S1 Guideline: Dermatological inpatient rehabilitation in adult atopic dermatitis

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<ul><li><p>558 Guidelines DOI: 10.1111/j.1610-0387.2011.07686.x</p><p>JDDG | 72011 (Band 9) Deutsche Dermatologische Gesellschaft u. a. Journal compilation Blackwell Verlag GmbH, Berlin JDDG 1610-0379/2011/0907</p><p>PreambleGuidelines are systematically developeddescriptions and recommendations thatare designed to assist doctors and pati-ents in making decisions concerning ap-propriate healthcare measures (preven-tion, diagnosis, therapy, and follow-up)under specific medical conditions. Gui-delines represent the current state ofknowledge (controlled clinical studies,expert knowledge) and thus are subjectto ongoing revisions, and if necessary,updates. Guidelines are not intended torestrict physicians from choosing themethods they consider most appropriate,nor does following a guideline necessa-rily guarantee diagnostic or treatmentsuccess. The field of medicine is in con-stant flux, and thus guidelines are not in-tended to be exhaustive. The choice ofappropriate treatment is decided by thedoctor and patient.</p><p>IntroductionRehabilitation has a long tradition inGermany. Over the years, the area of re-habilitation has undergone continual ad-vancements and has also become morespecialized. The last major advancementcame with the German Social SecurityCode (SGB) IX. According to 1 SGBIX, people who have a disability, or whoare threatened with impending disability,are entitle to receive assistance to helpthem live autonomously and to ensuretheir equal participation in society, and</p><p>to avoid or fight discrimination. Corre-sponding to the specifications on qualitymanagement in the SGB V, the new German Social Security Code IX requires rehabilitation facilities to makerecommendations together with centralassociations of care providers for ensuringand developing the quality of services offered ( 20, section 1 SGB IX). Guide-lines are one part of quality management(Beckmann et al. 2005, Wehrmann2005).</p><p>Comment: Despite wide variation inevidence levels in the literature, thisguideline on inpatient rehabilitationfor adult patients with atopic derma-titis was developed to address this in-creasingly relevant (epidemiologicallyand economically) disease and its tre-atment. The variation in the literatureis due to the complexity of the diseaseitself as well as rehabilitation measu-res. The identification of individualparameters (as in an experiment) is all but impossible (Mller-Fahrnow,2000).In 2006 the Guidelines on Rehabilita-tion in Pediatric and Adolescent Medicine were published along withGeneral Preliminary Remarks on Rehabilitation in Pediatric and Adoles-cent Medicine and the Guidelines(AWMF registry).</p><p>The basis for the formulation is a litera-ture search of the databases Medline andDIMDI.</p><p>The guideline was created between Apriland December 2000 by the authors Buh-les, Wehrmann, and Amon (2005) overthe course of one meeting and several telephone conferences. It was then forwar-ded to experts in the field and relevantself-help groups. The last revision was inthe fall of 2009. There was no financialsupport for the creation of the guideline.The guideline is valid for three years.</p><p>Target groupAdult patients with atopic dermatitis(Novak and Bieber 2005, Wthrich et al.2005), whose ability to work or whoseeveryday life is threatened or impairedand who, due to the complexity of thedisease, require multi-dimensional, reha-bilitative treatment. </p><p>Comment: Atopic dermatitis is a here-ditary (polygenetic), chronic, recurrentnon-infectious disease of multi-factorial etiology that involves immun-ological changes (e.g., total IgE is oftenelevated and there is detection of speci-fic IgE). The typical clinical appearanceconsists of severe pruritus with far-reaching consequences for the patientslife.</p><p>ObjectiveThis guideline is intended to help dermatologists, family physicians, andevaluators and insurers in regard to patients with atopic dermatitis who re-quire inpatient medical rehabilitation as</p><p>Guideline</p><p>S1 Guideline: Dermatological inpatient rehabilitationin adult atopic dermatitis*Norbert Buhles, Jochen Wehrmann, Klaus-Dieter Hinsch, Wolf Nrnberg</p><p>*Synonyms for atopic dermatitis include atopic eczema, neurodermatitis, endogenous eczema, etc.</p></li><li><p>Guidelines 559</p><p> Deutsche Dermatologische Gesellschaft u. a. Journal compilation Blackwell Verlag GmbH, Berlin JDDG 1610-0379/2011/0907 JDDG | 72011 (Band 9)</p><p>opposed to those who receive outpatientservices or acute inpatient care. It shouldalso help achieve targeted, optimized,multimodal therapy (Nrnberg 2005) inview of the rehabilitation goal of the pa-tient and his or her functional limitati-ons (ICF; Niederauer et al. 2005). </p><p>Need for rehabilitation From the point of view of disability insu-rance, rehabilitation is considered neces-sary when a persons ability to work isthreatened (e.g., long periods of unemployment, uncertain continuedemployment at his or her current job;see: atopy and occupational eczema;Diepgen 1998). Accident insurance alsocovers rehabilitation measures for occu-pationally-related skin diseases (Diepgenet al. 2005). Statutory health insurersconsider rehabilitation to be necessarywhen everyday activities are restricted (or there is impending restriction) for alonger period of time, especially whenthere is a need for nursing care, and if amulti-dimensional, interdisciplinary tre-atment approach is needed in addition tocurative measures (Rehabilitationsricht-linien [rehabilitation guidelines] 2004). </p><p>Comment 1: The German Pension Administration (Deutsche Rentenversi-cherung Bund [DRV]) has publishedthe Guidelines on Necessary Rehabili-tation in Skin Diseases (2005) inwhich the need for rehabilitation in patients with atopic dermatitis is eluci-dated: Depending on individual factors as well as occupational and social conditions in chronic recurrent forms with shor-</p><p>ter symptom-free intervals if a larger and/or visible body surface</p><p>area is involved if a therapeutic effect or optimization</p><p>of treatment with the goal of the mostcomplete healing possible is onlyachievable with the methods of reha-bilitation </p><p> if other atopic diseases are present(even if there is less skin involve-ment)</p><p> with certain risk factors (need foreducation, psychosocial stress). Thedegree of psychological effect largelydetermines the choice of rehabilita-tion center with a psychosoma-tic/dermatological treatment focus</p><p> for certain occupations, medical re-habilitation cannot always eliminatethe considerable hazard or limitati-</p><p>ons presented by that occupation. Itmust be reviewed whether supportfor participation in employment isindicated. Corresponding functionalcapacity evaluation (FCE) modelsshould be used. (Buhles 2003, Erb-ster 2003).</p><p>Comment 2: On 1 April 2004 the Ger-man Rehabilitation Council (Bundes-arbeitsgemeinschaft fr Rehabilitation[BAR]) put forth the Recommendati-ons for outpatient dermatological rehabilitation which take into accountthe requirements of the SGB IX and theInternational Classification of Functio-ning, Disability, and Health (ICF). Similar to inpatient rehabilitation, outpatient measures also represent a holistic concept of rehabilitation inclu-ding a social medicine assessment. Out-patient rehabilitation also includes acomprehensive, rehabilitation-specific,and interdisciplinary treatment spec-trum, which is tailored to the indivi-dual patient situation and may consistof physical, psychological, nutritional,social, and educational components(BAR 2004). Outpatient rehabilita-tion may not be appropriate in the following situations: if curative therapy ... is adequate the type or extent of disability or </p><p>limitation is beyond the scope of outpatient rehabilitation</p><p> lacking mobility severe multimorbidity inadequate psychological stability the need for nursing care and conti-</p><p>nued medical supervision the need to be removed temporarily</p><p>from his or her social surroundings Comment 3: With the aim of targeted,effective, and efficient rehabilitation,in March 2004 a new rehabilitationguideline was created for German sta-tutory health insurers (rehabilitationguideline 2004). The implementationof the guideline varies considerably byregion (Nrnberg and Wehrmann2009).</p><p>When choosing an appropriate rehabili-tation site, desired factors such as low number of allergens, increased UVradiation exposure, or diminished envi-ronmental hazards may be taken into account (climate therapy).</p><p>Suitability for rehabilitation The necessary insurance requirementsmust be fulfilled, the patient must be</p><p>physically and psychologically able toparticipate in rehabilitation measures,and he or she must be sufficiently moti-vated or able to be motivated. </p><p>Rehabilitation prognosisThe prerequisite for approval to partici-pate in a medical rehabilitation programis a positive prognosis for the success ofrehabilitation. The prognosis for successof rehabilitation is a medically-foundedprediction of the likelihood of success ofrehabilitative measures based on the disease, the prior course of the disease,and the potential for compensationthrough the furthering of individual positive context factors by means of appropriate measures taken over a reasonable amount of time (Rehabilitati-onsrichtlinien [rehabilitation guidelines]2004). Disability insurance requires a positive prognosis for restoring or atleast stabilizing the patients ability to work, or for those applying for disabi-lity payments, a statement on their ability to work. </p><p>DiagnosisEven before rehabilitation begins, amulti-dimensional diagnosis should bemade for a targeted referral of the pati-ent. This requirement has already beenaddressed by the previously mentionedrehabilitation guideline and is found in a4-page application form with variousquestions on disease history and diagno-sis, co-morbidity, functional limitations(everyday activities, work, autonomy),context factors (social environment, useof social services), statements on the pa-tients ability to participate in rehabilita-tion measures, the prognosis for success,and the clearly stated requirements of re-habilitation (Bekanntmachung 2004).Examples of screening measures for psy-chosocial factors include the FLQA(Freiburg Life Quality Assessment) andthe MHF (Marburg Skin Survey [Mar-burger Haut Fragebogen]) (Augustin et al. 2000).The diagnosis in the rehabilitation clinicalso includes a specific diagnosis of thepatients ability to function in his or heroccupation if there are questions on thepatients employment situation and ability to work (ICF InternationalClassification of Functioning, Disability,and Health).The first Functional Capacity Evaluation(FCE) model in the field of dermatology/</p></li><li><p>560 Guidelines</p><p>JDDG | 72011 (Band 9) Deutsche Dermatologische Gesellschaft u. a. Journal compilation Blackwell Verlag GmbH, Berlin JDDG 1610-0379/2011/0907</p><p>allergology was developed by Buhles(2003) in the form of the occupation-tested skin protection plan. As a prac-tical occupational ability measure for(atopic) hand eczema, the functional diagnosis also focuses on participation inemployment (Erbster 2003).</p><p>Therapy goalsTreatment goals are formulated based onthe diagnosis, taking into account thepatients ability (expectation and motiva-tion), the tasks of social medicine, andthe duration of treatment. The reader isreferred to treatment goals for dermato-logy in Vol. 18 of the DRV papers fromJanuary 2000, and for psychology thePsy-BaDo Manual (Heuft, Senf 1998).The use of the ICF (Niederauer et al.2005) is increasingly necessary.</p><p>Therapy elementsThe treatment of atopic dermatitis requi-res an individual combination of therapyelements that are stage-appropriate andsuited to the patients needs1, 2 (Nrnberg2005) external therapy systemic therapy phototherapy hydrotherapy/balneotherapy climate therapy diet relaxation techniques information/education sports therapy psychotherapyA complete list is found in the guidelineNeurodermatitis, AWMF registry 013/027(Werfel et al. 2008).</p><p>EvaluationThe SCORAD score and co-morbidityshould be evaluated at specific intervals(admission, discharge, 6 months after di-scharge) and the duration of the patientsstay. If therapy goals are included in theevaluation, the patients self-assessmentand the observer assessment should bedifferentiated. Methodological problemswith operationalization should also betaken into account. </p><p>If a new fee system is adopted for inpatient rehabilitation services, it is</p><p>possible that not only co-morbidity butalso complications related to the disease (Vieluf and Ring 1991) willhave to be taken into account (Buhles et al. 2000).</p><p>To evaluate psychosocial parameters, aquality of life survey (e.g., FLQA) or adisease-specific survey (e.g., MHF) maybe used (Augustin et al. 2000). </p><p>Economic parametersCurrent results of outcomes research demonstrates the clinical, patient, andeconomic benefits of treatment.</p><p>Economic costs may be divided into direct and indirect costs. Indirect costsin particular due to lost working days(unemployment insurance, compensa-tion, loss of productivity), re-trainingmeasures, or disability/early retirementquickly lead to four-figure amounts per case per year (Gieler et al. 1999,Rychlik and Kilburg 2000, Ehlken et al. 2005). Given that the incidenceof atopic dermatitis continues to rise,clearly these costs should be reduced if possible.</p><p>ImplementationIn a guideline clearing procedure, theguidelines were given a level 1 rating andsubsequently published in book form(Korting et al. 2007) and in a journal ofdermatology (2008). This occurred inagreement with the Germany Society ofDermatology (DDG) and the workinggroup on rehabilitation in dermatology(AReD). In addition, insurers have beeninformed since, in the context of theirown quality management and legal requirements, they must pay special attention to guidelines (Beckmann et al.2005). Relevant self-help dermatologygroups were also included. </p><p>The new guidelines on medical rehabi-litation (Rehabilitation Guidelines[Rehabilitationsrichtlinien] 2004) require increased social medicine com-petence on the part of the prescribingphysician. This means there is a betterchance of implementation of the guide-lines since adhering to them facilitatescomplying with the requirements (Bekanntmachung 2004).</p><p>Consensus-building procedureAuthors: Norbert Buhles, Askepios-Nordseeklinik, Westerland/ Sylt; JochenWehrmann, Rothaarklinik, Bad Berle-burg; Klaus-Dieter Hinsch, DRV-KlinkBorkum-Riff, Borkum; Wolfgang Nrn-berg, Osteeklinik Khlungsborn for theAReD (working group on rehabilitationin dermatology) for the sub-commissionon rehabilitation of the Quality Com-mission of the German Society of Der-matology (DDG) and the German Der-matologists Association (BVDD).Created on: 08/2001Last update: 11/2009Next update: 10/2012</p><p>Correspondence toDr. med. Norbert BuhlesDermatologische AbteilungAsklepios NordseeklinikNorderstr. 81D-25980 WesterlandTel.: 04651-841500Fax: 04651-841509E-mail: n.buhles@asklepios.com</p><p>ReferencesAugustin M, Amon U, Bullinger M, GielerU. Empfehlungen zur Erfassung vonLebensqualitt in der Dermatologie. Der-matol Psychosom 2000; 1:...</p></li></ul>

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