 3.8% and 5.2% in favour of outpatient participants (RR=0.73; 95% CI: 0.62 to 0.87). The duration of unemployment and sickness benefits were marginally lower for outpatient patients. Conclusions Outpatient rehabilitation achieved slightly better outcomes. The benefit of outpatient rehabilitation was strongest in patients with more severe restrictions of participation. The study explores how using administrative data may enable evaluative rehabilitation service research.