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176 Musculoskeletal & Neurological Rehabilitation KCE reports 57
8.5.4 Example: stroke and neurological rehabilitation
The organisation of neurological rehabilitation has been described in the paragraph
“underlying conceptual ideas”. Additionally it is worth mentioning that early
rehabilitation in neurology (phase B) is mainly carried out in specialised neurological
hospitals and in rehabilitation hospitals and, very rarely, in general hospitals.
8.5.5 Example: LEA and THR
The conceptual reflection in terms of a “phasenmodell” is not used for Rehabilitation
after orthopaedic surgery, implying that individual needs are far less considered. In the
acute phase, patients stay in the acute hospital. The duration of the inpatient stay is
mainly defined by the prospective payment system based on the RDRG’s.
Patients are discharged home or to a rehabilitation hospital for further training. In the
latter situation, the period is defined under ‘Anschlussheilbehandlung (AHB)’ and refers
to the period directly after acute hospitalisation.
An approval by the health insurance companies prior to admission is necessary. The
initial length of stay approved is 3 weeks. A prolongation of inpatient stay can be
requested by the physician and needs to be approved by the health insurance company
before it is granted. Patients discharged home may use rehabilitation services at home
or in a system of outpatient services.
In general, the rate of total hip replacements (THR) in Germany can be considered as
one of the highest in Europe, next to France and Switzerland. In 2003, estimations were
made at 145-183 THPs per 100.000 habitants in Germany compared to 66-90/100.000
and 101-132/100.000 for Italy and the United Kingdom respectively. 182 The average
length of stay in the acute hospital was 14,1 days in 2005. 183 International comparison on
the average LOS after THR revealed that this is longer than hospitals in the UK and US.
A longer pre-operative hospitalization and the admission to the intensive care unit as a
general practice rule were suggested as explanations for these higher LOS in
Germany. 184 After a stay in the acute hospital patients are mainly referred to
Anschlussheilbehandlung (AHB), which is a service of inpatient rehabilitation following
an acute hospital stay. On average, the AHB-LOS is 15,7 days. 183 As mentioned earlier,
the German health care system is characterized by the sectoring system between acute
hospitals and rehabilitation services. Recent health-policy measures were implemented
to facilitate enhanced collaboration between both sectors by introducing integrated
health care plans [Integrierte Versorgung]. The implementation occurs over several
phases and THR is one of the first indications using this type of health care plan.
However, data on the effects of the integrated health care plan for THR on LOS were
not found.
The incidence of lower extremity amputations in Germany is estimated at 230-
660/100.000 habitants for diabetes patients and 2-9/100.000 for non-diabetes
persons. 185, 186 No significant changes were observed in the incidence for the period
between 1990-1998. More recent data were not found. The average total length of stay
in the acute hospital and rehabilitation centre was 9,8 months. 187 In the group of
patients with complications, the average LOS was 19,9 months. No distinction was
being made between the LOS in the acute hospital and the LOS in the rehabilitation
unit. Additionally, it was not clear if only the inpatient rehabilitation was considered or
whether it concerned the total rehabilitation period, inpatient as well as outpatient. As
only one source was found on the care trajectories of patients with amputations of
lower extremity, generalization of the findings is jeopardised.