EPHA finalist 2023, Mediclin Staufenburg Klinik, Germany for its Post-COVID rehabilitation programme.
The MEDICLIN AG comprises over 35 clinics, representing the second largest rehabilitation group in Germany in conjunction with Asklepios Kliniken GmbH & Co. KG and Rhön-Kliniken AG.
In face of the emerging post-COVID syndrome (PCS), leading physicians and therapists of the MEDICLIN from all PCS-relevant disciplines formed interdisciplinary working groups and developed a novel, interdisciplinary, standardised diagnostic and therapeutic concept for the treatment of PCS. These specialists shared their “best practices” using online web-meetings on a regular basis.
The health problem is the PCS. About 10-30 % of patients develop PCS which is characterized by fatigue, dyspnoea, neuropsychological disorders, sleeplessness, joint and muscle pain, psychosomatic sequelae and others. Elaborate studies from UK [Office for National Statistics, UK, 2021] indicate that about 14% of patients show PCS 12 weeks after the acute infection, 9% with minor and 2,5% with major restrictions in everyday activities. The RKI estimated up to 1 Mio patients. Vaccinations and the rise of Omicron reduced the propensity to develop PCS, but it still can develop de novo.
Over all, PCS represents a major burden for the health systems and workforce due to the high degree of extended incapacity to work. In the absence of a causal therapy, remedy may be offered by stationary or out-patient rehabilitation, since here multimodal therapies are applied. Patients admitted to our clinics thus come from payors such as the DRV, German pension fund, but also from health insurance companies, from the Professional Association of Healthcare and Social Welfare Workers or the Association of Occupational Accident Insurance Funds. By recommendation, patients may be admitted by their practitioner who submits applications to the responsible payor.
THE PROJECT
Head physicians from eight clinics all over Germany together with Administrative Directors, Quality and Project management, Marketing and heads from Therapy and Psychotherapy formed the initial working group. They comprised all major medical faculties relevant to PCS. The working group met on a regular basis weekly in online meetings to develop the initiative. After definition of the outlines of the concept, further multiprofessional and interdisciplinary working groups, generally ranging from four to 12 members, were set up including all relevant therapeutic groups.
These therapeutic groups defined standardized approaches to diagnosis and therapy of the PCS. Since PCS requires interdisciplinary care, the goal was to provide the best possible therapy in all clinics, mostly irrespective of their primary specialty. Therapists leading in their respective fields shared their best practice knowledge to standardize treatment across all contributing hospitals. The concept was broadly rolled-out in many clinics. The rollout process comprised starter-kits with all necessary information, training of the therapists and staff including audits by quality management.
Clinical data from all patients with PCS were documented during rehabilitation for analysis by the RehaResearch Center of the MEDICLIN. In total, several hundred employees in the different clinics were involved.
INNOVATIVE ASPECTS
– a novel therapeutic concept for the PCS was developed within a short period of time. First descriptions of a PCS came up in the second half of 2020, from beginning to May 2021 the concept was established, providing a comprehensive standardized diagnostic and therapeutic approach to PCS. At that time, a perspective for treatment was not readily available and the uptake was immediate. Clinical data successfully demonstrated the beneficial effects of this concept.
-The concept allowed for a standardized approach to the patient irrespective of the primary clinical faculty. Our data show that only 10% of patients present with one symptom, but over 60% of patients demonstrate with three or more symptoms from different specialties. The “a priori” multidisciplinary approach has, therefore, been the focus of the concept. Such an approach is rare in the German health system, being traditionally divided into sectors and faculties.
– The interdisciplinary approach has extended to the cooperation of physicians and therapists from different medical fields, since an online expert board could be implemented. Patients with special problems or diagnostic uncertainties were presented. This was well esteemed by the patients and the physicians, since this allows to provide the best possible treatment on an individual basis.
– The project management also has had innovative aspects, since from the beginning regular multiprofessional meetings brought together medical personnel with administration, commercial, quality management and controlling to cover all aspects of this project beyond the medical focus. That enabled a regular, structured communication securing a high degree of transparency. This was a pre-condition for the successful rollout in the clinics.
The rollout involved communication, a “starter-kit”, training of personnel, auditing by quality management, documentation and controlling of patients with the PCS. As part of this process, external communication was aligned with the project, informing patients and payors not only by press releases, but also by presentations, podcasts, social media and others. Frequent requests for interviews or participation in discussion rounds are proof of the high public interest.
– MEDICLIN is committed to evidence-based medicine in rehabilitation and fosters clinical research, having founded the MEDICLIN RehaResearch Center. With the initial lack of medical knowledge, all stakeholders agreed that clinical documentation and study of the PCS patients was mandatory. All PCS clinics, therefore, were committed to participate in a clinical study to investigate the course of the disease and the effects of the rehabilitation. A “checklist” comprising all major symptom categories was implemented and all medically relevant, pseudonomized data of patients were sent to the research center. Data obtained from over thousand patients have so far been analyzed. These data demonstrated that PCS is a major burden for many patients with a focus on fatigue, dyspnea and neuropsychological symptoms, but convincingly demonstrated the significant benefit of rehabilitation in patients with PCS. These data could be presented and published.
– Is this approach restricted to MEDICLIN? Clearly not. With the evolution of the PCS and its treatment, The Deutsche Rentenversicherung is in the process to define the prerequisites for rehabilitation clinics to be accredited by the DRV as “clinics specialized in the treatment of the PC syndrome”. These pre-conditions include an interdisciplinary standardized concept involving at least internal medicine, neurology and neuropsychology as well as an access to a psychotherapist or psychiatrist allowing also web-based communication. That indicates that concepts based on interdisciplinary and multiprofessional care have reached the mainstream and therefore may be established in the German health care system on a broad basis.
RESULTS
- Treatment concept for PCS: A treatment concept was developed based on the existing medical knowledge, since the medical need of patients was obvious. This was especially true in the early phase of the COVID-19 pandemia, when vaccination was still absent. Many hospitalized patients suffered from ongoing pneumological problems and from deconditioning after a stay in the ICU. Patients with chronic comorbidities such as diabetes or CV diseases showed a retarded recovery. Rehabilitation strongly contributed to the recovery of these patients. In later phases, especially when the vaccination rate and/or virus type changed, other symptoms of PCS became more prevalent, that is fatigue and neuropsychological deficits. Rehabilitation significantly also improved these symptoms. This is also true for patients with psychosomatic diseases, which were either aggravated due to infection or developed de novo after traumatizing events.
- Proof of clinical benefit of rehabilitation: To show the effects of rehabilitation on the symptoms of PCS was another mandatory objective. Since hardly any experience existed, there was no indication, if rehabilitation would help patients. Clinical data were needed to be obtained right from the start, in order to show, if improvements occurred or if the treatment concept needed to be adapted. Not all clinics were experienced in the gathering of clinical data, however all coworkers could be trained and the clinics regularly delivered clinical data. The results demonstrated that rehabilitation significantly improves the major symptoms of PCS. This is true despite the wide variety of symptoms, which are encountered with PCS. These data also were published.
- Standardized approach to PCS across all clinics: Experts from different specialties worked closely together to set up an interdisciplinary diagnostic and therapeutic concept, which was executed in a similar fashion in all clinics irrespective of their primary specialty. This included the admission and discharge process. A diagnostic test panel was standardized including psychological and functional tests. Therapeutic modules were coordinated between different therapists. By sharing best practices from leading departments, others could profit and be trained accordingly.
- Online expert board meetings: Experts from all specialties were regularly available for consultation for patients and clinics. The expert board allowed to discuss with patients and to make recommendations for diagnosis, further treatment or socio-medical evaluation. This service was widely used and had different effects: i) as an excellent learning experience for all involved; ii) for the development of an interdisciplinary view on PCS and iii) for patients who highly appreciated the contact with experts. Additionally, the expert board followed up on the medical, so that medical knowledge was always updated and integrated into the therapeutic regime.
- Project management and rollout: Due to the urgency with that PCS developed, solutions needed to be found in a timely fashion. This was achieved by the use of online meetings and the establishment of multiprofessional. Early on, medical personnel closely worked together with employees from administrative departments, controlling, quality management and communication to define a roll-out plan which contained all necessary “building blocks” to bring the concept to live in the different clinics. As a result, the concept could be rolled out within four months. Information was, therefore, obligatory on a regular basis to ensure transparency. External communication was executed in parallel with the degree of realization of the concept and the public and important stakeholders, e.g. payors were informed.
