Utilization and effectiveness of medical rehabilitation in foreign nationals residing in Germany.

Abstract

In Germany, the proportion of foreign national residents receiving an invalidity pension is higher than that of Germans. Lower utilization and effectiveness of medical rehabilitation are presumed to be the main reasons. We aimed to examine whether differences in utilization and effectiveness of medical rehabilitation between Germans and foreign nationals are attributable to differences in socio-demography, socio-economic background and health status. Utilization of rehabilitation was analyzed for household members aged 18 years or above enrolled in the German Socio-Economic Panel in 2002-2004 (n = 19,521). Effectiveness of rehabilitation was defined by the occupational performance at the end of rehabilitation. It was examined by using an 80% random sample of all completed medical rehabilitations in the year 2006 funded by the German Statutory Pension Insurance Scheme (n = 634,529). Our study shows that foreign nationals utilize medical rehabilitation less often than Germans (OR = 0.68; 95%-CI = 0.50; 0.91). For those who do, medical rehabilitation is less effective (OR for low occupational performance = 1.50; 95%-CI = 1.46; 1.55). Both findings are only partially attributable to socio-demographic, socio-economic and health characteristics: After adjusting for these factors, ORs for utilization and low occupational performance were 0.66 (95%-CI = 0.49; 0.90) and 1.20 (95%-CI = 1.16; 1.24), respectively. It can be concluded that differences in the utilization and effectiveness of medical rehabilitation between Germans and foreign nationals cannot be explained only by socio-economic differences or poorer health before rehabilitation. In addition, factors such as the ability of the rehabilitative care system to accommodate clients with differing expectations, and migrant-specific characteristics such as cultural differences, seem to play a role.

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Utilization and effectiveness of medical rehabilitation in foreign
nationals residing in Germany

Patrick Brzoska1, Sven Voigtländer1, Jacob Spallek1,2,3, Oliver Razum1

1 University of Bielefeld, School of Public Health, Department of Epidemiology & International Public
Health
2Johannes Gutenberg-University Mainz, University Medical Center, Institute of Medical Biostatistics,
Epidemiology and Informatics (IMBEI)
3Bremen Institute for Prevention Research and Social Medicine (BIPS), Department of Prevention and
Evaluation



Corresponding author
Patrick Brzoska
Dept. Epidemiology & International Public Health
School of Public Health, University of Bielefeld
P.O. Box 10 01 31
33501 Bielefeld, Germany
Tel. + 49 521 106-3836
Fax + 49 521 106-6465
E-mail: patrick.brzoska@uni-bielefeld.de

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Abstract
In Germany, the proportion of foreign national residents receiving an invalidity
pension is higher than that of Germans. Lower utilization and effectiveness of medical
rehabilitation are presumed to be the main reasons. We aimed to examine whether
differences in utilization and effectiveness of medical rehabilitation between Germans
and foreign nationals are attributable to differences in socio-demography, socio-
economic background and health status. Utilization of rehabilitation was analyzed for
household members aged 18 years or above enrolled in the German Socio-Economic
Panel in 2002-2004 (n=19,521). Effectiveness of rehabilitation was defined by the
occupational performance at the end of rehabilitation. It was examined by using an
80% random sample of all completed medical rehabilitations in the year 2006 funded
by the German Statutory Pension Insurance Scheme (n=634,529). Our study shows
that foreign nationals utilize medical rehabilitation less often than Germans
(OR=0.68; 95%-CI=0.50;0.91). For those who do, medical rehabilitation is less
effective (OR for low occupational performance=1.50; 95%-CI=1.46;1.55). Both
findings are only partially attributable to socio-demographic, socio-economic and
health characteristics: After adjusting for these factors, ORs for utilization and low
occupational performance were 0.66 (95%-CI=0.49;0.90) and 1.20 (95%-
CI=1.16;1.24), respectively. It can be concluded that differences in the utilization and
effectiveness of medical rehabilitation between Germans and foreign nationals cannot
be explained only by socio-economic differences or poorer health before
rehabilitation. In addition, factors such as the ability of the rehabilitative care system
to accommodate clients with differing expectations, and migrant-specific
characteristics such as cultural differences, seem to play a role.

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Keywords
Effectiveness, foreign nationals, Germany, migrants, rehabilitation, utilization

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Introduction
About 7.3 million people residing in Germany (9% of the total population) have a
foreign nationality [1]. They or their parents have migrated to Germany, many as
“guest workers”, in the 1950s and 1960s. Foreign nationals differ from Germans in
different health aspects, for example because of the more straining jobs many of them
held, but also because they face barriers to access in the health care system [2]. The
consequences are evident from the higher proportion of foreign nationals receiving an
invalidity pension, compared to the proportion of Germans of a similar age [3]. Aside
from different working conditions, two explanations have been proposed for this
finding. First, utilization of medical rehabilitation – a measure of tertiary prevention
aiming to mitigate consequences of disease and disability – is considerably lower in
foreign as compared to German nationals [4-7]. Second, those foreign nationals who
attend medical rehabilitation do not benefit by this health care intervention in the
same way as Germans do: On average, effectiveness of medical rehabilitation is lower
for foreign nationals than it is for Germans [8-11].

However, previous results have shortcomings which possibly limit their validity. As
regards utilization, the studies either do not adjust for confounding factors such as age
differences [6;7], do only use data from particular regions of Germany [4], or restrict
their analyses to selected diagnostic groups [5]. Available studies on the effectiveness
of rehabilitation face similar limitations. All have small sample sizes, and in some,
patients were sampled from one rehabilitation clinic only [6;8;10]. Another study used
representative routine data but operationalized the effectiveness of rehabilitation by
means of treatment progression [9] which is an indicator prone to social desirability

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bias and ceiling effects [12]. In addition, these studies only controlled for a limited set
of confounding variables.

Considering the shortcomings of previous research, our study had two objectives.
First, we wanted to assess possible differences in utilization and effectiveness of
medical rehabilitation between Germans and foreign nationals by using a national
sample and representative data as well as a more robust indicator of rehabilitation
effectiveness. Second, we aimed to examine whether possible differences in these
outcomes are solely attributable to differences in the socio-demography, socio-
economic background and health status of the two population groups or whether there
are additional determinants that need to be considered.

Methods
We used two different data sources to examine determinants of the utilization and
effectiveness of medical rehabilitation.

Utilization of medical rehabilitation
The utilization of medical rehabilitation was analyzed using data from the German
Socio-Economic Panel (SOEP). The SOEP is a national longitudinal household
survey which was set up in 1984. The initial sample contained approximately 12,000
adults in 6,000 households, among which households headed by a foreign national
were oversampled. Later on, several additional samples were added. Wagner et al.
provide further information on the SOEP, its data quality and the methods used [13].
In the current analysis, we included household members aged 18 years or above who
took part in the survey during the years 2002 and 2004 (n=19,521). Choosing a three-