Berufsbezogene Problemlagen und erwünschte Unterstützungsangebote bei chronisch entzündlichen Darmerkrankungen

The body as an obstacle and the "other". How patients with chronic inflammatory bowel diseases view their body, self and the good life

BACKGROUND

Treatment of chronic inflammatory bowel disease (IBD) aims to improve patients' quality of life and the extent of treatment success is measured via patient reported outcomes (PROs). However, questionnaires used to collect PROs often include scales that are not specific to IBDs. Improving these scales requires a deeper understanding of patients' lived experience. With this study we give first insights and develop hypotheses on how patients with IBDs experience their body and self and how they adjust their life plans in the context of precision medicine (PM). The guiding question is to understand what they need to achieve a good life, while facing their disease.

METHODS

We developed a conception of the "good life" that draws on Philippa Foot's "naturalized" approach and distinguishes six different dimensions that are relevant for a good life. This conception guided us as we conducted 10 qualitative interviews with patients suffering from IBD who were in precision medicine clinical research settings. The interviews aimed to gain insights for answering our research question: How do body experiences affect the good life of patients with IBD? We analyzed the interviews with interpretative phenomenological analysis (IPA).

RESULTS

Five group experiential themes emerged: (i) Life options and plans, (ii) other people's responses, (iii) strategies to deal with others' responses, (iv) perception of the body and self, and (v) perception of life as good despite suffering. We report here on three of them (i, iv and v), which are primarily relevant for evaluating the outcomes of PM care. Whereas with "life options and plans (i)," our study predominantly confirmed previous research, with "perception of the body and self (iv)," we found that some of the patients changed their relationship to their body and themselves. They perceived the body or the disease as the "other" and their self appears divorced from their own body. Although this might be an avoidance strategy patients use to assign responsibility for their condition and its "disgusting" symptoms to the "other," it is important to include it in patient reported outcome (PRO) assessments.

CONCLUSIONS

We conclude with the insight that the multi-dimensional approach based on Foot's concept of a good life is well-suited as a basis for investigating the quality of life of people with IBD. Interviews based on this concept produced results that go beyond the understanding of health-related quality of life (HRQoL). Additionally, we offer some considerations about patients' opportunities for achieving a good life and suggestions for further developing patient reported outcome scales.

Berufliche Teilhabe nach einer medizinischen Rehabilitation aufgrund von Erkrankungen des Verdauungssystems. Repräsentative Analysen auf Basis der Routinedaten der Deutschen Rentenversicherung

Ziel Erkrankungen des Verdauungssystems wie Morbus Crohn (MC) oder Colitis Ulcerosa (CU) gehen mit Problemen in der beruflichen Teilhabe einher, machen aber nur einen kleinen Teil aller Rehabilitationsleistungen der Deutschen Rentenversicherung (DRV) aus. Die medizinische Rehabilitation ist eine gute Behandlungsoption, ihre Wirksamkeit hinsichtlich berufsbezogener Zielgrößen ist jedoch unklar. Ebenso liegen bislang keine repräsentativen Befunde zur Rückkehr in Arbeit nach einer gastroenterologischen Rehabilitation sowie zu relevanten Einflussfaktoren vor. Diese Lücke zu schließen ist Ziel der vorliegenden Analyse.

Methodik Verwendet wurde die Reha-Statistik-Datenbasis der DRV. Eingeschlossen wurden Rehabilitand*innen, die in 2017 eine medizinische Rehabilitation aufgrund einer Erkrankung des Verdauungssystems abgeschlossen haben. Die Analysen wurden für die Gesamtgruppe sowie differenziert nach den Diagnosegruppen MC, UC, Divertikelkrankheiten (DI) sowie Erkrankungen des Pankreas (PA) durchgeführt. Berufliche Teilhabe wurde sowohl über eine monatliche Zustandsvariable bis 24 Monate nach der Rehabilitation als auch als Quote aller Personen, die nach 12 respektive 24 Monaten im Erhebungsmonat und den 3 vorhergehenden Monaten sozialversicherungspflichtig beschäftigt waren, operationalisiert. Für die Analyse der Einflussfaktoren auf stabile berufliche Teilhabe wurden multiple logistische Regressionsmodelle mit schrittweisem Einschluss, getrennt für die Quoten nach 12 und 24 Monaten, kalkuliert.

Ergebnisse Insgesamt flossen 8.795 Datensätze in die Analyse ein (darunter MC: n=1.779, 20%; CU: n=1.438, 16%; DI: 1.282, 15%; PA: n=761, 9%). Der Altersdurchschnitt in den Gruppen lag zwischen 44 (MC) und 54 (DI) Jahren, der Anteil der Frauen zwischen 28% (PA) und 57% (MC). Zwischen 16% (DI) und 32% (PA) der Rehabilitand*innen wiesen Fehlzeiten von 6 und mehr Monaten im Jahr vor der Leistung auf. Zwei Jahre nach der Rehabilitation lagen die Rückkehrquoten in Arbeit bei 69% (MC), 71% (CU), 68% (DI) und 58% (PA). Die stärksten Einflussfaktoren auf stabile berufliche Teilhabe waren die Fehlzeiten und das Entgelt vor Rehabilitation sowie die Arbeitsfähigkeit bei Aufnahme.

Schlussfolgerung Zwei Jahre nach der Teilnahme an einer gastroenterologischen Rehabilitation in Deutschland befinden sich 6 bis 7 von 10 Betroffenen in stabiler beruflicher Teilhabe. Relevante Einflussfaktoren auf die Entwicklung sind Arbeitsunfähigkeit und Entgelthöhe im Vorfeld der Rehabilitation. Die Ergebnisse unterstützen eine Erweiterung des Reha-Konzeptes um arbeitsbezogene Aspekte.

[Inflammatory Bowel Disease - Challenges in the Workplace and Support for Coping with Disease]

PURPOSE

Patients with inflammatory bowel diseases (IBD) are often impaired in their ability to be employed due to IBD symptoms. The aim of this study was to explore work-related problems and support requested by IBD patients and develop rehabilitation programs meeting their needs.

METHODS

A total of 235 IBD patients (97 rehabilitants, 138 outpatients) completed a questionnaire assessing disease-specific impairments, work-related concerns and the need for support services. Subjective work disability was determined with the SPE scale.

RESULTS

Participants were on average 46 years old, 60% were women, 45% suffered from Crohn's disease and 67% worked full-time; 72% (n=170) had a negative subjective prognosis of gainful employment. Participants reported an average of 12 disease-specific and 22 work-related problems. About 50% of the participants reported disease-specific problems, namely fatigue (66%), weakness (55%) and urge to pass stool (55%). The three most common work-related problems affecting more than 50% of the respondents almost every day were reduced work ability (56%), worrying about not being fully efficient (55%) and stress at work (53%). Support services requested were counselling for information on the disease (91%), treatment options (88%), social law benefits (85%) and exercises to increase physical fitness (84%).

CONCLUSION

The wide range of work-related physical and psychosocial impairments affecting IBD patients reveals a need to extend current rehabilitation services, with a stronger occupational focus and to implement a standardized screening for work-related problems. Disease-specific support services can be developed and addressed in a multimodal and interdisciplinary setting such as the rehabilitation sector.

[Medical Rehabilitation for Inflammatory Bowel Disease: Access, Process, and Results - Further Analyses of a Randomised Controlled Trial]

BACKGROUND

MERCED is a pragmatic randomised health care trial on the effectiveness and benefit of medical rehab in socially insured employees with chronic inflammatory bowel disease. After on average 8 months post rehab the intervention group showed, compared to continued routine care, a moderate but clinically relevant additional benefit in indicators of social participation, clinical and psychological status. However, no differences were observed for employment status, days off work, and subjective vocational prognosis.

METHODS

We used questionnaire-based reports and ratings of the 211 members of the intervention group on access to medical rehab, its processes and subjective global success as well as a range of health effects calculating pre-post differences.

RESULTS

Contact with three employment/work related services (focused on vocational counselling, legal advice, aftercare) were reported by 33, 48, and 23% resp. of all rehab patients. Patients with pronounced vocational problems had equally frequent contacts as those without. Compared to 12 other services the three received inferior ratings on a scale from 1 (very good) to 5 (very bad): mean 2,5 - 2,3 - 3,0 resp.

CONCLUSION

Medical rehab's relative neglect of vocational elements may partially explain its ineffectiveness in improving participation in work and employment. From MERCED's procedures and results we inferred recommendations to intensify access to medical rehab and its vocational orientation and evaluate its effects.