Barriers to applying for medical rehabilitation: a time-to-event analysis of employees with severe back pain in Germany.

Abstract

ObjectiveLongitudinal studies on barriers to applying for rehabilitation in Germany are lacking in light of the suspected underutilization of rehabilitation services. The aim of this study was to examine application behaviour in persons with disabling back pain and to identify relevant predictors for making an application.DesignA prospective cohort study with randomized sampling of insurants in the German Pension Insurance, using a questionnaire at baseline and followup with linked administrative data for 1.5 years.Subjects/patientsEmployed persons (age range 45–59 years) with a high degree of limitations due to back pain and a self-reported risk of permanent work disability (not applied for disability pension, no medical rehabilitation within the last 4 years).MethodsMultivariable Cox regression was used to examine the influence of pre-selected variables on making an application in the follow-up period.ResultsOf 690 persons, only 12% applied for rehabilitation. Predictors for making an application were: support from physicians (hazard ratio (HR)=2.24; 95% confidence interval (95% CI) 1.32–3.80), family, and friends (HR=1.67; 95% CI 1.02–2.73), more pain-related disability days (HR=1.02; 95% CI 1.01–1.03), and worse work ability (HR=0.86; 95% CI 0.75–0.97). An intention to apply at baseline mediated the effect of family and physician support on the application.ConclusionThe low number of applications for rehabilitation despite disabling back pain indicates access barriers to, and underuse of, medical rehabilitation.LAY ABSTRACTMedical rehabilitation in Germany aims to enable participation and work ability in persons with chronic conditions, but requires an active decision to apply. This study included 690 persons with severe back pain and followed them for 1.5 years. The aim was to analyse applications for medical rehabilitation in this group and to determine the influencing factors. Only 12% of persons included in the study applied for rehabilitation, mostly after approximately 1 year. Factors making an application more likely were: more disability days and support of the application by their physician, family, and friends. Factors that made an application less likely were: better work ability and being more strained by household chores. The results show that only 1 out of 10 persons in need because of back pain actually end up in rehabilitation, and that possible barriers must be addressed.