Ganten J-U, Raspe H H
Institut für Sozialmedizin, Universitätsklinikums Schleswig-Holstein, Lübeck.
Rehabilitation (Stuttg). 2003 Apr;42(2):94-108. doi: 10.1055/s-2003-38812.
Multidisciplinary team care is an opportunity to improve the long-term metabolic situation of patients with diabetes mellitus, hence can help reduce the individual and financial burden of diabetes-related complications. The aim of this study is to evaluate the extent to which patients undergoing rehabilitation carried by the German Federal Insurance Institute for Salaried Employees (BfA) were treated in accordance with recent evidence-based clinical practice guidelines on diabetes mellitus.
We extracted specific treatment recommendations relevant to inpatient rehabilitation from national and international evidence-based guidelines and allocated them to general subjects of diabetes care (e. g. [disease specific] education, physical activity, psychosocial interventions). In the "Classification of Therapeutic Procedures (KTL)", an instrument used to classify therapeutic procedures in rehabilitation, we then identified those procedures that represented the recommendations of the guidelines. The coded procedures were allocated to the general aspects of diabetes care, too. In total, 9 "therapeutic modules" were designed, each containing guideline-recommendations and coded procedures. Using the KTL codes documented as a routine in discharge reports, we were able to describe, analyse and evaluate the procedures performed during rehabilitation. The data set we used contained KTL codes and medical information from 9,456 patients whose rehabilitation was carried by the BfA diagnosed with either diabetes mellitus type 1 or 2, who received an inpatient rehabilitation procedure during the years 2000 and 2001.
The number of patients who received at least one procedure out of the particular therapeutic module is as follows (numbers in brackets represent the total number of KTL codes in that therapeutic module): Therapeutic module "Education (3)" - 98.66 %, "Exercise Training (63)" - 92.42 %, "Nutrition Training (14)" - 96.44 %, "Stress (18)" - 35.33 %, "Motivation (15)" - 82.87 %, "Coping Skills (15)" - 27.42 %, "Social Work (26)" - 11.44 %, "Alcohol and Nicotine (24)" - 3.69 %, "Diabetic Complications (81)" - 75.42 %. On average patients received procedures out of 5.2 different therapeutic modules. The results were consistent over subgroups (type 1/type 2 diabetes, men/women) but varied considerably between clinics. The care provided in clinics with higher numbers of diabetic patients is more in line with guideline specifications.
A substantial number of patients received procedures out of the therapeutic modules "Education", "Exercise Training", "Nutrition Training" and "Motivation". In other therapeutic modules (e. g. "Alcohol and Nicotine") deficits were noted. These deficits as well as the substantial variation between clinics demonstrate the need to develop clinical practice guidelines for rehabilitation of patients with diabetes. In principle, the results of this study have to be interpreted carefully because we did not examine to which extent the documented processes are in accordance with the realities.
Inpatient rehabilitation of diabetic patients carried by the BfA can be characterised as multidisciplinary and in accordance with the recommendations of recent evidence-based guidelines. Certain problematic aspects should be put into focus. A guideline taking into account all rehabilitative aspects, including the preparation for and the care after the rehabilitation process, can be instrumental in reducing deficits in rehabilitative care as well as differences between clinics. To gain wide acceptance, guideline development should be coordinated by a scientific institute and involve members of all groups concerned (e. g. the rehabilitative team, GPs, patients). Within certain limits the "KTL" instrument permits evaluation of process quality in rehabilitation of patients with diabetes mellitus.
多学科团队护理是改善糖尿病患者长期代谢状况的契机，因此有助于减轻糖尿病相关并发症的个人负担和经济负担。本研究的目的是评估德国联邦受薪雇员保险协会（BfA）所开展的康复治疗中，患者接受治疗的情况与近期基于循证的糖尿病临床实践指南的符合程度。
我们从国内和国际循证指南中提取了与住院康复相关的具体治疗建议，并将其归入糖尿病护理的一般主题（如[疾病特定]教育、体育活动、心理社会干预）。在用于对康复治疗程序进行分类的工具“治疗程序分类（KTL）”中，我们确定了那些代表指南建议的程序。编码后的程序也被归入糖尿病护理的一般方面。总共设计了9个“治疗模块”，每个模块都包含指南建议和编码程序。利用出院报告中常规记录的KTL编码，我们能够描述、分析和评估康复期间所执行的程序。我们使用的数据集包含来自9456名患者的KTL编码和医疗信息，这些患者由BfA进行康复治疗，被诊断为1型或2型糖尿病，于2000年和2001年接受了住院康复治疗。
在特定治疗模块中至少接受一项程序的患者数量如下（括号内数字表示该治疗模块中的KTL编码总数）：治疗模块“教育（3）”——98.66%，“运动训练（63）”——92.42%，“营养训练（14）”——96.44%，“压力（18）”——35.33%，“动机（15）”——82.87%，“应对技巧（15）”——27.42%，“社会工作（26）”——11.44%，“酒精与尼古丁（24）”——3.69%，“糖尿病并发症（81）”——75.42%。患者平均接受了5.2个不同治疗模块中的程序。结果在各亚组（1型/2型糖尿病、男性/女性）中保持一致，但各诊所之间差异很大。糖尿病患者数量较多的诊所所提供的护理更符合指南规范。
大量患者接受了“教育”、“运动训练”、“营养训练”和“动机”治疗模块中的程序。在其他治疗模块（如“酒精与尼古丁”）中则存在不足。这些不足以及诊所之间的巨大差异表明，有必要制定糖尿病患者康复的临床实践指南。原则上，本研究结果必须谨慎解读，因为我们并未考察所记录的过程与实际情况的符合程度。
BfA所开展的糖尿病患者住院康复治疗可被视为多学科的，且符合近期循证指南的建议。某些存在问题的方面应予以关注。一份考虑到所有康复方面，包括康复过程的准备和康复后的护理的指南，有助于减少康复护理中的不足以及诊所之间的差异。为了获得广泛认可，指南制定应由一个科学机构进行协调，并让所有相关群体的成员（如康复团队、全科医生、患者）参与。在一定范围内，“KTL”工具可用于评估糖尿病患者康复过程的质量。
