RESUMEN
INTRODUCTION: There are hardly any publications about the outcome of cardiac rehabilitation considering patients with an increased need for medical, nursing and therapeutic care. The aim of this study, which consecutively included n=387 statutory health insurance inpatients over a period of 2 years, was to find out differences in outcome in self-care patients (Barthel index>70) as compared to patients with a need for complex care (Barthel index≤70). METHODS: Rehabilitation outcomes concerning physical capacity, emotional status and activities of daily living as measured by Barthel index, FIM index, HADS, clinical complications, exercise test, duration of rehabilitation and form of dismission were analyzed and compared between both groups. RESULTS: The inpatients with a Barthel index ≤70 at admission were older, had a longer stay in hospital and in rehabilitation, developed more complications and more often suffered from concomitant diseases. They were readmitted to hospital more often. They showed a comparatively higher increase in indices of self-care and a significant increase in physical performance tests. CONCLUSION: Higher medical care expenses of multimorbid cardiac inpatients are no contraindication against rehabilitation, because even in this group the specific rehabilitation aims of the healthcare payers can be reached.
Asunto(s)
Actividades Cotidianas/psicología , Rehabilitación Cardiaca/psicología , Rehabilitación Cardiaca/estadística & datos numéricos , Personas con Discapacidad/psicología , Personas con Discapacidad/rehabilitación , Autocuidado/estadística & datos numéricos , Anciano , Personas con Discapacidad/estadística & datos numéricos , Tolerancia al Ejercicio , Femenino , Alemania/epidemiología , Humanos , Tiempo de Internación/estadística & datos numéricos , Estudios Longitudinales , Masculino , Evaluación de Resultado en la Atención de Salud/métodos , Admisión del Paciente/estadística & datos numéricos , Prevalencia , Pronóstico , Estudios Retrospectivos , Autocuidado/psicología , Resultado del TratamientoRESUMEN
BACKGROUND: So far, for center comparisons in inpatient cardiac rehabilitation (CR), the objective outcome quality was neglected because of challenges in quantifying the overall success of CR. In this article, a multifactorial benchmark model measuring the individual rehabilitation success is presented. METHODS: In 21 rehabilitation centers, 5123 patients were consecutively enrolled between 01/2010 and 12/2012 in the prospective multicenter registry EVA-Reha (®) Cardiology. Changes in 13 indicators in the areas cardiovascular risk factors, physical performance and subjective health during rehabilitation were evaluated according to levels of severity. Changes were only rated for patients who needed a medical intervention. Additionally, the changes had to be clinically relevant. Therefore Minimal Important Differences (MID) were predefined. Ratings were combined to a single score, the multiple outcome criterion (MEK). RESULTS: The MEK was determined for all patients (71.7 ± 7.4 years, 76.9% men) and consisted of an average of 5.6 indicators. After risk adjustment for sociodemographic and clinical baseline parameters, MEK was used for center ranking. In addition, individual results of indicators were compared with means of all study sites. CONCLUSION: With the method presented here, the outcome quality can be quantified and outcome-based comparisons of providers can be made.
Asunto(s)
Personas con Discapacidad/rehabilitación , Cardiopatías/diagnóstico , Cardiopatías/rehabilitación , Hospitalización/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/normas , Garantía de la Calidad de Atención de Salud/normas , Anciano , Alemania , Humanos , Evaluación de Resultado en la Atención de Salud/métodos , Garantía de la Calidad de Atención de Salud/métodos , Indicadores de Calidad de la Atención de Salud/normas , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
INTRODUCTION: Cardiac rehabilitation is designed for patients suffering from cardiovascular diseases or functional disabilities. The aim of a cardiac rehabilitation is to improve overall physical health, psychological well-being, physical function, the ability to participate in social life and help patients to change their habits. Regarding the heterogeneity of these aims measuring of the effect of cardiac rehabilitation is still a challenge. This study recommends a concept to assess the effects of cardiac rehabilitation regarding the individual change of relevant quality indicators. METHODS: With "EVA-Reha; cardiac rehabilitation" the Medical Advisory Service of Statutory Health Insurance Funds in Rhineland-Palatinate, Alzey (MDK Rheinland-Pfalz) developed a software to collect data set including sociodemographic and diagnostic data and also the results of specific assessments. The project was funded by the Techniker Krankenkasse, Hamburg, and supported by participating rehabilitation centers. From 01. July 2010 to 30. June 2011 1309 patients (age 71.5 years, 76.1% men) from 13 rehabilitation centers were consecutively enrolled. 13 quality indicators in 3 scales were developed for evaluation of cardiac rehabilitation: 1) cardiovascular risk factors (blood pressure, LDL cholesterol, triglycerides), 2) exercise capacity (resting heart rate, maximal exercise capacity, maximal walking distance, heart failure [NYHA classification], and angina pectoris [CCS classification]) and 3) subjective health (IRES-24: pain, somatic health, psychological wellbeing and depression as well as anxiety on the HADS). The study was prospective; data of patients were assessed at entry and discharge of rehabilitation. To measure the success of rehabilitation each parameter was graded in severity classes at entry and discharge. For each of the 13 quality indicators changes of severity class were rated in a rating matrix. For indicators without a requirement for medical care neither at entry nor at discharge no rating was performed. RESULTS: The grading into severity classes as well as the minimal important differences were given for the 13 quality indicators. The result of rehabilitation can be demonstrated in suitable form by means of rating of the 13 quality indicators according to a clinical population. The rating model differs well between clinically changed and unchanged patients for the quality indicators. CONCLUSION: The result of cardiac rehabilitation can be assessed with 13 quality indicators measured at entry and discharge of the rehabilitation program. If a change into a more favorable category at the end of rehabilitation could be achieved it was counted as a success. The 13 quality indicators can be used to assess the individual result as well as the result of a population--e. g. all patients of a clinic in a specific time period. In addition, the assessment and rating of relevant quality indicators can be used for comparisons of rehabilitation centers.
Asunto(s)
Cardiopatías/diagnóstico , Cardiopatías/rehabilitación , Evaluación de Resultado en la Atención de Salud/métodos , Evaluación de Resultado en la Atención de Salud/normas , Evaluación del Resultado de la Atención al Paciente , Indicadores de Calidad de la Atención de Salud/normas , Índice de Severidad de la Enfermedad , Anciano , Algoritmos , Femenino , Alemania , Humanos , Masculino , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
The decision of the German legislator to limit rehabilitation programme participation under the health-insurance scheme to a duration of three weeks had been oriented less by rehabilitation-scientific findings rather than by economic considerations. This is the background for discussing the question to what extent medical experience and empirical data are providing new information as to the durations of rehabilitation necessary and feasible in the field of psychosomatic rehabilitation and as to measures capable of supporting its effectiveness without extending the duration of therapy.
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Política de Salud/legislación & jurisprudencia , Política de Salud/tendencias , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/tendencias , Trastornos Psicofisiológicos/rehabilitación , Medicina Psicosomática/legislación & jurisprudencia , Medicina Psicosomática/tendencias , Alemania , Trastornos Psicofisiológicos/economía , Medicina Psicosomática/economíaRESUMEN
Rehabilitation centers in Germany with a care supply contract according to section 111 Social Code Book Five - statutory health insurance (SGB V) are legally obligated to implement an internal quality management and to participate in comprehensive measures of external quality assurance which particularly aim at improving outcome quality ( section 135a SGB V). The legislator has left it to the central associations of health insurance funds and to the relevant umbrella organisations of care providers to develop these measures as well as the basic requirements on internal quality management in order to reach a joint agreement about it (cf. section 137d [1] and [1a] SGB V). The corresponding agreement was concluded on April 1, 2004. Whereas configuration of the internal quality management to a large extend lies in the discretion of the individual rehabilitation center, although it has to be geared to the objectives and principles set out in the agreement under section 137d SGB V, participation in the external quality assurance procedures of the central associations of health insurance funds (QS-Reha procedure) is obligatory for all rehabilitation centers with a care supply contract according to section 111 or 111a. The QS-Reha procedure comprises a survey of the central quality dimensions (structural, process and outcome quality as well as patient satisfaction) and permits related quality comparisons, which are utilized by the health insurance funds for quality oriented patient allocation and remuneration. The QS-Reha procedure had been developed to implement the legal requirements for external quality assurance in the field of medical rehabilitation ( section 135a in conjunction with section 137d SGB V) as well as to create a basis for quality focussed remuneration and patients allocation, whereas the Eva-Reha database had been developed by the Medical Service of Health Insurances in Rheinland-Pfalz for single case documentation with the objective of utilizing these data for internal quality management and, beyond this, also for various aspects of quality development across centers. The results generated in the framework of external quality assurance and internal management have to be integrated in the concept of internal quality management as they account for important sources of information with respect to the analysis of strengths or weaknesses of the facility. Irrespective of their origin quality relevant results should be integrated into a benchmarking system providing information to the operational and medical management of a rehabilitation center on the effectiveness and efficiency of the medical rehabilitation services provided. Up-to-date data, such as those generated by the Eva-Reha database, or sample survey data as those from the QS-Reha procedure can equally be used for such a benchmarking system and complement each another in a meaningful way. In this paper the main features of the QS-Reha procedure and the Eva-Reha database are described, with the objective of pointing out the particular perspectives of their data structure and results for continuous improvement in the framework of internal quality management.
Asunto(s)
Bases de Datos Factuales/legislación & jurisprudencia , Documentación/métodos , Garantía de la Calidad de Atención de Salud/legislación & jurisprudencia , Indicadores de Calidad de la Atención de Salud/legislación & jurisprudencia , Centros de Rehabilitación/legislación & jurisprudencia , Benchmarking/legislación & jurisprudencia , Documentación/normas , Alemania , Humanos , Evaluación de Resultado en la Atención de Salud/legislación & jurisprudencia , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Garantía de la Calidad de Atención de Salud/normas , Centros de Rehabilitación/normas , Centros de Rehabilitación/estadística & datos numéricos , Gestión de la Calidad Total/legislación & jurisprudenciaRESUMEN
PURPOSE: Development of a computer software for supporting medical quallity management by documenting progression and results of medical rehabilitation in neurologic, orthopaedic, and geriatric patients. METHODS: The software "Eva-Reha" (Evaluation of Medical Rehabilitation) was generated using C ++ in a client-server structure with Interbase being the underlying relational database management system. The software is network-compatible and runs under Windows NT and Windows 2000. RESULTS: "Eva-Reha", developed by the "Medizinischer Dienst der Krankenversicherung Rheinland-Pfalz (MDK RLP)" supports quality management systems in medical rehabilitation. Since 2003 the MDK RLP provides neurologic and geriatric rehabilitation centres with the software free of charge. With the help of "Eva-Reha" progression and results of medical rehabilitation can be displayed metrically, thus facilitating individual rehabilitation planning and supporting motivation of the rehabilitation team. Therapeutic strategies can be evaluated for different ICD-10-diagnoses or impairment groups. Moreover, "Eva-Reha" provides valuable data for administration and controlling purposes, e. g. age structure, case mix, impairment on admission and medical as well as rehabilitative procedures. The system generates a request for extension in a set form which facilitates communication between rehabilitation centres and sponsors.
Asunto(s)
Evaluación de Resultado en la Atención de Salud , Rehabilitación/normas , Programas Informáticos , Anciano , Documentación , Evaluación Geriátrica , Alemania , Humanos , Sistemas de Registros Médicos Computarizados , Centros de RehabilitaciónRESUMEN
The classification of patients for phase B, C and D of neurological rehabilitation follows the suggestions of the Bundesarbeitsgemeinschaft für Rehabilitation (BAR) based on defined clinical criteria and on neurological rehabilitation assessment. The focus of this study is to define the intervals of the complete FIM(tm)-index, intervals covered empirically as well as by evaluations of physicians, that permit utmost accuracy in assigning patients to phase B, C and D of neurological rehabilitation. Therefore, data records of 3686 patients from 4 neurological rehabilitation centres were evaluated. The patients' functional autonomy was classified by FIM(tm) on admission, in intervals of 14 days and at discharge, at the same time all patients in addition were assigned to phases B, C or D by the rehabilitation centre physicians. Statistical analysis of a total of 11,247 links of the phase classifications and FIM-indexes at 6 measurement points showed that correct correlation to phase B, C and D could be obtained on average in 79 to 89 % of the cases, based on the assumption that 18 - 36 points of the FIM-index assign to phase B, 37 - 90 points to phase C and 91 - 126 points to phase D. Discrimination between phases B and C could be obtained accurately in an average of 84 %, discrimination between phases C and D in an average of 89 %. Conformance of the FIM-intervals with TAR-based groups of care efforts compared to the evaluation by physicians indicate that the FIM(tm) represents the need for care with greater validity. If assignment to phases B, C and D would have been done on the basis of the FIM-index instead of evaluation by a physician, 8,9 % fewer patients would on admission have been classified for phase C but, instead, 4,5 % more patients for phase B and 4,4 % for phase D. In case of using the FIM-intervals for classification, 12,1 % more phase B patients could have changed to phases C or D. Of the phase C cases, 17,7 % could have been transferred to phase D before discharge. The number of phase D patients would have remained unchanged comparing admission and discharge. FIM-orientated classification for the phases of neurological rehabilitation offers considerable advantages: operationalized criteria, possibility of statistical evaluation, objectiveness, reliability, validity, reproducibility of the decisions, sensitivity to change, prognostic sensitivity, and suitability as an instrument for internal and external quality assurance.
Asunto(s)
Actividades Cotidianas/clasificación , Daño Encefálico Crónico/rehabilitación , Evaluación de la Discapacidad , Anciano , Daño Encefálico Crónico/clasificación , Daño Encefálico Crónico/economía , Análisis Costo-Beneficio , Femenino , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Centros de Rehabilitación/economíaRESUMEN
Clinical practice, effect studies, the time structure of psychotherapeutic processes and treatment outcome data show that the legally provided treatment time of no more than 3 weeks for inpatient medical rehabilitation is usually not sufficient to achieve satisfactory and long-term stable psychotherapeutic improvement. In an evaluation study in a psychosomatic rehabilitation clinic the change in symptoms of 266 inpatients was recorded using the German version of the CES-D scale (ADS-L) and the Symptom Check List SCL90R. Values obtained after 21 days of treatment were compared with data obtained on discharge after an average of 45 days. Multiple patient characteristics, therapy parameters and process aspects were studied empirically in order to select patient groups which show sufficient effects after a 3 weeks treatment. Irrespective of patient characteristics, therapeutic experience, clinically significant and long-term stable effects were only achieved after treatment periods exceeding 3 weeks.