Die Rehabilitation
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What is meant by intention-to-treat? Why should data be analyzed in controlled trials in a way that all participants are included in the group to which they were randomly assigned, regardless of whether they completed the intervention given to the group? In this Tutorial, the logic of the intention-to-treat principle is outlined. It is shown that study results may be biased by excluding patients post hoc thus producing spurious effects that do not exist in the population under study. The intention-to-treat strategy avoids this bias.
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Book 9 of the German Social Code, effective as of July 1, 2001, was designed to bring about fundamental improvements in the situation of people with disabilities or at risk of being disabled. Somewhat more than two years after having come into force an extensive hearing on political level took place concerning the translation into action of this code. ⋯ The author draws an interim balance concerning the translation into action of Book 9 of the German Social Code. The main emphasis of this statement is on the establishment of common service points as well as on the state of the arrangement of common recommendations at the Federal Rehabilitation Council.
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Chronic back pain has a high personal impact, is frequent and of outstanding economical relevance. Analysis of the international literature indicates strong or moderate evidence for the effectiveness of multimodal multidisciplinary team care of chronic back pain. Our review aims at a complete review and critical appraisal of German studies of inpatient medical rehabilitation. ⋯ In the era of evidence based medicine, inpatient rehabilitation has to show its usefulness, necessity and efficiency as any other type of health care. For the German system of inpatient rehabilitation of chronic back pain available evidence is not conclusive, due to a lack of randomised controlled studies. The prevailing design of observational cohort studies has severe limitations in proving a causal relationship between outcomes and intervention. The international literature however provides more valid evidence in favour of the multimodal multidisciplinary intervention in chronic back pain. Under the assumption of a "class effect" of medical rehabilitation the German data seem to corroborate the conclusions drawn from international studies.
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In this paper, the concept of Shared Decision Making, i. e. the participation of the patient regarding the selection of therapeutic goals and treatment options, is presented. The degree of patient participation in medical decisions varies widely across different models of the physician-patient relationship. According to the paternalistic model, the physician knows best what is in the patient's interest; patient participation is limited. ⋯ Both physicians and patients require the ability to make shared decisions. Structural restraints include time and institutional inflexibility. To conclude, shared decision making is a promising approach to enhance patient participation in rehabilitative care.
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Clinical practice guidelines are relevant to all parties involved in the health system. For rehabilitation under the German pension insurance scheme, there are two main aspects: the integration of rehabilitation into the curative guidelines in terms of "local tailoring" on the one hand and the development of guidelines for rehabilitative processes, demand-oriented control of rehabilitation access, and rehabilitative aftercare on the other hand. The elaboration of effective standards is aimed at avoiding over-provision, under-provision or misdirected provision of care and, simultaneously, at ensuring that quality assured treatment is offered to the rehabilitees. ⋯ There are many initiatives by the providers of rehabilitation as well as the scientific medical societies to develop and implement rehabilitative clinical practice guidelines, e. g. the guidelines programme of the BfA (Federal Insurance Institute for Salaried Employees), which is aimed at developing rehabilitation process guidelines for selected indications, the guidelines activities of the VDR (Federation of German Pension Insurance Institutes), and the input of the "Guidelines" commission of the DGRW (German Society of Rehabilitation Science). It is hoped that in the years to come the parties involved in German health care provision will be open to the advantages of clinical practice guidelines. Rehabilitation under the German pension insurance scheme, with respect to its experience with quality assurance, its responsibilities for structure and concept and a growing acceptance on the part of care providers, already holds a well-founded starting position.