German Statutory Pension Insurance Scheme Research Articles

Breast cancer patients’ return to work (B-CARE): protocol of a longitudinal mixed-methods study aiming to explore medical and occupational rehabilitation of patients with breast cancer in Germany

IntroductionIn recent years, research has been done on determinants of return to work (RTW) in cancer survivors and their long-term work outcomes. Nevertheless, little is known about the survivors’ evaluation...

Quality management in medical rehabilitative care by the German statutory pension insurance scheme.

This paper aims to provide an insight into the quality management approach for medical rehabilitation services of the German statutory pension insurance scheme. In the 1990s, the German statutory pension insurance scheme initiated a quality management programme in rehabilitation, which is subject to continuous development. The main objective of implementing quality management in rehabilitative care was quality control and quality improvement. To achieve these goals, five main tools for quality measurements were applied: a classification of therapeutic services, standards of rehabilitative interventions, patient surveys, peer review, and surveys that address structure of care. These tools enable the assessment of the structural and process quality of rehabilitative care, as well as aspects of rehabilitation outcome. As a result, quality of rehabilitation care becomes more measurable, transparent, and hence can be improved on well-founded grounds. These measurements allow implementing comparisons and benchmarking of rehabilitation facilities, thereby creating incentives for quality improvements. Therefore, the development and implementation of quality management measures in facilities of inpatient and outpatient medical rehabilitation is an ongoing process and expands to other areas of rehabilitation.

Two-Part Models and Quantile Regression for the Analysis of Survey Data With a Spike. The Example of Satisfaction With Health Care.

Background: Results of patient satisfaction questionnaires can contain a spike at the value corresponding to a complete satisfaction. A possible interpretation is that there are two types of respondents, those who are willing to provide a negative evaluation to one or more items proposed in the questionnaire and those who will always provide a completely positive evaluation irrespective of the item. The aim of the present study is to compare various statistical approaches to the analysis of such data using data from a rehabilitation patient survey of the German Statutory Pension Insurance Scheme as an example.Method: We used data from 272,806 respondents who participated in the survey from 2008 to 2011. We illustrate four models: linear regression, logistic regression, a two-part model based on the assumption of two underlying populations and quantile regression, which does not require any distributional assumptions. For each model we consider the relationship of the satisfaction score with two covariates.Results: While providing correct estimates of the mean values (marginal effects), the assumptions of the linear model are violated which can lead to false interpretations. A two-part regression which consists of a logistic regression followed by a linear regression conditional on not being fully satisfied is a useful alternative. For research questions focusing on specific parts of the distribution, logistic regression as well as quantile regression are to be considered.Discussion: Data with a spike represents a statistical challenge but a range of modeling approaches is available to provide sound interpretations and correct answers to research questions.

Potentials of the Third German Socio-Medical Panel of Employees (GSPE-III) for Research in the Field of Migration and Rehabilitation: The Example of Utilization of Rehabilitative Care

The majority of previous studies shows that migrants use medical rehabilitation less often than non-migrants. In some cases, opposite results have been reported. Previous research, however, has different limitations. The present study examines the use of rehabilitation among migrants and non-migrants by means of the Third German Socio-medical Panel of Employees (GSPE-III). The study is based on the first wave of the GSPE-III, extended by administrative data from the insurance accounts of the respective study participants. The survey was conducted in May 2013 and comprises a risk cohort of insurants of the German Statutory Pension Insurance Scheme (Deutsche Rentenversicherung Bund) who are at risk of reduced social participation and who received sickness benefits in 2012. We compared non-German nationals, German nationals with a migration background and German nationals without a migration background. Based on the Andersen Healthcare Utilization Model, the quality of life, the self-perceived risk of a reduced earning capacity as well as demographic and socio-economic factors were taken into account as covariates using a logistic regression model. Of the 2,413 respondents surveyed, 2.7% were foreign nationals and 4.4% were German nationals with a migration background. As compared to Germans with no migration background, Germans with a migration background and non-German nationals did not significantly differ in their utilization of rehabilitation (adjusted odds ratio=0.78, 95%-CI=0.47-1.30 and adjusted odds ratio=0.99; 95%-CI=0.53-1.88, respectively). The GSPE-III allows overcoming some limitations of previous studies by means of detailed data on migration background as well as the possibility to consider confounding factors at different levels and to link survey with routine data. The results contradict the majority of previous studies and show that epidemiological research on the utilization of rehabilitative care among migrants is inconsistent. For the interpretation of the present findings, it is also necessary to take into account the special properties of the GSPE-III and the comparatively small sample size.

Inpatient Rehabilitation for Children and Adolescents With Diabetes in Germany Between 2006 and 2013.

In Germany, inpatient rehabilitation is a well-established additive option in the therapeutic concept for children and adolescents with diabetes. However, its contribution in pediatric diabetes care is not known exactly. Our objective was to analyze inpatient rehabilitation in pediatric diabetes over eight years in Germany. We requested secondary data from the German Statutory Pension Insurance Scheme to evaluate all completed inpatient rehabilitations for children and adolescents with diabetes (ICD-code E10-14) reimbursed by this institution between 2006 and 2013. For each type of diabetes, we analyzed the distribution of admissions by year, age-group, sex, nationality, and other documented diagnoses. All analyses were conducted via remote computing with IBM SPSS Version 24. Between 2006 and 2013, 5,403 admissions to inpatient rehabilitation for 4,746 children and adolescents with diabetes were documented. For type 1 diabetes (T1D; 88.5% of admissions), the number of yearly admissions increased from 458 in 2006 to 688 in 2013 (p=0.013), especially for age-group>5-10. The increase for type 2 diabetes (T2D) was not significant. Admissions were more frequent for girls (53.6%, p≤0.001), age>10-15 years (42.8%, p=0.001), and German nationality (98.5%). Obesity (T1D: 11.1%; T2D: 87.9%) and mental disorders (T1D: 11.6%; T2D: 27.4%) were the most frequent documented diagnoses in addition to diabetes. This study provides a comprehensive overview of inpatient rehabilitation for children and adolescents with diabetes over many years in Germany. Until 2013, inpatient rehabilitation remained important in pediatric diabetes care, especially for children with mental disorders or obesity.

Satisfaction with rehabilitative health care services among German and non-German nationals residing in Germany: a cross-sectional study

ObjectivesRehabilitation following medical conditions is largely offered as in-patient service in Germany. Foreign-national residents use rehabilitative services less often than Germans and attain less favourable treatment outcomes. These differences are...

Individual and Contextual Reasons for Drop-outs in Vocational Retraining

The study focusses on the explanation of the individual, process-driven, and institutional factors and their interplay, and on the subjective accounts for the high drop-out rates in vocational retraining which are reported by the German statutory pension insurance scheme. 454 participants of 2-year lasting vocational retraining schemes in 3 vocational promotion centers and 3 education providers took part in the questionnaire survey. Furthermore, experts, dropouts and participants were interviewed and group discussions with experts and participants were conducted. Drop-out is not a definite term. Instead, it consists of different dimensions. 3 personal factors for predicting a drop-out could be identified: suffering from depression, negative health assessment and lack of social support. Generally speaking, drop-out of vocational retraining is a complex and mainly situational process which can hardly be predicted by personal factors, job-biographies or foregoing unemployment.

Leistungstrends der rehabilitativen rheumatologischen Versorgung in Deutschland

Recent Deutsche Gesellschaft für Rheumatologie (DGRh, German Society of Rheumatology) guidelines emphasized the significance of coordinated multidisciplinary care and rehabilitation of patients with inflammatory rheumatic diseases. Nationwide data from the German pension insurance funds showed that inpatient rehabilitation due to rheumatoid arthritis (RA) varied by a factor of 2.6 between the different German states. From 2000 to 2012 rehabilitation measures were reduced by one third, most significantly in men with ankylosing spondylitis (AS). Rehabilitation measures because of RA or AS were provided up to 14 times more frequently by the German statutory pension insurance scheme compared with a large compulsory health insurance which is responsible for rehabilitation measures after retirement. In rehabilitation centers with high numbers of patients with inflammatory rheumatic diseases, higher structural and process quality were demonstrated. In 2011 a total of 40% of RA patients in the national database of the collaborative arthritis centers showed medium or severe functional limitations. Among these disabled RA patients inpatient rehabilitation was reduced by about 50% between 1995 and 2011. Out of all RA patients from outpatient rheumatology care with severe functional limitations 38% had no functional restoration therapy within the previous 12 months with a high variation between rheumatologists. Experiences from other European countries may inspire German rheumatologists and other involved health professionals to initiate a wider range of rehabilitative interventions in the future.

Use of health care services by people with mental illness: secondary data from three statutory health insurers and the German Statutory Pension Insurance Scheme.

A discipline- and sector-specific analysis of health-care utilization by persons with mental illness in Germany is an indispensable aid to planning for the provision of adequate basic care. Secondary data from three statutory health insurers and the German Statutory Pension Insurance Scheme for the period 2005-2007 were evaluated to identify insurees with mental illness (ICD-10 diagnosis groups F0-F5). In the period 2005-2007, 3.28 million (33%) of 9.92 million insurees had at least one contact with the health-care system in which a mental disorder was diagnosed. 50.4% (1,651,367) of these insurees had at least two mental disorders. Nearly all (98.8%) of the insurees with a psychiatric index diagnosis had at least one somatic diagnosis coded as well. 95.7% of treatments were provided in the outpatient setting. Somatic medical specialties provided the majority of treatments both in ambulatory care and in the hospital. For example, 77.5% of persons with severe depression were treated with five kinds of treatment that were provided exclusively by primary care physicians and other specialists in somatic medicine in private practice, sometimes in combination with psychiatric treatment or psychotherapy. There was a high degree of comorbidity of mental and somatic illness. The fact that the vast majority of treatment was provided in the outpatient setting implies that cooperation across health-care sectors and disciplines should be reinforced, and that measures should be taken to ensure the adequate delivery of basic psychiatric care by primary care physicians.

Akzeptanz und Praktikabilität der Reha-Therapiestandards für Kinder und Jugendliche: Ergebnisse der Anwenderbefragung

The introduction of evidence-based therapy standards in child and adolescent rehabilitation of the German statutory pension insurance scheme (Deutsche Rentenversicherung Bund, 2011) was accompanied by a user survey that gave the participating rehabilitation centres the opportunity to comment on the new therapy standards and to suggest modifications.The survey questionnaire encompassed various topics related to the therapy standards, amongst them quality, comprehensibility, and acceptance, evaluation of feedback, and reasons for noncompliance with therapy standard requirements. For each of the 3 indications, a separate questionnaire was applied to assess modification suggestions regarding KTL therapy elements, the minimum percentage of patients to be treated accordingly, and the minimum duration of therapeutic procedures for each evidence-based treatment module. Responses from 14 rehab centres (return rate 54%) were obtained and analyzed.According to the majority of the responding rehabilitation centres, the therapy standards for child and adolescent rehabilitation fulfilled the quality features of topicality, multidisciplinarity, and relevance for routine rehabilitative practice. The degree of empirical grounding was evaluated more inconsistently. Difficulties with coding of KTL therapy elements were cited as the primary reasons for failing to comply with requirements in 2008.Exemplarily, the results of the user survey regarding the rehabilitative treatment of children and adolescents with obesity (age group: 8 years and older) are presented in detail.Concluding, the modifications to the therapy standards in child and adolescent rehabilitation introduced on the basis of the user survey are set out.

Risiken der Priorisierung in der 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.

Pathological Gambling

The number of pathological gamblers seeking treatment has risen continuously till the present, and the trend shows no sign of reversal. Estimates of the number of pathological gamblers in Germany range from 103,000 to 290,000, corresponding to 0.2% to 0.6% of the population. Pathological gambling often accompanies other mental disturbances. Doctors who learn that their patients suffer from such disturbances should ask targeted questions about gambling behavior to increase the chance that this problem will be detected early on. This article is based on an analysis of secondary data obtained from the German Statutory Pension Insurance Scheme and the Federal Statistical Office and on a selective review of the literature on comorbidities and available interventions. The rate of inpatient treatment for pathological gambling tripled from 2000 to 2010. Most pathological gamblers are men (70%-80%). More than 90% of the patients suffer from more than one mental disturbance; 40% of them carry five different psychiatric diagnoses. Simple screening instruments for pathological gambling are easy to use in routine practice and facilitate the diagnosis. As with alcoholics, only a small fraction of pathological gamblers receives the appropriate support and treatment. Educational seminars to raise awareness among physicians and targeted measures for early detection might result in more of the affected persons getting suitable help.

Die Nutzung von Routinedaten in der rehabilitationswissenschaftlichen Versorgungsforschung bei Menschen mit Migrationshintergrund: Möglichkeiten und Grenzen

Little is known about the rehabilitative care of populations with a migrational background. Using the assessment of rehabilitation effectiveness as an example, we outline the potentials and limitations routine data from social security carriers has for this research field. We draw on an 80% random sample of all completed medical rehabilitations in the year 2006 funded by the German Statutory Pension Insurance Scheme (n=634 529). The assessment of rehabilitation effectiveness was based on the occupational performance at the time the rehabilitation was completed. Migrational background was defined by nationality. By means of logistic regression adjusted for socio-economic/-demographic and health-related variables, we examine whether rehabilitation effectiveness differs between German and non-German nationals. Non-German nationals have a higher chance of completing medical rehabilitation with a lower occupational performance - irrespective of differences in socio-economic/-demographic and health-related variables. Odds ratios for a lower rehabilitation effectiveness were 1.23 [95%-CI=1.16;1.30] for Turkish nationals and 1.47 [95%-CI=1.38;1.56] for persons from the former Yugoslavia. Different aspects limit the validity of the analysis. (1) By using nationality, only a selection of all persons with a migrational background can be identified. (2) Important covariates cannot be considered. (3) The assessment of rehabilitation effectiveness is inaccurate, because valid data on occupational performance prior to rehabilitation is missing. Similar to routine data from other social security carriers, data from the German Statutory Pension Insurance Scheme has limitations for health services research on populations with a migrational background. Solutions comprise the application of computer-aided procedures for an accurate operationalisation of migrational background and the use of survey data for a valid assessment of rehabilitation effectiveness.

Utilization and effectiveness of medical rehabilitation in foreign nationals residing in Germany

In Germany, the proportion of foreign national residents receiving an invalidity pension is higher than that of Germans. Lower utilization and effectiveness of medical rehabilitation are presumed to be the main reasons. We aimed to examine whether differences in utilization and effectiveness of medical rehabilitation between Germans and foreign nationals are attributable to differences in socio-demography, socio-economic background and health status. Utilization of rehabilitation was analyzed for household members aged 18 years or above enrolled in the German Socio-Economic Panel in 2002-2004 (n = 19,521). Effectiveness of rehabilitation was defined by the occupational performance at the end of rehabilitation. It was examined by using an 80% random sample of all completed medical rehabilitations in the year 2006 funded by the German Statutory Pension Insurance Scheme (n = 634,529). Our study shows that foreign nationals utilize medical rehabilitation less often than Germans (OR = 0.68; 95%-CI = 0.50; 0.91). For those who do, medical rehabilitation is less effective (OR for low occupational performance = 1.50; 95%-CI = 1.46; 1.55). Both findings are only partially attributable to socio-demographic, socio-economic and health characteristics: After adjusting for these factors, ORs for utilization and low occupational performance were 0.66 (95%-CI = 0.49; 0.90) and 1.20 (95%-CI = 1.16; 1.24), respectively. It can be concluded that differences in the utilization and effectiveness of medical rehabilitation between Germans and foreign nationals cannot be explained only by socio-economic differences or poorer health before rehabilitation. In addition, factors such as the ability of the rehabilitative care system to accommodate clients with differing expectations, and migrant-specific characteristics such as cultural differences, seem to play a role.

Prävention als Aufgabe der Rentenversicherung: Innovative Modelle ergänzen bewährte Konzepte

Health-related strategies aimed at ensuring long-term participation in working life are gaining increasing importance against a background of longer working lives and demographic change. Medical and vocational rehabilitation under the German statutory pension insurance scheme are among these strategies. For a long time already, preventive concepts have been taken into account in rehabilitation so that the pension insurance's prevention approach is mainly based on the experience gained with preventive-modules in rehabilitation and follow-up care. Having so far only been able to offer in-patient prevention benefits, the statutory pension insurance scheme now can offer out-patient prevention measures, given the amendment it initiated to change Section 31 (1) no. 2 of Book 6 of the German Social Code which came into effect on January 1, 2009. The common guidelines of the statutory pension insurance institutions directed at ensuring continued working capacity were revised relative to the preventive benefits contained and were supplemented by recommendations for their use. The changing occupational demands in modern service society have thus been taken into account, and prevention benefits can be implemented in a more flexible manner following successful trials. The concept of out-patient prevention measures following along at the workplace and during leisure time is intended to enhance sustainability of acquired health-promoting behaviours in every day (working) life. At present this new concept is being tried out in various circumscribed pilot projects by several pension insurance institutions, partly in combination with in-patient components. On account of their specific know-how and their regional networks with enterprises, rehabilitation facilities are destined as locations for carrying out pension insurance prevention benefits.

Entwicklung eines standardisierten Rückenschulungsprogramms für die orthopädische Rehabilitation

Medical rehabilitation in Germany is still lacking in patient education programmes that meet certain quality requirements such as the use of manuals, patient-oriented didactics, and evaluations of effectiveness. For patients with chronic low back pain, no standardized and evaluated back school programme has so far been available for routine use. In this paper, we demonstrate the development of a quality-assured back school based on a health-education programme of the German statutory pension insurance scheme. Both topics and didactics incorporate treatment evidence, practice guidelines, quality criteria for patient education and theories of health and illness behaviour. First, formative evaluation was conducted to assess patient acceptance and practicability of the manual. Second, effects of the back school programme were assessed on a short-term (at the end of rehabilitation), medium-term (6-month follow-up) and long-term (12-month follow-up) basis in a randomized controlled study of patients with low back pain (n=360). Results show a significant medium treatment effect in patients' knowledge about chronic back pain and its treatment at the end of rehabilitation (p<0.001; eta (2)=0.080). Furthermore, small to medium effects were also observed among some secondary outcomes, such as motivation to physical activity, pain beliefs and pain intensity. After the programme's medium- and long-term effects have been demonstrated, it will be recommended for implementation in medical rehabilitation. The manual meets the requirements that allow for a successful transfer into clinical practice.

Einstellung zur psychosomatischen Rehabilitation: Entwicklung eines Patienten-Fragebogens

The transition from home to psychosomatic rehabilitation is problematic for many patients. They show little treatment motivation because of insufficient information and fear of stigmatization. Pre-treatment seeks to reduce these problems. The patient-questionnaire for stance toward psychosomatic rehabilitation was developed and tested for performance criteria. A German statutory pension insurance scheme sample of psychosomatic rehabilitation patients (n=317) were recruited for testing psychosometric attributes and were questioned before and after pre-treatment. To determine whether the questionnaire can show clinically relevant changes, 124 patients with pre-information were compared with 88 patients without intervention. Additionally, clinically relevant changes for patients without knowledge of psychosomatic rehabilitation (n=70) were analyzed. Factor analysis shows a three factor solution with ten items. The discriminatory power was good. High reliability was found for two factors and lower reliability for one factor. The patient-questionnaire for stance toward psychosomatic rehabilitation contains three scales: "knowledge", "confidence", and "motivation", and can be characterized as a reliable and economic instrument. After pre-treatment a general improvement was observed regarding patients' stance toward psychosomatic rehabilitation. The analyses result in significantly higher mean for patients with pre-treatment. Patients without previous information showed less "confidence" and "motivation". Pre-treatment can have a positive impact on the stance toward psychosomatic rehabilitation.

Ökonomische Evaluation einer medizinisch-beruflich orientierten Maßnahme bei Patienten mit muskuloskeletalen Erkrankungen - Eine Kosten-Nutzen-Analyse aus Rentenversicherungsperspektive

Musculoskeletal 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. This 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. The 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. The 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. Compared 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.