Quality assurance of rehabilitation by the German pension insurance: an overview

The German pension insurance has in recent years developed a comprehensive programme for quality assurance in rehabilitation, and has implemented the programme into routine practice. Different aspects of rehabilitation are evaluated with differentiated instruments. Issues dealt with inter alia include the quality of rehabilitative care in a narrower sense, the structure and organisation of the rehabilitation centres, as well as quality from the patients' perspective. On the whole, positive results predominate. Big differences in quality however have been found between the rehabilitation centres. The data collections and data evaluations carried out make a continuous process of quality assurance reporting possible for use by rehabilitation centres and pension insurance agencies. This will enable targeted initiatives for quality improvement. The methods and procedures of quality assurance are enhanced at regular intervals, and the scope of quality assurance is extended. Thus, rehab quality assurance is also expanded to cover ambulant rehabilitation or rehabilitation of children and young people.     

Stepwise occupational reintegration under the German pension insurance scheme--results of comprehensive routine data analyses and participants surveys

This paper presents for the first time research results of a comprehensive analysis on stepwise occupational reintegration (SOR) provided under the German pension insurance scheme. SORs under the German pension insurance scheme directly after medical rehabilitation have recently become possible as legal changes came into force in April 2004; until then, they had been provided by the health insurance funds independent of earlier medical rehabilitation. Against the background of this amendment of the law, the present study was commissioned by Deutsche Rentenversicherung Bund to get information relative to indication, introduction, implementation and results of the new SOR procedure. Analysis of routine data from the German pension insurance scheme pertaining to more than 140 000 insured persons treated in more than 1 083 medical rehabilitation centres, as well as of more than 6 500 participant surveys, resulted in a so far unique database for investigating SOR. This database offers a comprehensive collection of data and experiences relative to the amount of SOR prescribed and realized, to participants, procedure and results of SOR under the pension insurance scheme. This amount of data has never before been available when SOR was provided by the health insurance funds. The data collected suggest pinpoint indication of SOR, a positive rating of participants and an effective contribution to reintegration into working life and prevention of premature retirement. According to the present data, medical rehabilitation centres and their recommendations have an important influence on SOR utilization. Findings suggest major differences in the recommendation behaviours of rehabilitation centres, the possibilities offered by SOR not made use of to the same degree everywhere.     

Rehabilitation in Germany: new challenges of a structured social security scheme

The structured social security scheme established in Germany is clearly reflected in the configuration of the German rehabilitation system. For medical rehabilitation the institutions of statutory pension insurance and statutory health insurance are of particular importance. Within the past decades differentiated supply structures were built up and re-built within the rehabilitation system. As a consequence, insured parties receive different rehabilitation benefits depending on which insurance is responsible. This article outlines central elements of the German rehabilitation supply structure as well as the numerous rehabilitation forms and benefits. Moreover, perspectives of a recently passed law of rehabilitation and the participation of handicapped people (SGB IX) (SGB=social law), which forces insurers into increased co-operation and restructuring, are presented.     

Evaluation of outpatient rehabilitation: goals,conceptual framework and study design of a health and pension insurance joint research project

In Germany the statutory health and pension insurance schemes are the main providers of medical rehabilitation, the majority of rehabilitation measures being given in an inpatient setting. Over the last few years, the health and pension insurance schemes have strengthened the extension of outpatient rehabilitation, and have funded a comprehensive evaluation study in this context. In this evaluation study outpatient rehabilitation in centres with different conceptual backgrounds is compared with inpatient rehabilitation in rehab clinics, indications considered being cardiology and orthopaedics. Overall, 14 rehab centres and more than 2000 patients were included in the project. The patients were interviewed and medically examined before and after the measure. A follow-up was done after six and twelve months. In addition to the rehabilitants themselves, the rehab centre physicians as well as the office-practice physicians were interviewed about the outcome of the rehab measure. One year after rehabilitation, data were collected from the relevant health and pension insurance funds concerning the benefits the patients had received. Due to the study's non-experimental design, validity of the results is confined to rehabilitants participating on an outpatient basis and who had been found medically suited for this type of rehabilitation, were capable of travelling to the rehab centre on their own within less than 45 minutes and had voluntarily opted for the outpatient setting. The findings of the study show that outpatient rehabilitants' motivation and expectations differ from those found in inpatient rehabilitation. The health economics analysis performed is restricted to the costs involved in the rehabilitation measure as such as well as the health-related benefits provided to the rehabilitants in the twelve-month study period. The issue of whether increasing outpatient rehab measures will lead to decreasing costs in the rehab system as a whole had not been considered in the framework of this project.     

Upgrade, expand, systematize--an analysis of the status of, the need for reform in, as well as innovative projects for follow-up care in rehabilitation under the German pension insurance scheme

Rehabilitation benefits provided under the German Pension Insurance scheme are of central importance to insureds, in terms of protection in cases of loss or reduction of their earning capacity. Due to this safeguarding effect for the gainfully employed population, rehabilitation benefits at the same time are important to the insured community and to society as a whole. In 2003, some 846 000 insured persons had received medical and other benefits for rehabilitation. Designing these benefits to be as effective as possible is among the pre-eminent goals of the statutory pension insurance scheme. To this end, the statutory pension insurance institutes have initiated a quality assurance programme designed to enable utmost quality of the benefits provided. This programme in the first line covers inpatient medical rehabilitation of, as a rule, three weeks duration. An issue hardly investigated so far is sustainability of the effects achieved by these rehabilitation measures. Among the possibilities for ensuring lasting success are follow-up measures or benefits arranged for already during the in-patient stay, a service field which until recently had hardly been known in Germany. A stock-taking carried out in 2004 by the author and supported by LVA Schleswig-Holstein, a regional pension insurance institute, has for the first time realized an overview of this kind. Its essential findings are presented in this article, supplemented by a partial update vis-à-vis completion of the initial investigation.     

Evaluation of an indicator-based screening procedure for identifying quality problems in medical rehabilitation of the German statutory accident insurance

In the context of medical rehabilitation quality assurance, the use of screening procedures aims at specifically screening for rehabilitative cases that might be affected by quality problems. These may then be subjected to more elaborate quality management procedures. In the study presented, a criteria-based screening checklist designed to tap potential quality problems among rehabilitative cases in the German statutory accident insurance medical rehabilitation system was evaluated regarding its validity and suitability for routine use. Checklists were filled out by accident insurance administrators in three regional insurance funds who were instructed to evaluate all current rehabilitation cases (n=189) with regard to potential quality problems. For validation of the instrument, case reviews by physicians familiar with medical and administrative features of the accident insurance rehabilitation system were used. About a fifth of all cases reviewed using the screening checklist (22%) were classified as potentially problematic in terms of quality. Absence of relevant documents, delays in document receipt, and complications during treatment were cited as the most frequent problems. Concordance between the screening checklist and physicians' ratings concerning the quality of rehabilitative cases was moderate. Sensitivity and specificity were insufficient when using physicians' ratings as a validation criterion (0.53 and 0.56, respectively). Accident insurance administrators rated the screening checklist as a useful and practical quality management instrument. Concerning its insufficient validity using physicians' ratings as a validation criterion, the suitability of the checklist as a screening instrument is questionable. The instrument's potential of introducing the accident insurance administrators' expertise and knowledge into medical rehabilitation quality management strategies is highlighted. Further research on methodological aspects of the instrument as well as its content features is warranted. Starting points for modifications are outlined.     

Instruments for quality assurance in centers for medical rehabilitation

In 1994, the German statutory pension insurance scheme started to develop a quality assurance programme in rehabilitation clinics, involving scientists giving support to the project. Established as a routine in 1998, the programme is based on the integrated use of different instruments relating to structural, procedural as well as outcome quality. Analysis and evaluation of data follow a concept of clinic comparisons, assessing particular groups of clinics of similar structure. The specific instruments used are described, their development is outlined and their application explained.     

Medical rehabilitation--quantitative developments and structural changes in the past and future

Usually, only recent developments concerning application for, treatments and costs of inpatient rehabilitation are in focus and reported regularly to all those involved. This contribution, however, analyses the long-term development of data in the context of rehabilitation under the German statutory pension insurance scheme since 1968, seeking to gain insights relative to the present and future situation in the field of rehabilitation.     

Outpatient and inpatient orthopaedic rehabilitation--results of a study comparing outcome and costs

This article presents main results of a study comparing outcome and costs of various all-day outpatient and inpatient orthopaedic rehabilitation forms. The results were obtained within the scope of a comprehensive evaluation programme commissioned by the federation of health (VdAK) and pension insurance institutes (VDR). The purpose of this evaluation was to examine the quality of different types of various rehabilitation care. The outcome comparison comprises a longitudinal follow-up of various somatic, psychosocial und occupational reintegration parameters up to one year after rehabilitation as well as outcome assessments from the perspective of patients and physicians in rehabilitation centres and general practice. The costs are estimated on the basis of data from health and pension insurance funds. The results show extensive corresponding of results und assessments in the different forms of rehabilitation care for comparable patient groups. There are no indications of poorer care quality in outpatient rehabilitation, while economic analyses show better cost effectiveness in outpatient treatment by comparability of treatment, patients, and results. Results suggest that outpatient care, offered in the same quality as in the examined rehabilitation centres, is an alternative or complement to inpatient care at least for those patients, who can be treated in both the outpatient and inpatient setting.     

Evaluating the rehabilitation process by means of peer review: examination of the methods used and findings of the 2000/2001 data collection in the somatic indications

This paper reports the results of a peer review system that was implemented in the context of the quality assurance programme of the statutory German Pension Insurance scheme. The data reported refer to the 2000/2001 data collection period for medical rehabilitation in the somatic indications. Examination of inter-rater reliability for judgements of individual raters shows satisfactory results only in orthopaedics. In the quality assurance programme, rehabilitation centres are usually evaluated by the mean of 20 rater judgements. The reliability of this aggregated measure is satisfactory in all indications. The results of 561 rehabilitation centres show that those quality criteria are in particular need of improvement that refer to subjective concepts of patients (e. g., subjective theories of illness). Between peer review procedures in 1998 and 1999, the quality scores of rehabilitation centres had improved whereas between 1999 and 2000/2001, no further improvement can be shown. However, those rehabilitation centres with a low quality score in 1999 (lowest quartile of the distribution) underwent a positive development between 1999 and 2000/2001. Reasons for this trend and possibilities for improving interrater reliability of the peer review process as an element of the quality assurance programme of the German Pension Insurance scheme are discussed.     

Risks of prioritization in rehabilitation

Prioritization, on the one hand, is a necessity in everyday medical practice. On the other hand, a vivid controversy is taking place in particular as to how prioritization can be formalized in order to allocate resources in the German (statutory) health care system in the best possible manner. Some believe prioritization to be just a preliminary stage for rationing resources. Others point out that if human dignity, medical needs, and solidarity within society are taken into account properly, prioritization can contribute to an improvement of distributive justice and quality control in the health care system. With respect to the rehabilitation system this has already been discussed in the late 1990s, when the main rehabilitation carrier--the German statutory pension insurance scheme--had been forced by legislation to implement major cutbacks in rehabilitation spending. In this article, the authors analyze whether the German social code book IX (SGB IX), in force since 2001, has added new aspects to this debate, and consider the question of whether prioritization can be a useful approach in the rehabilitation system.     

Quality Assurance in Rehabilitation under the German Pension Insurance Scheme

Ten years after its introduction, the German Pension Insurance's quality assurance programme is firmly established within the rehabilitation system. Regular, substantive reporting to rehabilitation centres and pension insurance organisations has contributed to improving the quality of rehabilitation. Legal codification of quality assurance stipulations has existed since 2001. The programme is in constant development, e. g. by optimization of patient interviewing and inclusion of evidence-based clinical practice guidelines. New programmes, e. g. in inpatient rehabilitation of children and youths or in outpatient rehabilitation, are being developed together with the German health care organizations. In the field of vocational rehabilitation quality assurance had started out with a conceptual study followed by projects concerning client interviewing, evaluation of documentation instruments, and analyses relative to the most important outcome factor, namely the vocational reintegration results achieved. External quality assurance is a mayor input factor for the rehabilitation centres' internal quality management. In future, rehabilitation centres will be asked to demonstrate the appropriate use of this information. It will remain the centres' decision which method of quality management system implementation they choose. Quality assurance results of every centre are planned to be made publicly accessible in the medium term, in particular to the insureds. Moreover, the results of the quality assurance programmes are intended to clearly impact the allocation of patients as well as the remuneration of the rehabilitation centres concerned. Quality assurance and quality management will continue to play a major role in the political discussion of health care.     

Medical rehabilitation from the viewpoint of the established physician

In view of the not inconsiderable numbers of pension insured who have undergone no medical rehabilitation prior to their being pensioned prematurely, the principle of "rehabilitation comes before pensioning" hence not being implemented for this population, it is deemed justified to inquire into the causes of this situation. In the framework of the present study of 902 questionnaires returned by office practice physicians, it is presumed that the office practice physician is the controlling agent in inducing appropriate patients at the right time to participate in a rehabilitation measure. The following indicators are presumed to decisively influence this steering function: Attitude towards medical rehabilitation; Disease/disability-specific experience with medical rehabilitation measures; Satisfaction with the rehabilitation clinic selected by the pension insurance administration; Awareness of the rehabilitation clinics' range of rehabilitative services and the various treatment modalities available; Awareness of pertinent legal provisions; Cooperation between office-practice physician and pension insurance administration.     

Practice problems in disability assessment of applications for psychosomatic rehabilitation

In 2008 the German statutory pension insurance handled about 1 600 000 applications for medical rehabilitation. The overall approval rate was 70%, with a range between 60 and 86% in regional pension insurances. The majority of applications were refused on the ground that ambulatory medical or psychotherapeutic treatment was sufficient. Physicians frequently argued that ambulatory psychotherapy was unavailable due to long waiting lists or lack of psychotherapists. The problem whether shortcomings in ambulatory care can constitute sufficient reason to affirm a need for inpatient rehabilitation is discussed. It is necessary to improve the basis for needs assessment by the medical services (e. g. personal assessment, contacting family doctors). A survey of the further development (e. g. course of disease, disability days, and early retirement) of insurees whose applications for rehabilitation were rejected is recommended.     

Structure quality assurance in in-patient medical rehabilitation of children and adolescents

BACKGROUND: So far, the routine programmes of the statutory pension and health insurance institutes for quality assurance in medical rehabilitation have not included facilities for children and adolescents. Thus, a conjoint project of the statutory pension and health insurance institutes to assess and to describe the structure quality of in-patient medical rehabilitation clinics for children and adolescents was initiated. The aim of the project was a survey and an analysis of the currently existing clinic structures and the development of criteria for an evaluation of the structure quality. The Institute of Medical Psychology, University of Hamburg and the Department of Quality Management and Social Medicine, University of Freiburg were engaged to conduct the project. METHOD: A questionnaire was developed in a multi-stage process with expert involvement which covers general information, characteristics of structure quality as well as structure affiliated process characteristics of clinics. The survey was planned as a cross-sectional study. Data collection was accomplished from 1.12.2004 - 15.3.2005. RESULTS: A total of n = 177 facility addresses were available. The return rate was 83.3 %. Eventually, n = 79 facilities were included in the analysis. In sum, the results underline the heterogeneity of services in the field of child and adolescent rehabilitation. CONCLUSIONS: The results allow an analysis of the current clinic structures as well as a first comparison of clinics on the basis of the assessed structure characteristics.     

The ICD-10 and the Unified Diagnoses Code of the Pension Insurance. Guidelines for interpretation of the diagnostic codes within the legislative framework for pension insurance

The "International Statistical Classification of Diseases and Related Health Problems", Tenth Revision (ICD-10), has to be used by all social security funds in Germany since Jan. 1, 2000. For purposes of the official statistical classification of causes of death, it has been used since 1998. There are a number of fundamental differences between the ICD-10 and the ninth revision. In particular, a considerably higher degree of specification and differentiation warrant a thorough look at the ICD-10 in numerous respects. The Unified diagnoses code of the statutory pension insurance is an extract from the ICD-10 referring specifically to diseases occurring in medical rehabilitation and early retirement contexts. Several new four- and five-digit codes were added for statutory pension insurance purposes, hence are not contained in the original ICD-10. This extract will only turn out a practical tool if the physician is well-qualified in his particular field and is familiar with the sometimes very complex differentiations within the systematical register in volume I of the ICD-10. The article provides an overview of the structure of the ICD-10; deals with major novelties and alterations as well as practical problems; uses various exemplary diagnoses to illustrate a systematical approach in possibly problematical encoding; and recalls several general rules for diagnoses encoding in social medicine.     

The "rehabilitation sciences" promotional emphasis--a promotional program and its implementation

The German Federal Research Ministry and the German pension insurance have set up a special funding programme for medical rehabilitation research. Eight regional research networks with about 70 projects receive funds for a first three year period. Rehabilitation experts from several countries selected the promising networks and studies from more than 100 proposals. In these networks medical and social scientists from universities and other research units cooperate with rehabilitation centers and pension insurance institutes in order to combine forces for the development of German rehabilitation science. The programme aims at improving the research structures and at tackling the major challenges of medical rehabilitation research. The following subjects represent the main fields of the ongoing research: a) etiology, course and prognosis of chronic diseases and their consequences to rehabilitation, b) diagnostics in rehabilitation, c) evaluation and improvement of rehabilitation therapy, d) the patient's perspective in rehabilitation and e) rehabilitation system research. As yet funding is limited to the year 2001. Further support of the networks will depend on the results of a thorough evaluation of the progress of their research and their structural perspective.     

The assignment of orthopaedic rehabilitants to the traditional or the behaviour-medical rehabilitation approach--is it clinically relevant?

Rehabilitants with chronic orthopaedic diseases are assigned to either the traditional or the behaviour-medical rehabilitation approach by consultant physicians of the rehabilitation department within the Deutsche Rentenversicherung Bund (German pension insurance agency). The clinical relevance of this assignment was evaluated at the Rehazentrum Bad Pyrmont-Klinik Weser within a randomised controlled trial. In a sample of 363 rehabilitants the agreement of consultant physicians with the ratings of physicians and psychologists in the clinic was analyzed. We also tested whether rehabilitants treated in their assigned approach benefit more from the treatment than patients who by randomisation were not treated in their assigned approach. Results indicate that psychiatric comorbidity frequently is taken into consideration as a decision-making criterion in the assignment made by the consultant physicians. However, there is only little agreement between the assignment by consultant physicians and the ratings by treating physicians and psychologists. Further, rehabilitants treated in their assigned approach did not benefit more from the treatment than patients who due to randomisation had not been treated in their assigned approach but in the other. Therefore, the procedure applied so far for assigning rehabilitants to either the traditional or the multidisciplinary rehabilitation approach is not sufficiently valid. Concluding, implications for the modification of assignment criteria are discussed.