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Final report BERUNA (German)



Prof. Dr. med. Marthin Karoff,
Klinik Königsfeld der DRV Westfalen,
Klinik an der Universität Witten/ Herdecke,
Lehrstuhl für Rehabilitationswissenschaften kommissarische Leitung,
Holthauser Talstraße 2
58256 Ennepetal

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BERUNA – Job-relevant rehabilitation and aftercare

Prof. Dr. med. Marthin Karoff, Klinik Königsfeld der DRV Westfalen;
Klinik an der Universität Witten/ Herdecke, Lehrstuhl für Rehabilitationswissenschaften; kommissarische Leitung; Holthauser Talstraße 2, 58256 Ennepetal;
Prof. Dr. Eike Hoberg, Klinikum Holsteinische Schweiz; eine Klinik der Deutschen Rentenversicherung Nord; Frahmsallee 1-7, 23714 Bad Malente-Gremsmühlen;
Dr. Dipl.-Psych. Jörg Kittel, Institut für Rehabilitationsforschung, Norderney, Abteilung Königsfeld; Holthauser Talstraße 2, 58256 Ennepetal;

Project leaders
Prof. Dr. med. Marthin Karoff, Klinik Königsfeld der DRV Westfalen;
Klinik an der Universität Witten/ Herdecke, Lehrstuhl für Rehabilitationswissenschaften; kommissarische Leitung; Holthauser Talstraße 2, 58256 Ennepetal;
Dr. Dipl.-Psych. Jörg Kittel, Institut für Rehabilitationsforschung, Norderney, Abteilung Königsfeld; Holthauser Talstraße 2, 58256 Ennepetal;
Mag.rer.nat. Daniela Huber, wissenschaftliche Mitarbeiterin; Universität Witten/ Herdecke, Abteilung Königsfeld; Lehrstuhl für Rehabilitationswissenschaften


Running time
01.05.2008 to 31.03.2012


Dipl.-Psych. Nicole von Hoerschelmann, wissenschaftliche Mitarbeiterin; Mühlenbergklinik Holsteinische Schweiz;
Tanja Losch, Dokumentationsassistentin; Universität Witten/ Herdecke, Abteilung Königsfeld; Lehrstuhl für Rehabilitationswissenschaften;


The job-relevant concept was developed for patients with a cardiovascular rehabilitation diagnosis with additional presence of a particular professional problem.

The evaluation of the effectiveness of rehabilitation initially refers, from the perspective of the German Pension Insurance, to professional reintegration, as a prevention or delay of early retirement means cost savings in pension payments due to continuing contribution payments. The early identification of patients who show a risk of early retirement is highly important in rehabilitation. Once a pension claim has been made, the chance of a successful therapeutic intervention lies at approx. one third (Stevens et al., 1995; Bürger et al., 2001). The medical-professionally oriented rehabilitation (MPOR) represents, in conceptual terms, a diagnostic and therapeutic extension of the general medical rehabilitation. It should respond to and take into account professional and workplace-related problems of rehabilitation patients in the treatment in order to better achieve a return to work despite health limitations or impairments (Schliehe, 2010).

Aims and research questions
The aim was to evaluate job-oriented inpatient and post-inpatient measures in cardiac rehabilitation patients with job-related problems. The treatment offer should lead to a greater range of offers and a more strongly individualised reference to the professional lives of the rehabilitees. With respect to self-management and self-responsibility, the active participation of the patient was of central importance. The aim was to clarify whether a combination of intensified job-related rehabilitation and individualised job-related aftercare offers can improve the participation in working life one year after the rehabilitation. As a secondary target criterion, it should be examined whether the assessed bio-psycho-social factors can be predictors of a successful professional reintegration.

The BERUNA concept
During the inpatient stay, a focus was placed on the motivation to return to work in psychotherapeutic individual interventions and in consultations regarding participation in working life. The instrument of “Evaluation of Functional Performance Capability” (EFPC) according to Isernhagen served to measure the experience of the patients’ own performance capability and the limitations thereof. In concluding dialogues with their physician, the rehabilitees had the opportunity to be actively involved in planning further measures. As the transfer of the learned knowledge to the rehabilitees’ everyday lives is often difficult, where necessary, a further specially assigned therapist (social worker, psychologist, EFPC therapist) took part in the dialogue. For purposes of social-medical evaluation, weekly interdisciplinary team conferences took place with physicians, psychologists, social workers and physiotherapists. These conferences should also serve purposes of planning and coordination of job-related offers.

Selection of study participants
Patients could be considered as study participants if they showed an increased need for job-related treatment offers during the rehabilitation stay. This need was defined by the presence of a professional problem with the “Screening Instrument for Measuring the Need for job-related treatment offers in medical rehabilitation” (SIBAR; Bürger et al., 2007) at the beginning of rehabilitation.
Further criteria for participation in the study were a cardiovascular rehabilitation diagnosis, an insurance contract with the pension insurer DRV Westfalen or DRV North, age younger than 58 years and a distance between the clinic and the patients’ home of less than 70km.

Patients who provided written consent to participate following the presentation of the study and a detailed description were allocated to the two study branches intervention group (IG) or control group (CG) based on a specified randomisation plan.

Target criteria
As a primary target criterion, the professional participation of the rehabilitees twelve months after the end of the rehabilitation was examined. The professional reintegration was defined as successful if patients were classed as employed at the cited data collection time point. The drawing of pension, unemployment and the drawing of sickness benefits were counted as negative events.
With regard to secondary predictors, it was necessary to examine which variables determine a successful professional reintegration. To this aim, the somatic, emotional and social status of the rehabilitees were measured in order to be able firstly to evaluate changes in the quality of life and secondly to extract predictors for a successful professional reintegration.

Measurement time points
Data collection took place at four measurement time points: t1= at the beginning of the rehabilitation, t2= at the end of the rehabilitation/beginning of aftercare, t3= six months after the end of the rehabilitation/end of the aftercare and t4=twelve months after the end of the rehabilitation.

Measurement instruments
The job-related measurement instruments were the questionnaire “Effort-reward imbalance at work" (ERI; Siegrist, 1996) with the corresponding “bullying scale”, the “Job Description Scale” (JDS; Neuberger & Allerbeck, 1978), the “Scale for Measuring Subjective Prognosis of Employment (SPE, Theissing et al., 2005) and the self-rating of one’s own capability to work by means of the “Work-Ability-Index" (WAI; Tuomi et al., 2001). Factors of quality of life were measured through the Short Form Health Survey" (SF-12; Bullinger, 1995). The “Visual Analog Scale” (VAS; EuroQol Group, 1987) describes the general state of health. For the self-assessment of anxiety and depression in adults with physical complaints or diseases, the “Hospital Anxiety and Depression Scale- German version" (HADS-D; Herrmann et al., 1995) was applied.
The bio-psycho-social data of the rehabilitees such as age, sex, diagnoses, results on ergometry, work incapacity times (WI times) as well as employment status at the beginning of rehabilitation were gathered from the electronic patient files (EPF) of the clinic.

Study design
The comparison of the forms of rehabilitation offers was based on a two-factor orthogonal quasi-experimental design (2x4 design). The factor level “group” consists of the IG and the CG, and the factor level “time” consists of four stages (t1, t2, t3, t4).

Good response rates were achieved, with 95% to the survey at the end of rehabilitation, 77% to the survey six months after the end of rehabilitation and 73% twelve months after the end of rehabilitation. Besides the desire to make a pension claim due to reduction in earning capacity (50%), the study participants were characterised at the beginning of rehabilitation by high values of anxiety [MV 9.33 (sd 4.60)] and depression [MV9.23 (sd 4.49)], accompanied by low emotional well-being [MV 40,94 (sd 11,26)], strongly limited functional ability [MV 36.04 (sd 7.91)] and low capacity to work [MV 26,16 (sd 6.65)]. Nevertheless, one year after the end of the rehabilitation, an astonishingly high rate of professional reintegration was apparent, with 72% in the IG and 75% in the CG (p<.929). The majority of patients who were unemployed at the beginning of rehabilitation remained unemployed (IG: 69%, CG: 65%; p<.757). The rate of participation in the post-inpatient measure amounted to 42%. Compared to non-participants, participants showed themselves to be already more frequently convinced at the end of rehabilitation that they would be able to remain in employment until they reached retirement age (Chi2(1)=8.968; p<.01) and saw their employment as less at risk due to their state of health (Chi2(1)=7,380; p<.01).

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