The "Multi-step intervention approach" of the German Social Accident Insurance

The following information provides in brief how occupational skin diseases are to be handled at both administrative and medical level in Germany.

iDerm offers a full range of consultations, training and treatment of the insured person with occupational skin diseases in accordance with the so-called multi-step intervention procedure established by the German Social Accident Insurance (DGUV).

Depending on the severity or complexity of the skin disease, the patient will get either outpatient treatment (secondary individual prevention / SIP) or integrated outpatient/inpatient care (tertiary individual prevention / TIP).

The elements of the multi-step intervention approach were developed and scientifically evaluated in the 90s´ at the University of Osnabrück. They are continuously further developed and increasingly applied in other countries. It becomes evident how an interdisciplinary treatment, including a close cooperation between hospital and practice, can achieve the most effective results for the patient and the enterprise.

Scientific evidence demonstrates the efficiency of these measures to

  • avoid personal suffering
  • avoid loss of employment
  • improve quality of life
  • increase productivity of small- and medium-sized enterprises

 

Our medical centers at the University of Osnabrück and the statutory Accident Insurance Institutions Trauma Hospital (BUK) Hamburg offer services in all aspects of the multi-step intervention approach in treatment of occupational skin diseases in preventive medicine.

Primary, secondary, tertiary prevention: the German multi-step intervention approach in treatment of occupational skin diseases

 “Prevention is better than cure” is the motto of the German statutory accident insurance scheme. Due to specificities of the social insurance system, prevention concepts aiming chiefly at early detection of occupational skin diseases (OSD) but including all levels of prevention have been scientifically developed, implemented and evaluated. Meanwhile, this work has formed the basis for a nationwide systematic so-called multi-step intervention approach (Stufenverfahren Haut) to OSD by the respective statutory accident insurance bodies. 

By applying this approach, we offer quick preventive help for all severity grades of OSD for every employee regardless of his or her profession. Preventive medicine strategies are typically described as taking place at the primary, secondary, tertiary prevention levels. 

Primary prevention aims at avoiding occupational skin diseases in healthy individuals employed in workplaces that are hazardous to the skin. It should focus both on workplace-related and worker-related risk reduction strategies. Those strategies comprise change of work organization, technical measures (“no touch” techniques etc.), optimized personal skin protection (e. g. gloves, skin protection creams), continuous health surveillance (especially in risk groups) with access to preventive measures and training. One key-factor, however, is that in our understanding access to those strategies should be quick, easy and available to everyone even if there is only a slight suspicion that a dermatosis might be work-related. Our inpatient services are designed to meet those criteria. They encompass individual counselling by our interdisciplinary team of expert physicians, health educators and psychologists. Patients are seen for common conditions such as eczema as well as for more complex disorders that are linked with OSD. Individual counselling aims at clarifying disease symptoms, finding appropriate skin-protection methods (e. g. gloves, creams) in cooperation with each patient and, last but not least, assessing the case from a medical point of view for the Social Accident Insurance. A comprehensive report is sent immediately to the Social Accident Insurance Institution to ensure sustainable success in therapy and treatment.

Furthermore primary prevention includes the dissemination of medical knowledge in terms of health promotion and health education among the general population to raise awareness and to reach political decision makers. In 2007, the German statutory health and accident insurance institutions initiated a new campaign under the motto: “Your skin. The most important 2 m2 of your life.” iDerm is deeply involved in the coordination and organization of the Healthy Skin@Work Campaign at national and European level.

Secondary prevention aims at early disease detection to prevent skin disease chronification or progression of symptoms and focuses primarily on individuals with initial signs of OSD. Secondary prevention requires medical diagnostics and treatment, teaching, psychological understanding and an improvement of working conditions. Our secondary prevention measures include:

  • dermatological outpatient and inpatient therapy for severe cases
  • a multi-disciplinary intervention with a focus on teaching (seminars) and a systematic follow-up (6 months and longer as necessary)
  • immediate steps in prevention based on individual medical and educational counselling (3 hours, “ZIP-Zeitnahe Individual Prävention”), including application of protective measures (e. g. gloves, creams)
  • skin protection seminars (1-2 days)

 

For an early intervention, is it of vital importance how accident or health insurers are informed that an employee has developed an OSD. In Germany, even if there is just a slight suspicion that a dermatosis may be work-related a dermatologist’s report (Hautarztbericht) is filed with the respective statutory accident insurance institution. It is based on a detailed examination including patch testing and atopy screening. It also includes recommendations concerning therapy, personal skin protection and after-work skin care. Additionally our medical centers offer multi-disciplinary skin protection seminars to affected employees. For the purposes of optimal early intervention rapid medical treatment following completion of the report and documentation of progress at close intervals are now required as a rule.

The quality and operational effectiveness of the comprehensive scheme of secondary prevention measures which was newly introduced in 2006 are presently being analyzed by iDerm in a study (EVA_Haut).

Intensified comprehensive measures of tertiary individual prevention (TIP) are indicated when patients are forced to give up their profession due to severe recalcitrant OSD. TIP represents the ultima-ratio within the hierarchical multi-step intervention concept. Each patient remains off work for a total of 6 weeks to allow full barrier recovery. Our TIP treatment – also known as “Osnabrueck Model" comprises following the measures:

  • 2-3 weeks of inpatient dermatological diagnostics and treatment
  • intensive health-related pedagogic and psychological counselling
  • occupational therapy exercises of adequate skin protection methods (e. g. gloves) in a simulation model of the workplace
  • counselling by the case manager of the statutory accident insurance institutions
  • involvement of the occupational physician

 

After discharge the local dermatologist follows up the case at close intervals for another 3 weeks. This outpatient treatment as well as the sick leave expenses is covered by the statutory accident insurance bodies.

A key-factor factor in TIP is the seamless continuation of the initiated medical and preventive efforts when the patient re-integrates at work. Therefore, subsequent outpatient treatment by the local dermatologist is always indicated. It may be extended up to one year or longer. Our data reveal that 66 % TIP patients with severe OSD treated regularly by a local dermatologist for up to one year were successful in remaining in their respective (risk-) professions.

Furthermore, our TIP measures prove particularly successful in patients over 30 years of age - persons whose professional alternatives in the current employment market are limited. This observation emphasises the socio-political dimension of the German approach and our measures.

What to expect from the multi-step intervention approach?

At present a multi-center study which aims at evaluating the sustainability of the multi-step intervention approach is being conducted in cooperation with the German Social Accident Insurance (DGUV). The study started in 2005 (ROQ 1) with phase two running until the year 2015 (ROQ 2). First results show that due to the TIP measures 88,8 % of our patients were able to return to their respective job. Furthermore, a significant cutting back in cortisone therapy could be achieved; 93 % of our patients were completely free of using cortisone when getting back to their professional activity.

These findings reinforce our confidence that we are following the right course in efficient treatment of OSD and encourage us to continue our close collaboration with all stakeholders of the multi-step intervention approach.