title: [Criteria for assessing the need for rehabilitation and for sanctioning refund claims -- Würzburg rating scale for sociomedical expertising on the need for rehabilitation and on the justification of refund demands on statutory insurance].
abstract: The essential criteria governing the assessment of the need for rehabilitation must be reviewed before making a sociomedical decision on claims to the German Statutory Pension Insurance (GRV) for refunding expenditure on rehabilitation. For an objective view of such a sociomedical decision, one must specify more clearly the fundamental assessment criteria. The study presented here was based on an exploratory analysis using a specific rating scale (the "Würzburg Checklist") for the various aspects of necessary rehabilitation according to sociomedical assessment of the medical records and medical examination of the patient. The aim of such an analysis is to pinpoint the various necessary decisions one by one before arriving at a final sociomedical expertise enabling the insurance body to decide to meet the cost of rehabilitating a particular patient. Three Bavarian Statutory Sickness Insurance bodies conducted medical random checks by selecting a sample of applicants with musculo-skeletal disease (n = 483) and examining the medical records and the results of a personal examination of the applicant by the medical expert. Completion of the rating scale was done after the experts had made their decision. The rating was subsequently repeated by the clinicians when the patient was admitted to the rehabilitation hospital. Although there were significant differences between these three groups of physicians in the evaluation of the applicants in respect of requirement criteria, it was not possible to identify any particular tendency to a verdict. Assessing the criteria according to the records is limited to some extent. Factor analysis yields five subscales in the rating list with good internal consistency: overall impediment, forecasting the ability to being motivated for rehabilitation, professional efficiency rating, psychosocial stress, risk factors. These subscales, while fairly consistent, are discriminatively valid in respect of rehabilitation recommendations by the sociomedical experts. The results of this survey are a first approach to the development of a practically relevant structural tool for sociomedical assessment.
authors.affiliation: Arbeitsbereich Rehabilitationswissenschaften, Institut für Psychotherapie und Medizinische Psychologie der Universität Würzburg. k.meng@mail.uni-wuerzburg.de
authors.forename: K
authors.initials: K
authors.lastname: Meng
authors.forename: J
authors.initials: J
authors.lastname: Zdrahal-Urbanek
authors.forename: S
authors.initials: S
authors.lastname: Frank
authors.forename: A
authors.initials: A
authors.lastname: Holderied
authors.forename: H
authors.initials: H
authors.lastname: Vogel
mesh_terms: D000328:Adult; D004608:Eligibility Determination; D005104:Expert Testimony; D005260:Female; D005858:Germany; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics* / Q000592:standards*; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D010808:Physical Examination; D012044:Regression Analysis; D012046:Rehabilitation / Q000191:economics* / Q000592:standards