Background Physiotherapy in acute hospitals is highly relevant both for the recovery process of patients and for reducing hospital stay times. Nevertheless, this relevance is not adequately reflected in the current system of Diagnosis Related Groups (DRG). In university hospitals, the question of an appropriate job ratio for physiotherapeutic staff always arises in controlling discussions. An objective analysis of this question should offer a benchmark that is differentiated in terms of content and that takes case severity, patient numbers and specialist departments into account in the evaluation. Unfortunately, this data is very difficult to access, so although there have been initial attempts through the Association of University Hospitals in Germany (VUD), no results have been declared so far. Material and methods The hospitals' publicly accessible quality reports contain, among other things, information on inpatient physiotherapy staff and the number of beds. In order to be able to compare the physiotherapeutic capacity within the various university hospitals, the average number of full-time employees (FT) in 2022 was standardized to 100 beds using the corresponding number of beds. The average personnel capacity is presented purely descriptively by specifying the mean, median and standard deviation. Results On average, the 35 university hospitals analyzed have 3.10 FT per 100 beds for physiotherapeutic use. The median is 3.03 FT and the standard deviation is 0.98. Conclusion The benchmark carried out here based on the publicly available quality reports can provide an initial objective orientation about the different physiotherapeutic personnel capacities. In the future, a more detailed benchmark that also takes case mix points, specialist areas and case numbers into account inthe evaluation could significantly improve the quality of the results of the survey data.

ABSTRACT:To individually prescribe rehabilitation contents, it is of importance to know and quantify factors for rehabilitation success and the risk for a future healthcare use. The objective of our multivariable prediction model was to determine factors of rehabilitation success and the risk for a future healthcare use in patients with high-grade, chronic low back pain. We included members of the German pension fund who participated from 2012 to 2019 in multimodal medical rehabilitation with physical and psychological treatment strategies because of low back pain (ICD10:M54.5). Candidate prognostic factors for rehabilitation success and for a future healthcare use were identified using Gradient Boosting Machines and Random Forest algorithms in the R-package caret on a 70% training and a 30% test set. We analysed data from 154,167 patients; 8015 with a second medical rehabilitation measure and 5161 who retired because of low back pain within the study period. The root-mean-square errors ranged between 494 (recurrent rehabilitation) and 523 (retirement) days ( R2 = 0.183-0.229), whereas the prediction accuracy ranged between 81.9% for the prediction of the rehabilitation outcome, and 94.8% for the future healthcare use prediction model. Many modifiable prognostic factors (such as duration of the rehabilitation [inverted u-shaped], type of the rehabilitation, and aftercare measure), nonmodifiable prognostic factors (such as sex and age), and disease-specific factors (such as sick leave days before the rehabilitation [linear positive] together with the pain grades) for rehabilitation success were identified. Inpatient medical rehabilitation programmes (3 weeks) may be more effective in preventing a second rehabilitation measure and/or early retirement because of low back pain compared with outpatient rehabilitation programs. Subsequent implementation of additional exercise programmes, cognitive behavioural aftercare treatment, and following scheduled aftercare are likely to be beneficial.

Objectives To examine the effects of acupuncture and therapeutic exercise alone and in combination on temporomandibular joint symptoms in tension-type headache and to evaluate the potential interaction of existing temporomandibular dysfunction on the success of headache treatment. Design Pre-planned secondary analysis of a randomized controlled, non-blinded trial. Setting Outpatient clinic of a German university hospital. Subjects Ninety-six Participants with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups. Interventions Six weeks of acupuncture or therapeutic exercise either as monotherapies or in combination, or usual care. Follow-up at 3 and 6 months. Main measures Subjective temporomandibular dysfunction symptoms were measured using the Functional Questionnaire Masticatory Organ, and the influence of this sum score and objective initial dental examination on the efficacy of headache treatment interventions was analyzed. Results Temporomandibular dysfunction score improved in all intervention groups at 3-month follow-up (usual care: 0.05 [SD 1.435]; acupuncture: −5 [SD 1.436]; therapeutic exercise: −4 [SD 1.798]; combination: −3 [SD 1.504]; P = 0.03). After 6 months, only acupuncture (−6 [SD 1.736]) showed a significant improvement compared to the usual care group ( P < 0.01). Subjective temporomandibular dysfunction symptoms had no overall influence on headache treatment. Conclusions Only acupuncture had long-lasting positive effects on the symptoms of temporomandibular dysfunction. Significant dental findings seem to inhibit the efficacy of acupuncture for tension-type headache.

Premium subsidies can be used to address low demand for natural hazard insurance when it is partly caused by governmental disaster relief payments. We analyze how the introduction of ex ante premium subsidies affects the frost insurance demand of German winegrowers after the government changed insurance regimes to avoid ex post disaster relief payments. We find that the implementation of a premium subsidy in an immature market with low levels of participation, presumably caused by strong anticipation of disaster relief, is effective in increasing overall frost insurance demand. Receiving disaster relief payments 3 years before the introduction of the subsidy seems to make farmers more responsive toward the premium subsidy.

Im internationalen Kontext wird unter Rehabilitation eine Gesundheitsstrategie verstanden 1 , die durch verschiedene Massnahmen auf verbesserte Funktionsfahigkeit zielt, um Teilhabeeinschrankungen zu reduzieren, die Menschen mit gesundheitlichen Beeintrachtigungen in der gesellschaftlichen Interaktion erfahren 2 . Die aktuelle Resolution der Weltgesundheitsversammlung ,,Strengthening rehabilitation in health systems" 3 fordert in ubereinstimmung mit der UN-Behindertenkonvention 4 , dass fur die medizinischen Belange von Menschen mit Beeintrachtigungen adaquate Rehabilitationsdienste und Rehabilitationsprogramme zur Verfugung stehen mussen. Dies entspricht dem Prinzip einer bedarfsorientierten Leistungserbringung ohne Limitierung durch den Grad der Beeintrachtigung einer Person. Daruber hinaus sollen in allen Phasen der Gesundheitsversorgung diese Rehabilitationsdienste verfugbar sein, also vom Akutkrankenhaus bis zur Langzeitversorgung.

Objectives To compare the effects of acupuncture and medical training therapy in combination or individually with usual care on quality of life, depression, and anxiety in patients with tension-type headache. Methods In this single-center, prospective, randomized, controlled, unblinded trial, 96 adults (38.7(+/−13.3) years of age; 75 females/20 males/one dropout) with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups (n = 24). The treatment groups received six weeks of either acupuncture or medical training therapy as monotherapies or in combination (12 interventions each), or usual care. We assessed depressiveness (PHQ-9), anxiety (GAD-7), and health-related quality of life (SF-12) as secondary outcome parameters at baseline, six weeks, three months, and six months after initiation of treatment. Linear mixed models were calculated. Results Both, acupuncture (baseline to six-weeks change scores: mean: −2(standard deviation: 2.5 points), three months: −2.4(2.4), six-months −2.7(3.6)) and the combination of acupuncture and medical training therapy (−2.7(4.9), −2.2(4.0), −2.2(4.2)) (each within-group p < .05) significantly reduced depressiveness-scores (PHQ-9) to a greater extent than medical training therapy (−0.3(2.0), −0.5(1.6), −0.9(2.6)) or usual care alone (−0.8(2.9), 0.1(2.8), 0.2(3.6)). We found similar results with anxiety scores and the physical sum scores of the SF-12. No severe adverse events occurred. Conclusions Acupuncture and the combination of acupuncture and medical training therapy elicit positive effects on depression, anxiety, quality of life, and symptom intensity in patients with episodic and chronic tension-type headache. Acupuncture appears to play a central role in mediating the therapeutic effects, underscoring the clinical relevance of this treatment. An additive benefit of the combination of both therapies does not appear to be relevant. Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

Major amputation of the lower limb is a stressful and mementous procedure with high challenges for personal, social and occupational reintegration. The complex management of the rehabilitation process of patients after lower limb amputation (LLA) needs extensive knowledge in terms of medical issues, therapeutical strategies and social law. Even more, since sectoral structures clearly differ depending on the region and its population density. An innovative project, funded by the German Federal Joint Committee within a program to support innovations in medical supply (Innovationsfonds-Projekt) is evaluating and implementing a new model in the rehabilitation of patients with LLA. The key is to implement a medical care-manager who is helping the patients to get along with the new situation after LLA by offering different options and managing medical issues. Furthermore, the main goal of the project is to implement an outpatient interim rehabilitation in a university hospital for physical and rehabilitation medicine (PRM) directly after amputation and discharge from the surgical ward. The aim of this paper is to present the experiences, the obstacles as well as the challenges and possibilities of this new approach to postoperative rehabilitation after LLA. Furthermore, first results will be demonstrated.

Background: It has already been shown that it is feasible to use International Classification of Functioning, Disability and Health (ICF) Sets as self-assessment instruments. We used this idea to design an ICF-based screening tool to assess patients of a broadly based rehabilitation department. It was developed for the purpose of having a screening tool before taking the anamnesis, as well as for rehabilitation planning and follow-up. Methods and Materials: The Rehabilitation Goal Screening (ReGoS) instrument is a self-report questionnaire which was developed based on the most relevant domains from the ICF Core Sets for chronic pain and rehabilitation. The ICF categories were translated into plain language and 0–10 Likert scales were used. A retrospective analysis of routine clinical data using the ReGoS tool, Work Ability Index (WAI) and Hospital Anxiety and Depression Scale (HADS) in paper- or tablet-based form was performed. Results: The average age of the N = 1.008 respondents was 53.9 years (SD = 16.2). Of the respondents, 66% (n = 665) were female. At the time of the survey, 48.3% (n = 487) of the patients were employed. ReGoS results demonstrated that the highest restrictions on a scale from 0 to 10 were found in the areas of energy and drive (M = 5.79, SD = 2.575) and activities of daily living (M = 5.54, SD = 2.778). More than a third of the respondents rated their work ability as critical. Conclusion: The use of the ReGoS instrument as an ICF-based screening tool based on a self-report questionnaire provides relevant information for clinical diagnosis, participative goal setting and a detailed functional capacity profile.

Background In a large-scale project supported by the German Pension Insurance, factors influencing access to post-acute-rehabilitation were investigated. In a previous study, diagnosis was shown to be a decisive factor, but different attitudes and expectations with regard to therapeutic intervention were also revealed. The aim of this study is to analyze these expectations for gender-sensitive differences and to evaluate them in the context of the application process. Methods For this exploratory observational cross-sectional study, data collection (2014-2016) occurred in three acute care hospitals. Individuals aged 18-65 years who were treated for rehabilitation-related diagnoses were included. Questionnaire-based sociodemographic data as well as rehabilitation goals, wishes, and function-related information were collected. For this purpose, partly standardized survey instruments were used. The evaluation was carried out both descriptively and by means of univariate and multivariate binary logistic regression analyses. Results There are gender-sensitive attitudes and expectations towards post-acute-rehabilitation. While women were significantly more likely to report psychological distress and its influences on their illness in all corresponding questions, men rated their physical health-related quality of life and independence in daily functions significantly better (p<0.001 and p=0.029, respectively. In the combined analysis, applications from male subjects with older age showed a significantly higher approval rate (p=0.031 and p<0.001, respectively). Regardless of any sub-items, there was no gender-sensitive difference in the approval rate of Rehabilitation. Conclusion Female and male subjects show different attitudes and expectations towards post-acute-rehabilitation. A purely biological distinction in terms of gender ("sex") does not adequately explain these differences. However, the distinction in "gender", which includes cultural conventions, role models, and behaviors, can more accurately explain this through environmental and family-related factors. Incorporating these differences into therapy planning and implementation may contribute to better therapy outcomes and should be the subject of further research. Further development of the application documents is necessary to take a holistic view of patients.

Background: Most rare diseases are chronic conditions with variable impairment of functionality, which can result in a need for rehabilitation. To our knowledge, there are no systematic studies on the rehabilitation needs of patients in centres for rare diseases in the literature. Our hypothesis is that participation of these patients is so limited that there is an increased need for rehabilitation. For this reason, a survey on the need for rehabilitation was carried out in all patients presenting to the centre for rare diseases, in order to assess the need for rehabilitative measures to counteract disturbances in activity and participation. Methods: A cross-sectional study was performed to collect data using a written questionnaire from December 2020 to June 2021, including patients presenting personally in the center for rare diseases. Results: Nearly 70% of the participants assessed their own ability to work as critical. Of those surveyed, n = 30 (44.9%) had PDI total ≥ 33 points and, thus, a clear pain-related impairment. Conclusion: The results show functional restrictions in the areas of mental well-being and activity. As expected, the health-related quality of life is reduced as compared to healthy people. Almost half of the participants reported significant pain-related impairments, however, only 9% of all respondents stated that they had received appropriate pain therapy. The results show the need for rehabilitation-specific skills in the care and counseling of patients with rare diseases.

Zusammenfassung In Deutschland besteht ein deutlicher Mangel an internistischen Rheumatologen. Um diese Versorgungslucke zu reduzieren, konnen verschiedene technische Anwendungen genutzt werden. Dies reicht von der Hilfe bei der Fruherkennung und Diagnostik fur Hausarzte, uber Konsilsysteme mit Telemedizin, bis hin zur Videosprechstunde mit den Patienten nach Koordination in einem entsprechenden Netzwerk, das stufenformig aufgebaut ist, um die vorhandenen Spezialisten moglichst effektiv einzusetzen. Auch Apps fur die Nutzung am Smartphone oder Tablet konnen sowohl Arzte in Diagnostik und Therapie unterstutzen, aber auch vielfaltig Patienten bei den jeweiligen Krankheitsbewaltigungen helfen. Eine Sonderform sind dabei Digitale Gesundheitsanwendungen" (DiGAs), die gepruft wurden und als Medizinprodukte zugelassen und verordnungsfahig sind. Fur die Unterstutzung von Bewegungsubungen, wie sie bei rheumatischen Erkrankungen so wichtig sind, kommen auch Telemedizinische Assistenzsysteme in Betracht, bei denen uber 3D-Kamera und Computeranalyse zu Hause ein individuelles ubungsprogramm angeleitet und kontrolliert wird. Studien zu Anwendungen und Bewertungsoptionen fur Apps liegen bereits einige vor, hier besteht aber noch hoher Nachholbedarf. Abstract Among doctors for internal medicine, there is a clear shortage of rheumatologists in Germany. To reduce this unmet need, various technological applications can be used, ranging from tools for early detection and diagnostic investigation for general practitioners through to telemedical consultation systems or video consultation hours with patients based on prior coordination in an appropriate network that is built up in stages in order to use existing specialists as effectively as possible. Apps for use on smartphones or tablets can support doctors in diagnostic evaluation and treatment, but also help patients cope with illnesses in a variety of ways. A special form of these applications is called "digital health applications" (DiGAs). These have been tested and are approved as medical products and can be prescribed by doctors. Telemedical assistance systems can be considered for the support of movement exercises, which are so important in rheumatic diseases. These systems can be used for an individual exercise program instructed and controlled at home using a 3D camera and computer analysis. A few studies on applications and evaluation options for apps are already available, but high pent-up demand continues to exist.

Zusammenfassung Eine Majoramputation ist für die Betroffenen ein äußerst belastender Eingriff und mit großen Herausforderungen für die gesellschaftliche und berufliche Wiedereingliederung verbunden. Bei der Versorgung von Amputationspatient*innen besteht ein hoher Bedarf an ärztlicher und therapeutischer Behandlung sowie sozialmedizinischer Steuerung. Die sektoralen Versorgungsstrukturen sind regional sehr unterschiedlich aufgestellt und decken häufig den Bedarf nicht adäquat ab. Dem Entlassmanagement kommt hierbei eine Schlüsselposition zu. Ein Innovationsfondsprojekt des Gemeinsamen Bundesausschusses (G-BA) implementiert und evaluiert gegenwärtig modellhaft eine optimierte Versorgung für Menschen nach Majoramputation durch Einführung eines sektorenübergreifenden Caremanagement und der Einführung einer ambulanten Interimsphase in einer Hochschulambulanz für Physikalische und Rehabilitative Medizin (PRM) und Therapie. Der Beitrag berichtet über die Umsetzung, die gemachten Erfahrungen und über erste Ergebnisse.

Objectives The aim of this study was to compare the effects of acupuncture and medical training therapy alone and in combination with those of usual care on the pain sensation of patients with frequent episodic and chronic tension-type headache. Design This was a prospective single-centre randomised controlled trial with four balanced treatment arms. The allocation was carried out by pre-generated randomisation lists in the ratio 1:1:1:1 with different permutation block sizes. Setting The study was undertaken in the outpatient clinic of Rehabilitation Medicine of the Hannover Medical School. Participants and interventions: Ninety-six adult patients with tension-type headache were included and randomised into usual care (n = 24), acupuncture (n = 24), medical training (n = 24), and combination of acupuncture and medical training (n = 24). One patient was excluded from analysis because of withdrawing her/his consent, leaving 95 patients for intention to treat analysis. Each therapy arm consisted of 6 weeks of treatment with 12 interventions. Follow-up was at 3 and 6 months. Main outcome measures Pain intensity (average, maximum and minimum), frequency of headache, responder rate (50% frequency reduction), duration of headache and use of headache medication. Clinical results: The combination of acupuncture and medical training therapy significantly reduced mean pain intensity compared to usual care (mean = −38%, standard deviation = 25%, p = 0.012). Comparable reductions were observed for maximal pain intensity (−25%, standard deviation = 20%, 0.014) and for minimal pain intensity (−35%, standard deviation = 31%, 0.03). In contrast, neither acupuncture nor medical training therapy differed significantly from usual care. No between-group differences were found in headache frequency, mean duration of headache episodes, and pain medication intake. At 3 months, the majority of all patients showed a reduction of at least 50% in headache frequency. At 6 months, significantly higher responder rates were found in all intervention groups compared to usual care. Conclusions In contrast to monotherapy, only the combination of acupuncture and medical training therapy was significantly superior in reduction of pain intensity compared to usual care. Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

Objectives: To set up a comprehensive health programme for employees, with needs-based allocation to preventive and rehabilitative measures; and to evaluate the effects of the programme on work ability and sick leave. Design: Prospective single-group observational study. Methods: Employees of a university hospital were invited to participate in needs-based interventions of preventive or rehabilitative character. Allocation followed screening questionnaires, anamnesis and clinical examination. The selection of a preventive or rehabilitative measure appropriate to the needs of the patient followed screening questionnaires, anamnesis and clinical examination. Preventive offers can include back training courses, water gymnastics or stress management exercises. Rehabilitative measures can include 3-6 weeks in- or outpatient rehabilitation or one week intensive outpatient rehabilitation. The main outcome parameters were work ability and sick leave duration. Results: At this time of the project included 1,547 participants, who applied voluntarily to enter the programme. The mean age of participants was 44.3 years (standard deviation (SD) 10.3 years), and 72.0% were female. Needs-based allocation to a prevention (n=1,218) or a rehabilitation group (n=329) was effective, and enabled formation of 2 groups with different needs. Overall, more than half of the employees participating in the programme reported sick leave within the last 3 months. Participants in the preventive measures group reported significantly lower duration of sick leave than those in the rehabilitation group. Employees in the rehabilitation group had significantly lower work ability (Work Ability Index (WAI) 30.4 vs 36.6), but higher effects at 6-month follow-up (WAI 33.4 (standardized effect size (SES) 0.51) vs 37.9 (SES 0.17)). In the prevention group mean sick leave reduced significantly from 1.9 to 1.3 weeks (p<0.001) during the previous 3-month period, whereas in the rehabilitation group it reduced from 2.7 to 1.5 (p<0.001) weeks. Conclusion: Implementation of the comprehensive health programme was successful, using the multi-modal infrastructure of a university hospital. Allocation to suitable interventions in occupational health programmes following screening, anamnesis and clinical examination is an appropriate way to meet participants' needs. The programme resulted in improved work ability and less sick leave.

We examine the optimal size of risk pools with moral hazard. In risk pools, the effective share of the own loss borne is the sum of the direct share (the retention rate) and the indirect share borne as residual claimant. In a model with identical individuals with mixed risk-averse utility functions, we show that the effective share required to implement a specific effort increases in the pool size. This is a downside of larger pools as it, ceteris paribus, reduces risk sharing. However, we find that the benefit from diversifying the risk in larger pools always outweighs the downside of a higher effective share. We conclude that, absent transaction costs, the optimal pool size converges to infinity. In our basic model, we restrict attention to binary effort levels, but we show that our results extend to a model with continuous effort choice.

Background This study aims to evaluate the feasibility and efficacy of a complex health intervention, based on the combination of conventional Western medicine and traditional Chinese medicine (TCM), in an outpatient department of a university hospital for patients with frequent episodic or chronic tension-type headaches. Methods/design This is a prospective randomized controlled pilot study with four balanced treatment arms (usual care, acupuncture, training, and training plus acupuncture). Each arm will have 24 patients. After the initial screening examination and randomization, a 6-week treatment period follows, with treatment frequencies decreasing at 2-week intervals. After completion of the intervention, two follow-up evaluations will be performed 3 and 6 months after the start of treatment. At predefined times, the various outcomes (pain intensity, health-related quality of life, pain duration, autonomic regulation, and heart rate variability) as well as the participants’ acceptance of the complex treatment will be evaluated with valid assessment instruments (Migraine Disability Assessment, PHQ-D, GAD-7, and SF-12) and a headache diary. The acupuncture treatment will be based on the rules of TCM, comprising a standardized combination of acupuncture points and additional points selected according to individual pain localization. The training therapy comprises a combination of strength training, endurance training, and training to improve flexibility and coordination. Besides descriptive analyses of the samples, their comparability will be assessed using an analysis of variance (ANOVA) or chi-squared tests. Analyses will be performed on an intention-to-treat basis. Potential interaction effects will be calculated using a repeated-measures ANOVA to test the primary and secondary hypotheses. In supplementary analyses, the proportion of treatment responders (those with a 50% reduction in the frequency of pain episodes) will be determined for each treatment arm. Discussion This trial may provide evidence for the additive effects of acupuncture and medical training therapy as a combination treatment and may scientifically support the implementation of this complex health intervention. Trial registration Registered on 11 Feburary 2019. German Clinical Trials Register, DRKS00016723 .

Consumers regularly seek professional advice when purchasing financial products. It is often argued that advisers should solely be compensated by consumers, as then, an adviser has no incentive to give biased advice. In our theoretical model, we show, that a fee-for-advice remuneration system does not prevent consumers from biased advice, if they have an initial biased belief, which product best suits their needs and advisers face transaction costs for persuading consumers.

Using data from an insurance company, we examine the selection behaviour in the German market for private complementary long-term care insurance (CompLTCI). We provide a detailed analysis of the holding, the uptake and the lapse of CompLTCI policies. The analysis identifies the preference for insurance, the occupation as well as the residential location as unused observables. Our findings suggest that the socioeconomic status is a robust factor in explaining the uptake and lapse behaviour in the German market for CompLTCI. More generally, our findings indicate that the mere identification of unused observables is insufficient to derive robust conclusions about the redistribution between different risk types in insurance markets with long-term policies.

In this sham-controlled study, 53 patients received 10 sessions of acupuncture treatment over 5 weeks to investigate the effects of acupuncture on the pain and quality of life of patients with osteoporosis. The results showed significant favorable effects of verum acupuncture on quality of life. Both interventions showed sustained and clinically relevant effects on pain.

This article addresses the role of independent insurance intermediaries in markets where matching is important. We compare fee-based and commission-based compensation systems and show that they are payoff equivalent if the intermediary is completely honest. Allowing for strategic behavior, we discuss the impact of remuneration on the quality of advice. The possibility of mismatching gives the intermediary substantial market power, which will not translate into mismatching if consumers are rational. Furthermore, we offer a rationale for the use of contingent commissions and address whether or not the ban of any commission payments is an appropriate market intervention.