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

[Work-related medical rehabilitation]

Work-related medical rehabilitation is a multimodal, interprofessional program that reduces health-related discrepancies between job capacities and demands in order to support work participation of patients who are at an increased risk of failing to return to work (e. g. due to long-term sickness absence). The review outlines screening for patients who should be reached, diagnostics and treatments during work-related medical rehabilitation and evidence on the effectiveness of these programs. Moreover, tools supporting implementation of work-related medical rehabilitation are discussed.

[Comparison of behavioral orthopedic and classical orthopedic rehabilitation : A retrospective cohort study on the factors of mental comorbidity, gender and employment status]

BACKGROUND

Mental comorbidity plays an increasingly important role in determining the specific rehabilitation needs of patients in Germany in the context of other personal, social and occupational factors. In order to make the DRV's list of criteria more meaningful when assigning patients to one type of rehabilitation, this retrospective analysis is intended to determine from which of the two rehabilitation concepts examined (orthopedic rehabilitation or healing procedures (HV)/behavioral-medical orthopedic rehabilitation (BMOR)) patients with mental comorbidity (taking into account gender, employment status of the main orthopedic diagnosis) benefit more.

METHODS

Using the screening questionnaires HADS‑A, HADS‑D, SIMBO and BPI as well as a hospital questionnaire at the beginning of rehabilitation, data from 913 subjects (529 m/384 w) were collected and evaluated. Of these, 43% were assigned to HV and 57% to BMOR. Thus, in addition to the main orthopedic diagnosis, the frequency distribution of the factors psychological comorbidity, sex and, employment status (in the sense of unemployment) was determined. Using HADS, the benefit was determined at the end of the therapy by comparing the score medians.

RESULTS

Frequency distributions and the development of HADS scores show that the prior classification according to psychological comorbidity was correct. Women were more often affected by mental comorbidity and women achieved greater success in BMOR. Regarding the main orthopedic diagnosis, a high prevalence of cervical and lumbar spine complaints was found. According to logistic regression with model decomposition, the variables gender, HADS‑A and -D at the beginning of rehabilitation and the psychological comorbidity (yes/no) are suitable to correctly allocate the patients with 76.86% to one of the two types of therapy.

CONCLUSIONS

The presence of mental comorbidity appears to be a useful indicator that should be retained in the DRV's criteria catalog as one of the main criteria for allocation to BMOR. Female gender in connection with the presence of mental co-morbidity can also be considered a conclusive criterion. With regard to the main orthopedic diagnosis, cervical spine complaints may be particularly suitable as an allocation criterion.

Effectiveness of a screening tool to assess prevention and rehabilitation needs of 45 to 59 years old in primary care - study protocol of a pragmatic randomized controlled trial (PReHa45)

BACKGROUND

For years it has been stated that the need for prevention and rehabilitation is not always identified early enough. Although many individuals have regular contact with a general practitioner (GP), this access path for applying for a prevention or rehabilitation service has not been fully exploited. The important role of GPs in supporting the intention to apply is highlighted in the research. This study aims to evaluate the effectiveness of the "check-up 45 + " to support GPs both in identifying the need for prevention and rehabilitation services and in submitting applications.

METHODS

The study is designed as a two-arm, pragmatic 1:1 randomised controlled study (RCT), which will be conducted in about 20 general practices in the German states of Berlin and Brandenburg. Patients (n = 1,654) aged from 45 to 59 years will be recruited by medical assistants. In addition to usual care, both study groups will receive a questionnaire covering socio-economic and occupational variables to be filled out immediately in the waiting room. The intervention group passes through the "check-up 45 + ". This includes the completion of the "screening 45 + " that aims to assess the need for prevention and rehabilitation services. Medical assistants will immediately evaluate this 2-page screening tool. If a need is identified and confirmed by the GP, information and application documents will be handed over. Moreover, the application process for rehabilitation services is simplified. Primary outcome is the proportion of applications for prevention or rehabilitation services financed by the German Pension Insurance. Administrative data will be provided for this purpose. Secondary outcomes include the proportion of approved applications and completed services. In addition, the proportion of persons with a need for prevention or rehabilitation according to the "check-up 45 + " will be examined. Semi-structured interviews will be conducted and content-analysed to determine the practicability and acceptance of the "check-up 45 + " by the relevant stakeholders.

DISCUSSION

Prevention and rehabilitation need is insufficiently identified and addressed so far. This study will determine the effectiveness of the "check-up 45 + " in primary care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00028303, 03.03.2022).

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

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).

Pre-post changes in main outcomes of medical rehabilitation in Germany: protocol of a systematic review and meta-analysis of individual participant and aggregated data

INTRODUCTION

Multidisciplinary, complex rehabilitation interventions are an important part of the treatment of chronic diseases. However, little is known about the effectiveness of routine rehabilitation interventions within the German healthcare system. Due to the nature of the social insurance system in Germany, randomised controlled trials examining the effects of rehabilitation interventions are challenging to implement and scarcely accessible. Consequently, alternative pre-post designs can be employed to assess pre-post effects of medical rehabilitation programmes. We present a protocol of systematic review and meta-analysis methods to assess the pre-post effects of rehabilitation interventions in Germany.

METHODS AND ANALYSIS

The respective study will be conducted within the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A systematic literature review will be conducted to identify studies reporting the pre-post effects (start of intervention vs end of intervention or later) in German healthcare. Studies investigating the following disease groups will be included: orthopaedics, rheumatology, oncology, pulmonology, cardiology, endocrinology, gastroenterology and psychosomatics. The primary outcomes of interest are physical/mental quality of life, physical functioning and social participation for all disease groups as well as pain (orthopaedic and rheumatologic patients only), blood pressure (cardiac patients only), asthma control (patients with asthma only), dyspnoea (patients with chronic obstructive pulmonary disease only) and depression/anxiety (psychosomatic patients only). We will invite the principal investigators of the identified studies to provide additional individual patient data. We aim to perform the meta-analyses using individual patient data as well as aggregate data. We will examine the effects of both study-level and patient-level moderators by using a meta-regression method.

ETHICS AND DISSEMINATION

Only studies that have received institutional approval from an ethics committee and present anonymised individual patient data will be included in the meta-analysis. The results will be presented in a peer-reviewed publication and at research conferences. A declaration of no objection by the ethics committee of the University of Würzburg is available (number 20180411 01).

TRIAL REGISTRATION NUMBER

CRD42018080316.

Workability for persons with chronic diseases. A systematic review of validity and utility of assessments in German language / Valide und praktikable deutschsprachige Assessments zur Erfassung der Arbeitsfähigkeit bei Menschen mit chronischen Erkrankungen – eine systematische Review

Background

People with chronic diseases are often limited in their workability. Evaluating and enabling workability is central in rehabilitation. The aim of this study was to evaluate validity and utility of workability assessments in German for persons with chronic diseases.

Methods

The study is a systematic review. First, we systematically searched for literature in the databases Medline, CINAHL, PsycInfo, Cochrane HTA Database, DARE, CCMed, Sowiport, and BASE using following keywords: evaluation tool, chronic disease, workability, validity, and utility. Then, we evaluated the content and the quality of the studies based on criteria and decided if they were included.

Results

In total, validity and utility of eight workability assessments are described based on 74 studies. The assessments are: Productivity Costs Questionnaire (iPCQ), Work Instability Scale for Rheumatoid Arthritis (RA-WIS), Screening-Instrument Arbeit und Beruf (SIBAR), Screening-Instrument zur Feststellung des Bedarfs an medizinisch-beruflich orientierten Maßnahmen in der medizinischen Rehabilitation (SIMBO), Valuation of Lost Productivity Questionnaire (VOLP), Work Ability Index (WAI/ABI), Work Limitations Questionnaire (WLQ), and Work Productivity and Activity Impairment Questionnaire (WPAI).

Conclusion

The results revealed the availability of eight workability assessments for persons with chronic diseases in German language. They have strengths and weaknesses in relation to the construct, purpose, application, and evidence base. These could be the base for choice of an assessment. Overall, we suggest using workability assessment in order to meet the legal requirements for the use of standardized assessments and the increasing demand to establish evidence of the effectiveness of interventions.

Prognostic accuracy of the SIMBO regarding future return-to-work problems in patients with mental and musculoskeletal disorders

PURPOSE

A screening instrument (0-100 points) to predict return-to-work (RTW) problems was developed. We tested the predictive validity in patients with mental diseases (MD) and musculoskeletal diseases (MSD).

MATERIALS AND METHODS

A prospective multicenter study with questionnaires at admission and 3 months after rehabilitation was conducted. Patients with MD and MSD were included. The outcome was occurrence of RTW problems during the follow-up. Receiver operating characteristic analyses were performed. Sensitivity, specificity, and predictive values were calculated for each disease group using the threshold of 27 points.

RESULTS

There were 401 patients with MD (n = 250) and MSD (n = 151) included in the study, and 31.8% and 46.4% reported RTW problems during the follow-up, respectively. The area under curve was 0.885 (0.838-0.920) and 0.899 (0.841-0.943). The sensitivity rates were 87.1% and 87.5% and the specificity rates were 79.9% and 88.4% for MD and MSD, respectively. The post-test probability of experiencing RTW problems was 78.9% for MD and 77.8% for MSD. Analyses including only employed patients showed similar results.

CONCLUSIONS

The screening predicts short-term RTW problems after rehabilitation in patients with mental or MSD regardless of employment. The threshold of 27 points was confirmed as reasonable, but alternatives in the range of 20-30 points can also be recommended. Implications for Rehabilitation The SIMBO is a short and economic screening predicting future problems during the return to work (RTW) in patients with mental or musculoskeletal diseases. The SIMBO can be recommended to detect the initial RTW chance at the beginning of the rehabilitation process. This paper implied that there are mainly generic factors predicting the success of an RTW. Based on this it is possible to use one screening for different disease groups.

[Clinical anamnestic characteristics in neurological work-related medical rehabilitation : Necessity for a qualitative identification of severe restrictions of work ability]

BACKGROUND

Severe restrictions of work ability (SRWA) as a condition for participation in neurological work-related medical rehabilitation (WMR) have not been adequately described up to now. Similarly, the applicability of the screening instrument SIMBO-C for evaluating SRWA in neurological rehabilitation has not yet been answered conclusively.

OBJECTIVE

Determination of clinical and anamnestic characteristics of neurological SRWA and assessment of the applicability of the screening instrument SIMBO-C in neurological WMR.

MATERIAL AND METHODS

For the identification of SRWA clinical and anamnestic characteristics of 344 rehabilitants were routinely collected. The clinically and anamnestically determined SRWA was described quantitatively and content-analytically and correlated with SIMBO-C.

RESULTS

Of the rehabilitants 66% exhibited SRWA. Apart from the established characteristics of SRWA further person and disease-specific factors were found. The SIMBO-C score was significantly higher in the group with SRWA compared to the group without SRWA (45.6 ± 18.9 vs. 31.5 ± 12.5, p < 0.001); however, 31% of the group with SRWA and 50% of the group without SRWA demonstrated a SIMBO-C score ≤ 36 points and thereby a large overlap. The profile of the clinical and anamnestic characteristics in the group with SRWA was homogeneous, regardless of the SIMBO-C score.

CONCLUSION

The characteristics of neurological SRWA are mainly qualitatively shaped and may only partly be identified by SIMBO-C. A combined quantitative and qualitative approach is necessary in neurological WMR.

Prevalence and Characteristics of Work Anxiety in Medical Rehabilitation Patients: A Cross-Sectional Observation Study

OBJECTIVE

To investigate frequency, type, and characteristics of work anxieties in patients with somatic illness.

DESIGN

Cross-sectional observation study.

SETTING

Neurology, orthopedic, and cardiology rehabilitation clinics.

PARTICIPANTS

Patients (N=1610; age, 18-65y) with work anxieties.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients who scored high on at least 2 of 9 items in the work-anxiety screening questionnaire and who reported impairment were investigated with a differential diagnostic interview on work anxieties and with the Mini-International Neuropsychiatric Interview on non-work-related common mental disorders. Patients also filled out a self-rating questionnaire on their subjective symptom load and sociodemographic data.

RESULTS

Approximately 20% to 27% of the investigated inpatients in somatic rehabilitation (altogether n=393) received a work-anxiety diagnosis. Patients with orthopedic illness report highest work anxiety and have previous longest sick leave (20.6wk in the past 12mo). Patients with orthopedic illness suffer from work-related adjustment disorder with anxiety, social anxieties, and workplace phobias, whereas patients with cardiac illness are more often affected by hypochondriac anxieties. Anxieties of insufficiency and worrying occur equally in all indications.

CONCLUSIONS

About a quarter of patients in somatic rehabilitation are in need of additional diagnostic attention owing to work anxieties. Differential diagnostic of work anxiety is needed for initiating adequate therapeutic action. Somatic rehabilitation physicians should be aware of work anxieties in their patients, especially in patients with orthopedic illness with previous long-term sick leave.